Medication – Part 2, The Stigma behind Medication and Mental Health

Last time [Link] we looked at medication itself as a general concept in mental health, comparing it to generalised medical treatment. Part 2 is about looking at some of the social causes of Stigma in Mental Health and how that affects the social view of Mental Health Medication.

Part 2 – The Stigma Behind Medication and Mental Health

Stigma is an interesting word – it can mean both a mark of disgrace and a mark of grace depending on the context. In mental health, stigma is the mark of disgrace that excuses bad behaviour to people labelled with mental illness.

Fear of the unknown  – they were all bad

Words used to insult people have often held a mental health component in it – lunatic, psycho, bipolar, crazy, mad, loopy, schizo and so on. As soon as we do not understand why someone does something we assume there is a mental illness in that other person rather than ignorance in oneself. People who commit acts of violence are frequently called schizo, psycho, loony or crazy, even though statistically people with a mental health diagnosis commit less general crimes and specifically less violent crimes than people without a diagnosis. Often times there is retroactive arm chair diagnosing of people who have committed violence and atrocities, despite authorities investigating and finding no good indication of mental illness.

These were just bad people.

Sometimes bad people do have a mental illness, and when that is the case it confirms in our minds all those times we thought a bad person should be diagnosed.

Another aspect of bad people is that sometimes they have blue eyes. Not all people who have blue eyes are bad people. When bad people are known to have blue eyes, it doesn’t confirm to us that all blue eyed people are bad. This is an example of stereotyping and false categorisation.

The assumption of normal

It is well known that people who come from different lands have different expectations than us, different values, different ways of doing things and so on. We have a clear and easy way to say “oh, their difference is because of where they come from”. We might think their values and culture are a bit odd, even seeming to be ‘crazy’ if the differences are hard for us to understand. We don’t call the individual from that far off place crazy though, just their upbringing.

We assume that all people from our land will have the same values and ways of doing things. “It’s just common sense” is a common statement of frustration when you see someone doing something that you think is stupid or wrong. We assume we are all the same, doing the same things in the same ways, while at the same time wanting to be better than others, wanting to be special and unique. I find this to be a fascinating contradiction in terms – we are all the same, but I’m unique.

Within our society we have found different types of humans. We have the false binary of male versus female (there are more sexes than that, but it is a starting point to discuss from), where we expect men to behave one way and women to behave another. We also have different kinds of women – airheads, nerdy, sporty etc. We can then split the categories further… So it isn’t just one type of human, nor is it one type of woman, or one type of nerdy woman, it is lots of sub categories.

Neurodiversity is bringing in some interesting concepts of differences in humans. Two well known neurodiverse groups are ADHD (three sub types currently recognised) and Autism (dozens of sub types currently known by dividing by 5 axes on a 3 point scale). I strongly believe that we will create new categories for as yet unknown different types of neurodivergent peoples. Sometimes medication can help with some of the challenges that being neurodivergent brings, either addressing primary difficulties or societal difficulties. Often though, medication is not the solution.

When someone solves a problem differently, responds to an event differently or just seems odd we assume there is something wrong with them rather than accepting that they are unique to you. The challenge here is the distance from how you see yourself compared to others. You want to be unique and special, but not that unique and special. Your difference is ok, but theirs is wrong.

That labelling of wrong is a stigma that is often used to justify not making adaptations, allowance or understanding.

Neurodiversity is just one example of difference within humans that we stigmatise and is to the only one in the umbrella of mental health.

Dunning-Kruger Effect

There are two parts to the Dunning-Kruger Effect.
1) A cognitive bias in which people of low ability have illusory superiority and mistakenly assess their cognitive ability as greater than it is.

2) A cognitive bias in which people of high ability misestimate how hard a task is, thinking that it should be easy and undervaluing their own ability.

First we are more going to look at the first part.

Pretend you get a sprain in your foot. It hurts to use your foot, so you will walk with a limp for a while. There is no good treatment for the foot injury except to avoid using it and sometimes some judicious use of pain relief. After a few weeks the sprain will heal and you will be fine. Simple, right?

Imagine your friend has a broken leg. The femur (the bone between their hip and knee) snapped in a total fracture, which requires an operation to fix, a metal pin inserted, several screws and a cast for 3 months with some rehabilitation afterwards.

As you too have experienced a leg injury, you falsely equate your experience for theirs. You don’t see why they are making all this fuss with operations, casts and physiotherapy. You got by on a few pills and taking it light for a few weeks. In principle they are the same injury so should have the same treatment.

Now obviously you can see the errors here because the difference between a sprain and a complete break of the femur is easily understood and can be shown on an x-ray. Even so, it amazes me how many people do not understand that a broken bone is serious.

Let us substitute your sprain for a time that you felt a bit down when you were between jobs. It was tough, you didn’t feel like socialising, you were worried that people would judge you, you may have even taken some medication – either official antidepressants or unofficial substances like alcohol or marijuana. You were stubborn and got through it and once you got your new job it all got better.

Your friend has major depression. They are frequently out of action for an extended period of time, take regular medication and sometimes go in for electroconvulsive therapy. You falsely equate the two, thinking that they are both depression, right? Why is your friend making such a fuss?

In your ignorance you assumed you knew the territory and the complexity of the issue, undervaluing how hard the major depression is.

While not technically part of stigma, the second part of the Dunning-Kruger Effect is important to consider. Those who have actual experience of major psychiatric illnesses frequently undervalue their experience, stating to me “other people have it worse”, or “I shouldn’t be having this much trouble with it – it’s only depression”. In effect, people undervalue how much they are dealing with and how hard their life is simply because they are expects in managing it.

Eugenics

A nasty side of medicine is the definition of healthy and unhealthy in an ideal sense. Ironically it is an evolution of the misunderstanding of evolution. Eugenics was the belief that we could take evolution into our own hands and create a better human, and with that belief the definition of inadequate humans. Medicine was the tool used to define what healthy and inadequate was. Much like eugenics is a misapplication of the concept of evolution – mistaking the world as a single static niche; the misapplication of medical definition to define fitness tarnishes medicine as eugenics tarnishes evolution.

That can seem a bit confusing. Evolution is a great tool that is very accurate and is mis used by those who believe in this concept of eugenics. The tool is not the fault, the misapplication of the tool is. Similarly eugenicists misuse the tool medicine. Medicine is not the enemy, those who misapply it is.

Different cultures in history have dealt with difference in different ways. Some have honoured difference and divergence as a message or gift from the gods, while others have burned it with fire. Our recent history – about the last two hundred years – has been more of the burn it with fire kind with only the last fifty years opening up to difference being okay.

Once mental illness was medically defined, we segregated our people into monasteries, asylums and madhouses. Johnny acting a bit odd? Off to the madhouse. The last twenty years has seen more and more people leaving institutions and being managed in the community (some well, some poorly) with the locked ward and open wards only being used for significant problems.

Even then, it has been estimated that two thirds of our Australian gaols are populated by people who have a mental health condition that weren’t being addressed, so they were gaoled instead.

Big Pharma and Addiction

I frequently talk to clients who have been prescribed medication to help manage symptoms while they are getting therapy. The most common reasons clients say no to pharmacological intervention (meds) are:

1) Big Pharma

2) Fear of addiction

Big Pharma is the concept that there is a conspiracy of those who make medications to not really cure the problem but to just treat the symptoms such that the patient becomes a life long depend user.  You’ve all seen the cartoon about a scientist in a lab saying  “I’ve just cured cancer” and the other saying “shhh… we make too much money on the current system” or words to that effect.

When someone is convinced that there is a conspiracy it is very hard to convince them that they are wrong. You are the one that has been fooled, the evidence is a plant, you are working for Big Pharma etc – any contortion of logic to keep the belief. Don’t ridicule people who have one of these conspiracy theory beliefs – statistically 90% of the population has an illogical belief that contradicts evidence.

In this case, I look at the medications available 20 years ago and shudder… except that I look at the medications available 20 years before that. Basically, the medication available keeps getting better, more effective and with less side effects. Our own Australian science group, the CSIRO developed and created the HPV vaccine, which in one stroke effectively killed several types of cancer simply by preventing people from getting it. Why didn’t Big Pharma stop it?

There is a smidge of truth to the belief though. If the medication is out of patent, is not profitable enough or can’t be effectively sold, then the pharmaceutical company won’t develop or market it. They are a business, after all. Generally though, most treatments that work are sold because they bring money.

With the opioid epidemic being the latest addiction crisis brought about by the misapplication and erroneous intentions of health professionals, people are very worried about addiction to mental health products. Much like Big Pharma, there is mostly fiction in this and a it of truth.

Most mental health medications are not addictive, per se.  It is important at this point to take a mild detour into what is and what is not addiction.

According to ReachOut Australia [Link], “Addiction happens when someone compulsively engages in behaviour such as drug taking, gambling, drinking or gaming. Even when bad side effects kick in and people feel like they’re losing control, addicts usually can’t stop doing the thing they’re addicted to without help and support.” This could sound like mental health medication – you have to take it, you don’t like the side effects, you feel like you lose control when you don’t take it and you need help to stop it.

But that is also true for food, oxygen, insulin for diabetics, heart medication for people with various heart conditions and so on. A substance that is required for existence, quality of life or medical needs is not a substance that you are addicted to – it is a requirement.

Opioid addiction is a different kettle of fish. For a start, the medication is addictive in and of itself – it can lose efficacy over time (you need more dose to feel the same effect), they can alter the state of your mind in negative ways and people who become addicted to opioids can and will do actions that they would have normally regretted to feed their addiction. Common medical opioids are Codeine,  Hydrocodone (Vicodin, Hycodan), Morphine (MS Contin, Kadian), Oxycodone (Oxycontin, Percoset), Hydromorphone (Dilaudid) and Fentanyl (Duragesic). These are based on the derivatives of the opium plant. Each of these have specific medical uses that when used for a brief amount of time for specific things do not lead to addiction.

The error came in when it was thought that long term use of these medications would improve quality of life without leading to complications. This was meant with good intent but met with bad results for many people. Pain is awful, and anyone who struggles with chronic pain will tell you that it can be crippling, debilitating and ostracizing. To feel relief from pain can be wonderful, but to know it will come back shortly is awful. Many people with chronic pain can pinpoint the source event that led to their pain while some cannot. It is easy for the armchair observer to make the Dunning-Kruger error of thinking that they have felt pain and dealt with it, that there is no clear source of the pain or that people should just “get over it”. If it were that easy, patients would do that.

Medication mismanagement leading to opioid addiction is a tragedy that most mental health medication won’t fall into because it misses two primary categories. First of all the medication generally is not in the category of being addictive as opioids are. There are a few exceptions to this and your doctor should warn you about these, use the medication as a short term solution to symptoms and be working on a treatment plan for how to find a longer term solution. If you aren’t sure, ask your doctor or psychiatrist which of your medications are addictive medications.

Secondly the mental health medication is required for quality of life, much like pain relief, glasses, hearing aids, heart medication and insulin. Pain relief can be a temporary solution to a problem that will resolve in time and is analogous to short term mental health medications to help you through a short term psychosocial crisis. The rest are long term solutions to ongoing problems that are not going to resolve themselves. Someone with type 1 diabetes is not going to wean themselves off insulin without dying, nor will someone with a heart condition not need that medication (some exceptions apply). We don’t count these medications as addictions, so nor should we mental health medication.

The Naturalistic Fallacy

Our last major category of stigma is the naturalistic fallacy. In a nutshell, the naturalistic fallacy says that if all things are natural then all things are good and any unnatural thing makes good things bad. If you eat a balance of good food, do reasonable exercise and think good thoughts all of your problems should disappear.

Tell this to the people on Naru island. Tell this to someone in an abusive relationship. Tell this to someone with a heart condition.

It is a privilege to only need good food, exercise and good thoughts to have a good life. People who manage this have never known true adversity and will frequently falsely mistake their mild challenges as equivalent to someone else’s nightmare. Refer back up to the Dunning-Kruger effect.

It is true that many people who are struggling in their life do not eat well, do not get adequate exercise and tend towards bad thought patterns. These are certainly not helping. But to think that is the cause of the person’s trauma is a fallacious assumption. and leads to victim blaming, that is, stigma. Helping a person to fix their diet, exercise well and think good thoughts is just simply not enough to solve someone’s bad relationship experience, recover from rape, escape false imprisonment, or manage a significant biological illness.

It is true that many people who are struggling in their life do not eat well, do not get adequate exercise and tend towards bad thought patterns. These are certainly not helping. But to think that is the cause of the person’s trauma is a fallacious assumption. and leads to victim blaming, that is, stigma. Helping a person to fix their diet, exercise well and think good thoughts is just simply not enough to solve someone’s bad relationship experience, recover from rape, escape false imprisonment, or manage a significant biological illness.

The naturalistic fallacy often suggests that pharmaceutical products are unnatural and you should just take natural medicines and supplements. Referring to the opioid problem above, opioids are derived from a plant. They are natural products. Cyanide is also natural and not recommended as a medicine – it will kill you. Most supplements have been found not to contain the labeled ingredient – in the best case they contain the wrong dosage, in the worst not containing the active ingredient at all. Supplements are also made by the same company that makes the medications you are being prescribed, but supplements are unregulated while medications are heavily regulated and quality controlled.

Many people I meet for therapy state they won’t take medications prescribed by their medical practitioners (GP or psychiatrist), because they are worried about drugs and unnatural products, while in the same breath telling me about the unregulated drugs they do consume, such as supplements, marijuana, MDMA and meth amphetamines while drinking their excessive alcohol and stubbing out a cigarette (not during session, but you get the point). These people are self medicating on things that haven’t worked (otherwise they would need to see me), but refuse medications that might. It is an odd world.