Wednesday, April 23, 2014

No Easy Answers



Today's post is brought to you by Steve Lopez of the LA Times and is located over on Pete Earley's blog.  You can click HERE to read the touching story of Nathanial Ayers, a talented musician who suffers from schizophrenia and does not want to take medication for his condition.  On his third court appearance, a judge appointed a relative as conservator for Mr. Ayers so that medications can be given.  It sounds, from the article, like Mr. Ayers had intolerable side effects to an older anti-psychotic medication and has never been willing to try the newer, atypical anti-psychotics which have more favorable side effect profiles --unless, of course, you're the person having the side effects, in which case the "profile" may not matter.  Please read the article over on Mr. Earley's blog, then come back here to read about my thoughts.

So I'm hoping that the story has a good outcome, and here are a number of things that may happen here.  I go from best possible outcome to worse possible outcome, and feel free to shuffle the order on the shades of gray:

  • Best:  Mr. Ayers takes the medication, it works, his symptoms resolve, he feels better emotionally, and he is able to function better, and he has no side effects and decides he wants to continue it.  This would be the happy ending we all want to hear.
  • Mr. Ayers takes the medication with resolution of his symptoms, improved functioning, and no side effects, and no appearance of metabolic syndrome, but he does not recognize that he is doing better without the medications and wants to go off but the court insists he continue.
  • Not bad: Mr. Ayers takes the medication and it works with resolution of his symptoms and improved functioning, but he has side effects.  He decides the improvement is worth the side effects and chooses to continue taking the medication.
  • Mr. Ayers takes the medications and it works, but he has intolerable side effects and needs to go off it.
  • Mr. Ayers takes the medication and it works, but he has  side effects and the courts make him continue with a medication that makes him feel bad 
  • Mr. Ayers takes the medications and it doesn't work, so he stops taking it.
  • Mr. Ayers takes the medications and it doesn't work, but the court insists he continue taking it.
  • Mr. Ayers takes the medications and it doesn't work, and he has  side effects, and the court insists he continue taking it.
  • Mr. Ayers takes the medications and it doesn't work, and he has intolerable side effects, and the court insists he continue taking them and then has a stoke or heart attack or diabetes which may have been brought on by the metabolic effects of the ineffective, intolerable medication that the court made him take.  
  • The medication works and the patient stops it and has a tragic outcome, either for himself or for others.  
Unfortunately, what makes the scenario even harder, is that the medication may partially work or be  somewhat effective -- so perhaps a given patient is less irritable or combative, which makes it easier to manage him or her -- but still hears distressing voices or experiences intolerable emotions.  We don't know exactly how long to wait, how high a dose to give, or how many medications, alone or in combination, we need to try before we're sure there  is no adequate treatment.  Also, the tolerability of side effects and the acceptibility of risk are things that may be difficult for one person to make for another.  

This is a long way of saying that unless the patient has a positive response that he appreciates, the issue is not a simple one; it can be complex and nuanced in a way that many of the parties may not appreciate.  If our medications worked more reliably, and did not have side effects and pose the risks (risk, not certainty) of decreasing both the quality and quantity of life, then forced medication would not be such a difficult option.  But the issues of limited efficacy and tolerability exist before you even begin to address the civil rights of a person to decide their own care.

I hope we'll hear about the outcome from Mr. Lopez, and I do hope Mr. Ayers has a good response and decides, on his own, that he'd like to continue the medication.  And if it doesn't work, I certainly hope the court does not force him to take an ineffective agent that he does not want.  In our "meds are good" society, it's not that unusual for people to be on medications long after we've lost track of what it was we trying to target with them.
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On a different note, I spent my day with a police officer today who does crisis intervention.  As we stated the day, he received an email from a patient he had petitioned to the hospital 2 years ago, thanking him for forcing her to get care and for saving her life.  It was my feel-good story for the day.