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.

Debunking the Psychiatric Diagnosis Myth Workshop/Exercise

Introduction:
One of the greatest advances modern society has is medicine. Over the last hundred or so years we have refined the process of discovering and treating medical disorders, illnesses and disease to improve quality and longevity of life.

Materials:
Something large to write on, such as a white board, chalk board, large pad of paper or computer with overhead projector. Writing implement.

Workshop:
Ladies and Gentlemen, are there anyone here currently today who has ever been treated for asthma, diabetes, bone fractures or a heart condition? [If not, continue for a few more common ailments]

That is excellent. Would anyone like to talk to us about what prompted them to get aid? That is, what led you to seek medical treatment?

[Listen to a few stories if possible, but try not to get lost in the nitty gritty of specific stories. Write on the board “Symptoms”. If someone is getting to bogged down in details, point to the word “Symptoms” and say ‘can we stick to this for now?’]


Thank you. Now I would like to ask you if the treating doctor suggested one or more ideas about what might be happening that caused your symptoms?

[Listen to the responses. Write on the board, under “Symptoms” the word “Formulation”]

Thank you. Did the doctor narrow down their theories to a specific cause? How did they determine this cause?

[Listen to the responses. Ask questions about diagnoses and tests if they are not volunteered. If there was no test, ask how the doctor knew that this is what caused the symptoms. Write on the board “Medical Tests” and under that “Diagnosis”]

Thank you. What treatment did you receive from this tested diagnosis?

[Listen to the responses. Write on the board “Treatment”]
Thank you. Is or did the treatment work? Is it ongoing and having a positive effect? If the treatment didn’t work, did the doctors go back and review your diagnosis?


[Listen to the responses, if any]

Thank you. Now, has anyone here received treatment for a psychiatric diagnosis? Would anyone like to talk about their experiences? [Hopefully someone will volunteer to talk about their experience. If not, relate yours]


Thank you. First, what led you to seek medical assistance?

[Point to the word “Symptoms” on the board. Listen to their stories.]

Thank you. Did the doctor offer a range of possible explanations?

[Point to the board where it says “Formulation”. If the individual was only given one option, ask why the doctor didn’t explore further options. After all, there are different types of diabetes, different types of fractures, different types of heart condition etc. Why is there only the one formulation for this person in this situation?]


Thank you. What medical tests were performed to determine a diagnosis?

[Point to the words “Medical Tests” and “Diagnosis” when appropriate on the board. Listen to the response.
– If there were none, ask how you know if the diagnosis is right if there was no test?
– If it is a subjective mental state test (rate yourself on this scale out of X), ask if you were having a good day or a bad day when you were tested since this is known to bias results. Was a secondary subjective mental state test done?
– If it is a DSM-IV TR style “you have x out of y symptoms” show the scope of permutations this style of ‘diagnosis’ has. Also discuss umbrella terms. For example: Dyslexia describes a range of learning disorders which can include mixed laterality, hearing difficulties, cognition difficulties, colour blindness etc. Each have similar symptoms – the learning disorder, but each have different treatments and tests.
– If it was physical tests of exclusion (blood test shows that it is not thyroid, not mineral deficiency, not etc) then ask how they know what it is when they have only shown what it isn’t.]

Thank you. What treatment was offered for the diagnosis?

[Point to the word “Treatment” on the board. Listen to the response]
Thank you. Is or did the treatment work? Is it ongoing and having a positive effect? If the treatment didn’t work, did the doctors go back and review your diagnosis?

[Listen to the discussion, if any]

Thank you for your part. Now we will open up the discussion to the group. What were the key differences between the physical diagnosis and the psychiatric diagnosis? How did the medical system break down?

Disclaimer:
I am not suggesting that you dispense with a treatment plan just because no objective test was performed to prove what you were diagnosed with. The idea of this discussion is to recognise the difference between an unproven formulation and a proven diagnosis. Doctors treat formulations all the time, but they are receptive to their hypothesis being wrong. If you find your treatment isn’t working, or feel you should get a review of your “diagnosis”, then perhaps you should have a conversation with your doctor/psychiatrist.

Your doctor/psychiatrist has great knowledge. Understand the medical process so that you can better use them.

Neuroplasticity document

The Vermont Recovery page has some interesting articles. This one on Neuroplasticity is quite good. It is a downloadable PDF document.


“Neuroplasticity basically refers to the brain’s natural ability across the lifespan to form
new connections and change its structure in response to experience.  This means the brain can
change itself physically and functionally at any age to compensate for injury and disease and to
adapt to new situations or changes in the environment.”


“Traditionally, the adult brain was considered relatively hard-wired and fixed, a prognosis
that  lowered expectations about the possibility of  curing the alleged brain problems that
underlie psychiatric disorders.  Thus, in the medical world, schizophrenia and bipolar disorder
have been conceptualized as life-long, incurable brain pathologies that a person can learn to
manage, but never completely  resolve.    However, these hypotheses  have always been
problematic, for longitudinal  studies have  demonstrated again and again that  a significant
amount of people diagnosed with schizophrenia completely emerge from psychiatric symptoms
and no longer use medications.
4
  These individuals pose this challenge to neurobiology:  if their
previous symptoms were in fact due to a broken brain, are their brains now fixed?”