Medication – Part 1, Medicine Itself

In mental health, medication has a bad name. People are reluctant to take it for a range of reasons – it shows you are weak, it validates a real problem exists, fear of addiction, conspiracy theories around big pharma, or ignoring the real problem and only treating a symptom. Yet for any other medical condition we are far less suspicious of medicine.

Part 1 – Medicine itself

In Australia, generally your doctor is the first person you will meet when you are experiencing mild to moderate mental health problems. You will go to them and explain what you are experiencing and they should ask you some questions about it. Shortly afterwards you will most likely be prescribed some medication and or be given a referral to a counsellor. What the doctor has done here is hear a list of symptoms, done an assessment (the questions and your answers) and then made a judgement about your situation and implemented a treatment. Generally the treatment (medication and or counselling) will have a return to the doctor in x amount of time for follow up. The counsellor will also be sending reports to the doctor, just like if you went and had an X-ray for a suspected fracture – the doctor gets a report about that too.

If you have a more severe experience with mental ill health you might go straight to the hospital emergency department (ED) and see either a doctor there or a psychiatrist. The doctor will follow the same procedure outlined above while the psychiatrist will be doing a longer version because it has been deemed that your situation is more complex than a standard general practitioner can deal with. GP’s are well versed at many things, but they are not specialists – they are generalists in medical care. The psychiatrist will then generally give you a diagnosis, a script for medication, refer you to counselling and like the doctor, check in on you every now and then.

Psychiatric medication has a nasty stigma attached to it. Some of the reasons are empty and some have some interesting history. Good medical practices started a mere hundred and fifty years ago, which is practically modern history so far as our scientific knowledge is concerned. Good psychiatric practices slowly followed. Increases in our scientific understanding of bacteria, X-Rays and scientific method accelerated our medical knowledge to the point where a wound isn’t likely to kill you, we know that smoking cigarettes is bad for you and we are having this stupid debate about whether to vaccine or not (do it) after vaccines have pretty much eradicated nasty diseases such as polio, almost measles and some other stuff that should just die. Psychiatric medicine is still in its early stages and even only a few decades ago we had some pretty horrific problems with experimental drugs.

Medication
Medication

The distrust for most modern medicine is generally a thing of the past, while distrust for psychiatric medicine is still fairly fresh and relevant. Certain medications, such as antipsychotics and mood stabilisers, can seem like they turn functioning people into zombies, occasional side effects to some antidepressants can include increased suicidality (you want to kill yourself), or constantly feeling dizzy. In each of these cases, where the medication is not working as intended, one can ask oneself why we are taking them and who would ever prescribe these? In doing so we miss the large number of people who are prescribed these medications and have the desired effect, saving their quality of life, or where the side effect is far less bad than the symptom the medication is effectively treating.

Consider antibiotics. They treat bacterial infections in most people really well, saving millions of people on a yearly basis. A cheap, common and effective antibiotic is penicillin and its subtypes. Some people who take the penicillin derived antibiotics have a bad reaction and fall in the category of having a penicillin allergy. We don’t define all penicillin medications as bad and to be avoided… we instead recognise that some people are allergic to them. In a similar way it is noted that some antidepressants occasionally increase suicidality – an existing risk of being depressed in the first place, is now much worse. Much like those who are now known to be allergic to penicillin, we note on the patient’s/client’s record the “allergy” and avoid that medication in the future. Most people who take the medication get the primary result – antibiotic or antidepressant – and some get the side effect, the effect we don’t really want.

Yet people will avoid antidepressants fearing the side effect, but won’t avoid antibiotics for the same logical reason.

Medicine is about balancing costs. A well known antipsychotic medication makes life possible for people with a relevant range of diagnoses. However a common side effect is a metallic taste in their mouth. The benefit of this drug is that symptoms that prevent you from having a functional life are abated (psychosis, hallucinations, loss of drive), while a new symptom (metallic taste) is added. While not a fun effect, it is much less bad than being non-functional. The cost vs the benefit tips it into being a thing worth doing.

I don’t see brilliantly. I have a few problems with my eyes. One of them is the difference in the ability to focus with each eye, another is that one of my eyes is slightly turned giving me a stigmatism (horizontal lines don’t meet) and a third is that the cones of one colour are slightly offset to the other two.  Overall, things are a bit blurry, text more so. Glasses correct most of these issues. I have to say that wearing glasses is somewhat disconcerting – the world is yellower and more vibrant (yellow tint fixes the colour cone error) and things look amazingly crisp and vibrant – like someone upped the resolution on the video. These benefits are quite nice, but there are some costs. For a start my peripheral vision becomes munted and turning causes me to be dizzy. Walking is a bit odd as the field of focus goes a bit odd. Potentially I could adjust to this. Another cost is that I have to carry my glasses around with me and put them on when I read or do some other precision stile stuff. I have a bad habit of forgetting my glasses so they either don’t make it to where I need them, or they don’t make it home afterwards. Another cost is that I look a bit odd with tinted lenses.

I have decided that the cost is greater than the benefits. The cost I accept is that the world is a bit blurry and that if I read for too long I will have a headache. I know there will come a point in time where my eyesight will deteriorate enough that I will have to wear glasses all of the time, because the cost of not doing so will now exceed the convenience of not having to carry glasses.

Benefits and costs. If the cost of a medication was too high for most people, then either the medication is banned or it becomes a medication of last resort. What this means is that if your general practitioner is prescribing a medication, the odds are it is generally fairly simple and most likely to work, for a given value of “most likely to work”. We’ll get on to that. The more specialist levels of psychiatric drugs require either a psychiatrist to prescribe or another brain specialist like a neurologist.

Let’s take a slight detour here. Simply put, when we can’t isolate a cell based mechanism for the condition, we call it psychiatry. When we can, it is neurology. We know that the problem is in the brain for both. Parkinson’s Disease is a problem located in the substantia nigra, a region in the mid-brain section and is a degeneration of the motor and central nervous system. We know the actual biology of this, thus it is neurology. Depression is somewhere in the brain and seems to be affected by serotonin. Too much, too little, too much re-uptake or too little re-uptake (re-uptake is recycling of the present neurotransmitter) appears to change the balance in people with the resultant symptom of depression. But serotonin isn’t the only factor as there are many people who experience depression without having any positive effect of various serotonin medications. We aren’t sure which part of the brain, or parts of the brain, are the real culprit, thus it is psychiatry.

When you have a fracture of the bone, you can objectively test it, find it and treat it (most of the time). When you have a fracture of the psyche we can’t objectively test it – only subjectively test it, we can’t find it and our treatment of it is based on best guesses. However the guesses are well educated guesses and are generally pretty effective. You don’t need to know why you ache, or which specific part aches, for pain relief to be effective. Working out which form of depression you are experiencing and which treatment plan is best is a bit of scientific trial and error, where the first treatment tried is the one that has the best likely results with the least likely side effects. It may not be the right one, so after it is ruled out, it is time to move on to the next one. Most depression is addressed with the first treatment plan, but many require a third go before finding good results. Some forms of depression are not responsive to regular treatment and require specialist intervention. I often see those ones.

X-ray fractured femur
X-Ray – Fractured Femur
By © Nevit Dilmen, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=17373724

Breaking a bone requires treatment of the bone and probably physiotherapy afterwards. There is no point receiving physiotherapy without treating the break. However if the problem isn’t a break and more of a muscle problem, then a referral to a physiotherapist is enough. Similarly GP’s often treat mental health by first treating the symptom and seeing if that fixes the problem. If it is a mild case, a pill for a few months will help and no counselling (therapy) is needed. Most mental ill health is due to current circumstances which will resolve themselves in a bit of time. If the doctor thinks it is more complex, they will recommend a therapist to help you through it. Not all mental illness requires or needs a medication, so when appropriate the doctor will prescribe therapy in the absence of medication.

Next we will look at the stigma behind medication and counselling – a social perspective.