Monday, October 21, 2013

Meds or Therapy?

It's this funny thing, people talk about the rise in the use of medications like it's a bad thing (and perhaps it is) and the decline of psychotherapy by psychiatrists as also being a bad thing (and perhaps it is).  It's almost like a see-saw, and there is the thought by some that using medicine is a quick-fix, a way of avoiding looking at the more difficult issues that we as humans face in the natural course of human suffering.  It's funny -- as I started by saying -- because it seems like the combination of medications together with psychotherapy  may work best.

Let me address the quick fix thing.  First off, most psych meds take a while to work, they aren't quick fixes.  Second, we've all read that medication helps depression only 30% of the time, or the same rate as placebo, and this  because in clinical psychiatry it often takes a few tries to help someone -- switching medicines, augmenting one medicine with another, or trying some unconventional or creative cocktails. The study looked at a single trial of one medicine versus a sugar pill, not real life psychiatry.  And then we've got that *#$&~ DSM issue which boxes one in, says people have to "meet criteria" as though it's a totally real entity any more than diabetes is (-- see Psych Practice's post on just how scientific the diabetes diagnosis actually is) and there is the implicit criticism that if you take a pill for psychic pain that doesn't 'meet criteria' then it's just WRONG.  Can you imagine if you had a headache and wanted to take an aspirin to stop the pain, but you were told that since there wasn't an anatomical reason for the pain, taking that aspirin makes you a weak pill-popper?     

There are those who feel we should rely more heavily on psychotherapy, as though it's one or the other.  As though we know in advance who therapy will help heal of their mental  illness (we don't), or who therapy will help comfort during a painful journey.  I believe therapy is helpful to many people for many reasons: one is that for some people it provides tremendous insight and relief, though the two are not necessarily connected.  Another, is that by scheduling patient for hour-long sessions, it's so much easier to evaluate and understand them, to know the quirks of their personality and the patterns of their distress in relation to the nuances of their lives, and not just as a checklist of symptoms and side effects taken as independent variables apart from their environment and their perceptions of that environment.  You help them see their patterns, whether it's how they relate to authority figures or how they always feel worse (or better!)  when they stop their medicines.  Finally, when you're on a journey that may be long and painful, it's so nice to feel heard and cared about and like you're a human being whose emotions are important, and not like a person at the deli counter-- #16 today, "I'll have a script for Zoloft  please."    But as a cure, therapy doesn't always work, and we don't have a prescription for how long and how much therapy one needs, or of what type, before we can tell if a trial is adequate.  For medications, there are often some guidelines with regard to dose and time; for therapy there is not.  If you come for treatment of depression, how much therapy is enough to say we've given it a fair chance before adding medications?  Twice a week, 50 minute sessions, for two months or two years?  And what if the patient can't afford the cost of that and wants to try the $4 generic from Wal-Mart?  

So that you know where I stand: if it helps, go for it.  Meds (if the benefit outweighs the risk-- and yes that's important: sometimes the benefit does not outweigh the risk), therapy, light boxes, exercise, ECT, TMS, DBS, acupuncture, yoga, chocolate... I'm all for the reduction of discomfort for those who are seeking it, and I'm all for letting people heal as they will without the judgement of others telling them how to do it right. 

Hmm, I'm not sure what got into me today....


PsychPractice said...

Whatever got into you today, I'm glad it did. Nice post. And I agree-whatever works.

Tyke Chick said...

Ditto from me Dinah - with a rider though! - i.e. provided that the person (whether it be the clinician speaking with the person making the decision about their path, or the person themselves) has sufficient information to make an informed decision (it doesn't have to be the one as a clinician that I agree with, just that they make it based on good information - everyone is allowed to make "bad" decisions!). I know that's a whole other debate but for me it's an important point that I see done badly every day. I should probably clarify at this point that I'm a pharmacist working in an inpatient forensic setting and that I'm talking about meds that other people are prescribing here. We're getting better at helping folks make informed decisions about meds, and their potential place in someone's journey, but we still don't always think holistically about non-medication strategies that are meaningful to that person. And there are lots of pharmacists out there that don't actually help the issue because they can't see past the guidelines to the person that's going to be taking the meds. OK, rant over - there are lots of good staff/clinicians/etc. out there doing their best for the folks they're working with, often in hideous circumstances, and we've come a long way since cold baths and spinning chairs - but what I would love to happen is for people to show the same shock about what we do now in 50 years' time as we do now about our past - because for me that will mean that we're moving forward to getting things right more than we are now. Just to reiterate though - great post Dinah!

Anonymous said...


With all due respect, in my opinion, you're missing the point about meds. If someone takes an aspirin for a headache that may have underlying causes, it is not going to do some much good. It is not a moral issue of taking something for a quick fix.

If a primary care doctor or psychiatrist prescribes an antidepressant for someone who has symptoms that are screaming sleep apnea, again that is not going to do the person any good.

The problem in medicine generally is it has become a one size fits all type of deal. If someone exhibits certain symptoms, like depression/anxiety, an antidepressant is prescribed even though that can be due to many conditions. Many medical professionals aren't willing to take the time to tease out relevant information.

And just so you know I am not picking on meds, I will also mention CBT as that seems to also be a solution to everything even when there may be underlying causes contributing to a person's situation.


jesse said...

A most excellent post, Dinah, and to AA, I think your points here are right on and thoughtfully made. Just now on the PBS Newshour was a piece on how overuse of antibiotics are leading to dangerous resistant strains of bacteria.

What I might add is that we look for indications for use of psychotherapy, which can at one pole be supportive and at the other responsive to indications that the type of problem the patient brings to the session is particularly related to intrapsychic conficts (for example) or else caused by psychological factors. It is in these situations in particular that use of medication is only partially successful at best. Nothing is more important than a careful evaluation by someone able to make the requisite determinations.

Anonymous said...

Yeah, meds vs no meds, therapy vs no therapy are very individual decisions. We don't all want the same things, and we don't all want to accept the same risks. This is why I find AOT so scary. I don't want someone else ever deciding that I have to accept the risks of depot injections. Other people are cool with it, and that's fine for them. It's not fine for me.

I take psych meds, but I'm always weighing the risks vs benefits. I would never begin to tell someone else what they should or should not risk. That's their own business.


Joel Hassman, MD said...

Therapy first, unless the patient is profoundly dysfunctional with psychosis, impairing depression or mania or anxiety, suicidal (homicidal is difficult to label as purely a psychiatric intervention first in my opinion, especially these days), overt ADD, and other certain exceptions I won't waste further space labeling.

What, you expected me to say something different? But, do people really want to problem solve and get it right? Time, money, and energy, it has to be spent.

Good post by you to provoke contemplation. What would Freud say?

Anonymous said...

Freud would probably try to find meds, as he supported physical treatments and wish he discovered a helpful one instead of settling for psychoanalysis

AliceA said...

Do you really know the long term risks?

Are you sure?

If you knew your patient would lose 25 years of life, but feel temporarily better, immediately, would you say,

"Go for it"?

Would you engage in real informed consent before hand and tell them it might cost them 25 years of life to feel better this month?

AliceA said...

Antonymous, Freud was snorting cocaine and feeling no pain when he came up with his "best" ideas. He also labeled the person who identified as being sexually abused as "hysterical" and then came up with a whole theory of sexual repression as the root cause of "illness".

The Emperor Has No Clothes.

Dinah said...

I don't believe that Freud would have any objection to using medications (but obviously, I can't ask him).

Joel: How long? How many sessions before you'd allow a patient to try a medication?

AliceA: We know that patients with chronic psychiatric disorders have, on the average, shorter life spans. We don't know how much longer and estimates have varied from 7 years to 25 years. We don't know why and there are many theories: Increased suicide rates, lower socioeconomic status, increased smoking rates, poorer attention to diet/exercise and lifestyle issues, the much higher rates of drug/alcohol dependence associated with mental illness, some direct unknown genetic link (for example we see higher rates of depression with Crohn's disease, Parkinson's Disease, pancreatic cancer, and Huntington's Disease than with other chronic disorders. And of course, there is the concern that medications, especially those that cause weight gain and the metabolic syndrome, certainly contribute to morbidity and likely to mortality.

Still, patients who are suffering want to feel better now. We do tell our patients there are risks, we monitor lab work, and the choice in the outpatient setting is ultimately theirs (patients come in and say they've stopped their meds all the time). We don't know with any given individual that medications will shorten their lives: I've treated people in their 70's/80's/ and 90's who've been on medications for decades. We do know that suicide shortens peoples' lives, that living on the street psychotic is extremely dangerous and leaves a patient vulnerable to being the victim of violent crimes/homicide, and that suffering sucks.

It's not just psych meds -- Vioxx gave people heart attacks, thalidomide called babies to have deformed limbs, and I could go on. There is also evidence that SSRI's decrease cardiac deaths in 3 year follow-ups.

In short, the picture is complicated and we don't have the answers but to tell people what we do and don't know. And if your doctor doesn't give you a comprehensive list, listen to any commercial. Why would anyone take Cialis? In the middle of sex you get to have a 10 hour erection, and die of a heart attack while constipated.

Joel Hassman, MD said...

"How long, how many sessions until meds would be offered" I am asked?

It is an individual specific determination. As I said in my first comment at this thread, some presentations would suggest meds ASAP, per the level of profound and pervasive dysfunction from psychiatric disorders. But, if you are looking for some baseline number with an average population I have seen in private practice, I would say about 3-5 visits to get to know the patient and to get collateral history as relevant. In CMHC, I would probably go with the same number, but, how often are we being pressed to treat poverty and other overt sociological problems that meds only band aid?

If psychiatry really wants to maximize PR damage control after these past 2 decades of meds first and nowadays only attitude, it comes down to maintaining a responsible evaluation process that does not sell quick fix mentalities.

And let's be honest Dinah, more than not our colleagues won't agree to this. Frankly, I have become a glorified janitor in many of my travels these past 4 years in various settings. "Clean up the mess, and shut up, we aren't interested in hearing your opinion or treatment plan ideas."

Tell me I am wrong.