by Allen Frances
To take or not to take psychiatric medicine? That is the question.
Far too many people answer yes and take meds they don't really need for problems that would get better just with the passage of time and/or brief counseling.
More than 20% of Americans are on at least one psychotropic drug (sometimes several), too often not for real mental disorders, but for transient emotional distress or for the demoralization that comes from difficult life circumstances.
Meds that are very helpful for clear cut psychiatric disorders usually do more harm than good when used for the everyday difficulties that life throws at us.
When prescribed loosely, meds provide little benefit, risk harmful side effects, distract attention from solving the real life problems, and reduce people's trust in their own resilience and the help they can receive from family and other social supports.
Even for those who really need them, psych meds are not always prescribed well. Doses are often too high or too low. And doctors tend to add new drugs when old ones aren't working, without withdrawing the old ones. This irrational polypharmacy adds to the risks of drug- drug interactions and increases the burden of side effects. Lots of patients who do need to be on medication do better when on lower doses and fewer different types of pills.
But there is another side of the equation. Far too many people who need drugs don't take them - either because treatment is unavailable or because they don't realize or accept the fact that they need it.
So we are trapped in the cruel, dumb, and sometimes tragic paradox that the wrong people often take meds, while the right ones don't.
This terrible situation has many causes that have been discussed already in previous blogs. Our focus here will be on what has been a futile and harmful struggle between two different 'one glove fits all' mentalities.
On one side are medication fanatics- some of whom are psychiatrists but also many primary doctors who prescribe 80% of psych meds.
On the opposing side are die-hard anti-medication crusaders who try to persuade everyone, including those who really need meds, that they are globally unhelpful and globally harmful.
The best person I know to bridge this worrisome gap is Virgil Stucker. He is Founding Chairman of the Foundation for Mental Health Excellence and Founding Executive Director of the CooperRiis Healing Community. Virgil has spent most of his adult life living at close quarters with patients in therapeutic communities. He knows how important meds are in improving the lives of people who need them. But he also has close contact with user groups and understands the concerns of those who have been harmed by psych meds. If anyone can find a proper balance in this far too acrimonious debate, Virgil can:
" I was recently in Iowa on an emergency trip, thinking I was going there possibly to bury my 97 year old father. He was declining rapidly, experiencing profound hallucinations, severe confusion, and disorientation. It began with a fall that led a doctor to prescribe Tramadol. I reviewed this drug's side-effects and discovered it can produce hallucinations and confusion. When I presented this information to his prescribing doctor, the Tramadol was discontinued immediately and my father was back to himself within a day. The medication, which I also initially endorsed for his pain, could have led to his death, something that happens far too often in our country. This weekend we are celebrating my parents' 70th wedding anniversary; I am glad and joyful that they can both be there!
During most of these past 40 years, I have lived in therapeutic communities, in close day-to-day contact with people who have severe mental illness. I have seen psychiatric medication save lives and I have seen it harm lives.
Often I have helped orchestrate life-saving medication for people suffering from the dangerous hallucinations of psychosis. But other times, I have helped to create supportive conditions within which our psychiatrists could help people do much better by coming off what had been excessive cocktails of over prescribed medication.
I have so many memories both of people harmed by meds and of people saved by them.
Cynthia was a rising executive in a stressful situation when she was misdiagnosed with thought disorder and overmedicated with more than one antipsychotic. She improved when gradually weaned off meds and is back at work.
Jane had 50 prior hospitalizations for schizophrenia, most precipitated by her erratic excessive or inadequate use of medication. She came in a fog on a boatload of medications. Now hospital-free and independent, she has learned to stay faithfully on a low dosage of Clozaril that controls her symptoms without causing problematic side effects. Jane now has a full life, is an artist, works in a retail store, and has her own condo. Her recovery would not have been possible were she on too much or too little medication.
The path can be very hard at times. Aaron came to us riding the waves of psychosis, often erratically stopping his medications. His psychosis is persistent and it is clear that he needs an antipsychotic, but he persistently refused to take one. We continued holding on to him, caring for him, even though twice in the last five months, he had to be involuntarily hospitalized. We kept welcoming him back and, finally, finally, he has seen the necessity of selectively using a moderate level of medication. I think he will go the distance and has begun a new and perhaps his best year in a long, long time.
This coming Tuesday, we are getting another young man back. He initially came to us from a very poorly run hospital, where his medications were ineptly handled. He was so psychotic that we could not safely include him into our community. With his agreement we arranged for transport to a better hospital that treats its patients more respectfully and collaboratively. I visited him a few days ago in the hospital and found him to be present, centered, more understanding of his medications and ready for recovery. Wonderful!
Just two nights ago, I visited a potential applicant in her parents' home in NYC. Floridly psychotic, she was clearly unable to care for herself and her parents were also exhausted. With the careful help of a special mental health attorney in NYC we got her into a trusted hospital. Through the cloud of her delusions and hallucinations I could see a young woman with a spark of hope, hope that she might reclaim her life. She's at the beginning of the journey. I hope that she, too, can benefit from the selective use of medications, therapy, and social support.
It's not black-and-white...We need to find a common sense middle ground between opposing wholesale beliefs that psychiatric medicine is all good or all bad. We need to focus instead on the benefits of more selective, moderate and minimal use of medications.
How do we achieve this selective use model? Our current medical culture has set a high value on "evidence-based medicine," that is, on treatments that have been shown to produce overall improvement in large groups of subjects in research studies. Unfortunately, research studies cannot capture the individual differences among people that are critical in mental health recovery.
Whether or not medications are supportive for a particular individual's recovery is best decided by shared collaboration in an ongoing and trusting relationship between a person seeking recovery and well-trained clinicians, with openness on both sides to the observations of loving friends and family and a careful consideration of what has worked and what has not in the past.
There is no one size fits all. And it often takes time and patience to discover what will work best for any given person."
Thanks so much, Virgil, for sharing your wisdom and rich experiences.
Proper treatment must always be selective and customized to each individuals particular needs. It is equally important to fight both the overuse and the underuse of meds. Indeed, no one size fits all and meds that are essential for the few are harmful when overused for the many.
People who have short-term, stress induced psychiatric problems, even if they are severe, often do well with short-term medication, and sometimes with no medication ar all if intense support is available. Too much medication for too long will likely do them more harm than good.
People with long term, severe psychiatric problems usually require long term medication, along with social support, decent housing, vocational rehabilitation, and psychotherapy. Too little or too much medication and the lack of psychosocial support will risk deterioration, prison, and homelessness.
The biggest puzzle is what's best for those who once had persistent, severe problems that have responded well to medication over a substantial period of time, but who would now like to come off the medication.
There are risks on both sides. Staying on meds can cause serious complications, particularly if the person gains substantial weight on them. But going off meds can be a path back to illness and all of its dire consequences. I have seen hundreds of patients deteriorate badly after stopping meds. And sometimes meds that previously worked wonderfully well in maintaining recovery fail miserably in treating the relapse caused by their trrmination.
I used to be more enthusiastic about the possibility of psychosocial treatment replacing meds, or markedly reducing the doses need, even in the most severely ill. In the mid 1980's, I helped plan and conduct a large study that compared three medication strategies in the continuation phase of treatment for people who had recovered from a psychotic episode : 1) usual dose; 2) one fifth dose, and; 3) placebo. All groups also received intense family support in the community. Some people did fine with less or no meds. But the catastrophes remain unforgettable.
There will never be one right decision on psychiatric medicine that applies to everyone. In the US, there has been far too much acrimony and far too little cooperation among providers, families, and disaffected users- as if there were one right answer. This results in bad treatment and ineffective advocacy for the mentally ill. Mental health care in Europe is in much better shape because no such opposition hinders cooperative efforts in clinical decision making or political advocacy.
Let's hope Virgil has shown us the middle way.
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