Monday, September 26, 2011

The Psychotropic Media Wars


 Just in case you haven't had enough of people ranting about the efficacy (or not) of psychotopic medications in the popular media, I thought I'd refer you over to an article by Dr. Harold Koplewicz on The Huffington Post.  Here's a quote:


Good studies for psychiatric treatments are desperately needed. In the meantime, we have patients, in our case children and adolescents, who desperately need help. These children may be out of control, overwhelmed by anxiety, dangerously aggressive, disorganized in their communication, floundering in school. We need to help them. Medications, often along with behavioral therapy, can have a transformative effect. If they don't help, we are not forced to continue using them. We would like to see objective research catch up with the clinical realities but can't wait until that happens. Furthermore, falling back on pure non-pharmacological treatment is not the better alternative, since these treatments have rarely undergone objective evaluation.

As to the issue of psychoactive drugs actually harming patients by altering their brain chemistry over the long term, which Angell posits, here too data is lacking. It makes no sense to forego present benefit because of undemonstrated future harms. We try to weigh the risks of psychoactive drug treatment against the risks of forgoing treatment. That risk often includes academic failure, dropping out of school, substance abuse and even suicide. Unfortunately, the risks of avoiding demonstrated useful treatments are not something critics, like Angell, consider.

20 comments:

jesse said...

Sounds pretty reasonable to me.

Jane said...

He makes a good point about weighing the risks and benefits of treatment. Medication should be the last resort and not necessarily the answer...but how does your average psychiatrist weigh the risks and benefits of powerful meds? A lot of them only see patients for a 30 minute initial visit and then 10 minute med checks. How can a doctor reasonably decide in 30 minutes what the problem is and whether meds are the way to go? Of course I also hear of other doctors who interview patients for an hour or two, have their patients go see a psychologist for testing, etc...But those doctors are not exactly the norm. In a field of medicine where some doctors are prescribing after 30 minutes and others need hours to make a decision (plus the use of outside opinion), how does anyone know when the risks and benefits have been appropriately weighed? Where are the standards? Why do some doctors not feel comfortable diagnosing ANYONE in 30 minutes, and for others it is the gold standard.

Dinah said...

Why should medication be the "last resort?" Particularly in a population of voluntary patients who generally arrive requesting medication. Shouldn't the patient have some input?

jesse said...

The key in this is that the physician needs to be careful, thoughtful, and hopefully wise. Unfortunately there is no way to legislate this. There is no substitute for good training programs and minimal influences of corruption.

Jane said...

@Dinah: ...hmmm...I think it is on adult patients to seek out treatment and consent or not consent. But as to whether the meds actually get prescribed...well that's on the doctor. I did see a psychiatrist once who said on the first visit, "I don't want to prescribe you anything if I don't think you need it." And I don't think that's an attitude that should be held to just psychiatry. Like before someone gets gastric bypass I think they should try diet and exercise first or look at other less drastic measures. And I can remember feeling troubled at the number of people at my old college who were on ADHD medicine prescribed "as needed." And my god was it easy to get that prescription when it was time for exams. I actually did ask a friend how it's done and he told me you just go in, tell the doc some symptoms, and there is your prescription for adderall! And I remember thinking...maybe some of these people should try a study skills class or learn more about time management. Heck, I've met real ADHD people on stimulants every day, who can't concentrate more than 15 minutes on anything without it, who think these exam cram people are putting themselves at risk for heart attack.

Maybe to give a more controversial example, what about doctors who set up shop right across from college campuses and prescribe weed for headaches? This would not have bothered me so much until I lived in an area where everyone and their mother in law smoked weed. And I have learned that you CAN get addicted to weed. I didn't think that was possible, but I have met 19 year old college sophomores prescribed weed for PMS or Depression and they end up smoking morning and night and I really think it lowers the quality of their lives. If I were a doctor...I think I would feel really guilty about prescribing all these meds to college kids and letting them put themselves at risk like that. But that's just me and why I would like higher standards to get prescriptions for psychiatric disorders.

BTW, if you smoke weed and don't abuse it, more power to you! Everything in moderation. And I have no problem with doctors who prescribe weed...it's just that I think opening a practice across from a college campus and then erecting a HUGE ad on your front window saying that you will prescribe weed for PMS, migraines, Depression, etc is kinda shady.

Anonymous said...

Why should medication be the last resort? Dinah, aren't they meant to be used when nothing else helps? If something else helps why put a chemical into your body? Yes i know that there chemicals in the water, too.When my kids were little and had those growing pains that seem to come on at 2 am, I waited to see if a little massage would help. if the kid fell asleep, no Tylenol. if the pain persisted, Tylenol,and then we could both go back to sleep. All the kids getting antibiotics for ear infections that would clear on their own helped cause the antibiotic resistance problem that we have now.
With all the black box warnings on so many drugs, why on earth, of course they should be a last resort. Doesn't mean they should never be used.
It is also kind of funny that when things get quieter you post something that will likely stir things up.

Dinah said...

Jane,
I believe the issues with addictive medications and the issues you are discussing are a bit different. I'm not a fan of medical marijuana, it makes a farce of medicine.

Anonymous said...

I don't think medicines are meant to be used only when nothing else helps. Sometimes they help more quickly than therapy, for instance, and can then help a patient make gains in therapy.

jesse said...

Anon, the issue is not "last resort" but appropriate to treat the condition. If you develop pneumonia and it is treatable with an antibiotic do you say "no, just as a last resort?" That is why experience and integrity on the part of the physician is important. It comes down to whom you wish to be making those kind of decisions.

Dinah said...

It does seem that I enjoy stirring everyone up! I just don't like when people offend each other....but energized, engaged, interested-- yes.

Jesse is right--- appropriate treatment. "Last resort" is a funny idea in psychiatry because traditionally we have offered treatments that take time-- oh, like 5 days a week psychoanalysis for years at a time and therapy takes time, sometimes lots of it. While anti-depressants can help someone feel much better in a couple of weeks. By the time someone walks in a psychiatrist's door, they've often been suffering for a while and feel ready for last resort type stuff. But it's not just an issue of what's been tried or not, it's a matter of how badly a patient feels and how impaired/disabled he is. Often, medications move a person to a place where they are able to then do other work, whether it's therapy, or getting enough energy to exercise and cook decent meals.

Jane said...

Ahhh, Dinah, you gotta go easy on your colleagues who are prescribing weed. I think some of these people are ultra shady, but I have heard it works wonders for Bipolar disorder. The first person I ever met who smoked weed with a prescription had it to manage Bipolar. Later on I met a counselor who told me about it's effectiveness in managing racing thoughts in people she had met with Bipolar. So it's not all a farce! Some of these patients really do feel helped...There just needs to be high standards so people aren't just smoking weed cuz they wanna get high all the time.

rob lindeman said...

"If they don't help, we are not forced to continue using them."

Who is "we"? This choice of words is revealing. We the prescribers, are not forced to do anything. The prescrib-ee, sadly, if not forced by law, is often coerced by reason of distress, or lied to regarding the safety and efficacy of the drug.

wv = creac; what my elbows and knees say when I sit down (usually accompanied by "OY!")

Sunny CA said...

I am not a personal fan of psych meds, because I did not like their effect on me, but I have friends who have been helped by various psych meds, and taking meds is their first choice, not last resort. Having taken psychotropic meds myself, I know that they do work. However, I did not enjoy life without experiencing feelings, which was my experience on psychotropics. For many I am sure that would be a relief and ought not be denied those who want that (or maybe some people do still have feelings while on them).

Anonymous said...

@SunnyCA: The subjective experience of taking psych meds is, well, individual, as you well know, but I find it especially odd that you might think that people who choose to stay on them are doing so *because* the meds "take away their feelings". It's a little like saying Prozac made me really itchy, but I guess the people who take it like/don't mind being really itchy.

Dinah said...

anon: I don't think she said that, it was just a hypothetical speculation and one might understand why someone could opt for the absence of feeling if the only feelings in the space were those of being tormented.

SunnyCA does point out that the patient has the freedom to choose: she tried the meds, decided the bad outweighed the good, and stopped.

Liz said...

thank you for this cogent article. it's a complicated but extremely important issue that needs ongoing discussion.

http://pocketshrink.blogspot.com

Anonymous said...

Of course we do not wait to see if pneumonia kills a patient before prescribing medication. of course it makes sense to try meds rather than wait for therapy to start helping a severely depressed patient. The way the question was posed made it seem to me as though meds should be given because voluntary adult patients, knowing what they want, request them. Still, it seems that doctors prescribe very quickly, or at least that has been my experience.

Anonymous said...

As a patient with bipolar disorder who has been taking various medications for 17 years and have experienced some serious side effects including: drastic changes in my menstrual cycle (heavy, two-week long periods), weight gain, high blood pressure, and psoriasis, I definitely think that more research needs to be done in the area of psychiatric medications. Just because a medication is sedating doesn't mean it's effective.

Anonymous said...

OMG, last anon. I have been thinking that the real reason my psych meds for bp work is because they sedate the H out of me. So, they kill mania and even if I do get depressed, I am way too tired, unmotivated to get up and carry through my plans to end my travails on this planet. So do for me, it is not that they work to make me feel "well" and then you add in the w gain and other side effects. I stopped all except the anxiolytics because I am addicted to those. Do I feel better? N'really but those drugs are not the answer for me and I cannot take Li for other reasons.

Sideways Shrink said...

Over my brief ten years in practice, I have seen primary care/internists get looser and looser with how high and for how long they will let a patient try to control their "borderline" blood pressure (the definition of which has gotten higher) with weight loss and exercise with no results. Then finally that doctor gets to make their best guess about which potentially effective, potentially side effect causing medication to try the patient on--a patient who does not want that medication. Who wants damn medication anyways?
Patient choice and patient lifestyle changes they can choose instead of medication and the move away from paternalism that this embodies is a double edged sword: we patients get to choose our treatments while insurance companies no longer pay our practitioners for E&M codes (the education and management billing codes) which pay for the time it takes our doctors to educate us about our conditions and the treatments they are giving us.
What is that Kris Kristoferson song that Janis Joplin sang better? (I am young, but went to a hippy college....) "Freedom's just another word for nothing left to lose?" Who needs or trusts specialists, experts, or the highly trained in any field? D-I-Y reigns when their is no continuity of care and health care costs so much that providers and patients have become pitted against each other instead of against the money sucking leach in the system: insurance companies..