The Psychoactive Effects of Psychiatric Medication: The Elephant in the Room

Article The Psychoactive Effects of Psychiatric Medication: The Elep...

Do the benefits of psychiatric drugs outweigh their side effects?

A lot is being said about the pros and cons of psychiatric medication. While some of the apprehension stems from a lack of knowledge of how psychiatric drugs work, concerns are also being raised by users on the side effects that the drugs bring with them. We posed some commonly asked question to Dr Sabina Rao, consultant psychiatrist, Sakra hospital.

What are the most common concerns people have about psychiatric drugs?

People do not want to take psychiatric drugs. Some of the reasons I have heard over the years are- “they will change my brain “or “I will become dependent on them”. Other than thinking that they are going to get ‘hooked’ to psychiatric drugs, people believe that seeing a psychiatrist or taking medications is a sign of weakness. Seeing a psychiatrist or taking medications shows that you’re ‘ill’, or that you are 'crazy'.

Does this stem from the fact that psychiatric medication is often prolonged?

I can only think of antibiotics and pain killers that are short term. Everything else is long term. Psychiatric drugs are no different from any other medication in that context.  The incidence of depression in a World Health organization Survey showed rates of major depressive episode in India to be as high as 36 per cent. Another study showed the annual incidence rate of schizophrenia at three to four persons for every thousand. Rare illnesses such as schizophrenia might need long term medication, whereas common illnesses such as depression and anxiety might not.

So a person with depression/anxiety who takes their medication regularly and also follows through with any recommended therapy/ counselling may need to stay the course for six months, or maybe a year at most, in some cases. If the issue goes away, they don’t necessarily need to take the medications. If you have depression once, you have 50 per cent chance of getting depressed once again but you also do have a 50 per cent chance of not getting depressed again.  So it is possible that if you are on medication for six months to a year and you learn some skills on how to manage your depression. If you do get depreesed again, you might be able to use the skills you have learnt to deal with the depression. One might not need medicine at all.

At what point do psychiatrists usually prescribe medication?

Some patients come in knowing that something is not right and they might need medication in the treatment. Then there are those who walk in blindly and say, “I have been asked to see you, I am not sure why, but I certainly don’t want medicine.” People have to understand that just walking into to see the psychiatrist will not make you better. Even if the doctor recommends only counselling, one or two sessions is not going to cut it. You have to follow through and turn up for the number of prescribed sessions. Cognitive Behavior Therapy (CBT) for example, the way it should be done, is sixteen weeks of therapy, that is four months. And if you just can’t commit to that kind of time, at the very least turn up for half the number of sessions so you can develop some skills to manage your illness.

The doctor decides based on what you tell her/him. If you tell the doctor that, “I am feeling suicidal, I just cannot do this anymore, I am feeling hopeless and worthless and depressed,” I am going to prescribe medicine. This is because the illness will not be defined as "mild”. But if you say, "I am having difficulty at work and feeling overwhelmed and there are no suicidal thoughts," then I may say let’s just do some counselling. When you go into a psychiatrist’s office, go with an open mind. Psychiatric drugs are not addictive and are safe drugs which for the most part can be prescribed even during pregnancy.

But everyone wants a quick fix nowadays.

If a patient comes into my office when they first notice that something is wrong then we can attempt to ‘fix’ things in their time frames. But that rarely happens in India. People have usually progressed to a moderate to severe level of discomfort by the time they walk into a psychiatrist’s office.  If you have been having sleep problems for months, no doctor can fix it in a one or two days.  As in the case of any treatment, psychiatric treatment also requires time.

People have to understand that part of the treatment for common mental disorders is changing how one views and reacts to the stresses in the environment.  Changing your cognition that has been formed over years takes time and some effort from the patient’s side.

What usually is the ratio of medication to counselling?

For someone who has mild symptoms, the treatment can be only counselling. But like I said, by the time folks in India come to a doctor it is moderate to severe. At which point, just by guidelines, one must expect to be prescribed medicines. Of course there are patients who insist on no medicine, they have to be regular with therapy. You can’t make one visit and then go back to the same environment that’s causing you distress in the first place. Start with an intense weekly therapy and then you’ll need it less and less.

What about serious mental disorders?

In cases like bipolar disorder, schizophrenia or even major depression which can sometimes be accompanied by hallucinations, you won’t be doing yourself any favour by refusing medicine. These are serious mental illnesses that can disrupt your life in the way of employment, marriage and other facets of life. As of now, sadly, science has no solution that involves just therapy and no medicine. And in most cases, we can’t even start therapy without stabilizing the patient.

What about the side effects of psychiatric drugs? There is so much fear around this.

In psychiatric drugs for the common mental illnesses, the side effects are mild. Most patients call and say they have nausea, headache, dry mouth or tiredness and so on. These are considered mild side effects. But the benefits from them outweigh the risk of side effects. Also unlike the tricyclic antidepressants that we used to use in the past, the new drugs for common mental illnesses have very mild side effects. There is always an off-chance the one might develop a rare side effect, but that is rare.

But there are complaints of a sense of losing yourself from medicines for serious mental disorders. How does a person make peace with that?

There is a serious need to understand how this works. Let’s say someone has bipolar disorder. Some of them enjoy the mania so much and feel this surge of creativity and medication can numb that. But, the mania can often go to dangerous levels, life threatening levels. They might however want medication for the depression because they feel hopeless. In the rare but serious illnesses, families need to be involved. Families can help the patient make the right decisions. Of course you do feel sluggish and tired and may gain weight from the medicines, but if you don’t treat it, it spirals out of control. Schizophrenia without medicine can be very deteriorating. Yet over a period of time, even in the rare illnesses, one can pick up skills from counseling to deal with some symptoms and reduce or keep the medicine steady.

So being in touch with your mental health expert and monitoring your symptoms is half the job

More than half the job. In common mental disorders, you can even come off the medications in time and in many other cases you can stabilize or lower the dose needed to stay symptom free.

What about alternate therapies?

No doctor can stop a patient from trying out other methods, but they must be aware that alternate medicine can interfere with the medicine prescribed by a psychiatrist. We often don’t know how alternate medications work because there aren’t enough studies and psychiatrists are not experts in alternate methods of treatment. Yoga and meditation can often help you get better but if you pop another pill or powder, I have no idea about how that interacts with allopathic medication.

How do you react to the accusation that psychiatrists are often drug pushing for the lack of time?

I don’t blame people for thinking this way. But here’s how it works in India. The reality is that there aren’t enough psychiatrists, psychologists or psychiatrist social workers when compared to the number of patients. One meets a doctor who has a hundred patients in queue. You have probably turned up at the clinic at a time when your symptoms are moderate to severe, so the doctor has to give you medicine to stabilize things. Ideally you should then spend time with a psychologist, but often we are short of resources. So most doctors are thinking, at least I’ve solved part of the problem.

My thought is, even meeting a doctor for five minutes is support. Give therapy priority, find time in your busy schedule to go for counseling.

Write down what you want to say or ask your doctor and you’ll have a fruitful session. This is also true for an exam with an orthopedician, a dermatologist or any other physician. Doctors have full waiting rooms, and all of us want that to change. We’d like the luxury of spending time with our patients too.

Thanks, Mohamed, for this but such statements from physicians about psychothropic drugs are common, and invariably believed because a physician is the source. My research indicates a considerable gulf between patients' experiences and physicians concepts. From the evidence I have acquired over many years physicians have little genuine understanding of the drugs, that it is not simply the 'side effects' that are a problem but the core effects of the drugs.

Further to your appended Q&A:

1) The drugs are addictive. Why does your interviewee not know that?

2)There is already considerable evidence that like most drugs, cocaine, heroin, alcohol, they change the personality, particularly over time. Why does your interviewee not know that?

3) Most drugs are for physical problems, therefore require long-term medication. Evidence shows that without drugs a number of people make full recoveries.

4)It is well known that anti-depressives are exceptionally addictive. Over a 6 month period taking such drugs, coming off them could be catastrophic for the patient. Why does this 'expert' not know that? In fact, the patient could become even more deeply depressed.

5) I suggest that consulting a psychiatrist means long term involvement with health care, without a cure. Psychiatrists assume a controlling attitude towards patients that has an extremely negative affect on their well-being.

I can answer as both a prescriber and as a patient. Therapeutic psychoactive drugs should be reserved for patients who are faced with disability due to their condition. Severe and persistent psychiatric illnesses can lead to losing jobs, losing spouses, losing custody of one's children and losing one's home. Sometimes and far too often, they can even result in loss of life. In these situations, psychiatric medications when used appropriately and with the patient’s consent, can be lifesaving.

When used appropriately therapeutic psychoactive drugs are rarely addictive, are only used long term for persisting conditions and rarely have negative effects on a patient’s personality. Many of my patients have become well, tapered off their medications and are no longer in need of treatment with medication.

It is a shame a vocal few who feel they have had a negative experience with psychiatry try to poison the minds of individuals who may be in great discomfort and could benefit profoundly from appropriate psychiatric treatment.

Thanks, Robert, I appreciate your views but nevertheless the number of people who have come to me is not a minority. Have you read The Elephant in the Room?

While there is no doubt people gain, the reasons may not be straightforward. The medication appears not to be specific, but general, so its likely an assortment of drugs, many nin-medical, would help. Equally, there are many cases where help is not needed and people recover over time. Medical intervention may in fact stop such processes.

Your views are very helpful, and will go to my research.

I've re-read your piece, Robert, and although this discussion can go on forever it seems to me, with conflicting views, I find your belief in the non-addictive nature of psychiatric drugs astounding, certainly with the mounting evidence.

Isn't it the case that psychiatrists tend to control patients' experience, interpreting, writing down insights in less a scientific but rather anecdotal fashion? Do not psychiatrists surely claim or appear to claim infallibility?

If I'm infallible can I drop my malpractice insurance?

Robert, I respect your views on these matters but if you can read the essay. We both know that in mental health bringing such a suit would prove immensely difficult given the extraordinary weight attached to psychiatrists' opinions. I once set up a solicitor service in Maudesley Hospital, a well known teaching hospital, partly to discuss matters. I also set up a talk shop, inviting staff. Of course, none turned up. Forgive me, but I thought at the time their refusal had a great deal to do with having their ideas challenged-talking with patients on an equal basis. God forbid, as it were! Discovering disagreement in the midst of their practice! Ideas changed, even perhaps treatments reviewed.

My apologies for the apparent frivolity, but of course freedom from dogma and preconception will not necessarily help many cases-as you advised. But still I wonder.

I have several acquaintences described as psychotic who are doing well in life. History is full of successful psychotics-but before the advent of medical help.

Recently, the UK authorities have altered Valium's (a major tranquilliser) from low danger status to high-this after 50 years of doctors saying it poses no risk, and people like me saying it does. Now for the others? When do we teach doctor's to be responsible?

I've been teaching that in medical school since 1989.

thanks Robert-great to hear that

Can you tell me your experiences?

I present to you the benefits and risks associated with psychotropic drugs in the attached paper. Best regards

Thanks, Dickson, this will be useful. I have received a number of documents from people on here. Problem is, independent research does not confirm psychiatry's claims. I have been compiling users-of-these-drugs experiences, and they are very different from clinical understanding. Psychiatrists ignore patients' experiences preferring the suspect process of observation. My concern is that the drugs can alter patients' personalities and this in fact is what many complain of.

A few times I''ve heard people claim that 1) SSRIs are responsible for violence and 2) a journalist in the UK claims that all the school killers and mass killers in the USA were on SSRIs. I have posted now of course a few papers on these matters. It is worthwhile reminding ourselves that these drugs are tested on mice and rats and from there its extrapolated that they are beneficial to humans. Now there's a comedy element to some of this-we are not rats, our brains are not like rodent's brains. The experimenters stress out rats and when rats get listless they call that depression-exactly the same as human depression. Now they don''t actually ask the rats, and find out if they are depressed, equally they rarely ask humans either as its done through observation. Humans and rats are equivalent in more ways than one.

Is it possible that doctors have been indoctrinated, especially by drug companies, as many people in general are-believing what doctors tell them? Anyone who is interested/ The Dangers of Psychotropic drugs/on RG /and another paper on Personality Disorder.Psychiatry expanded tenfold on the back of the first, and a hundred fold on the back of the second.

The thinking behind personality disorder is derisible. I have gone through the monoamine hypothesis, the thinking behind the drugs, and personally I cannot see where it is scientific. It remains an hypothesis, but on the back of this people are supplied drugs throughout the Western World, usually on request, and honestly no matter what doctors say, they do not know the effects-they rarely ask.

My clients tell me. And what they say is vastly different to what doctor''s say. After a year on these drugs they begin, because of the effects of the drugs, to believe they are mad and the drugs do seem to send some that way.

But isn't that a confirmation bias. You are outspoken in your skeptism about psychopharmacology so patients who feel they have had a bad experience are going to seek you out. The folks who get better without adverse experiences go back to work and don;t have time for this.

But Robert, what if this point of view is right? What if David Cohen, Joanna Moncrieff, John Quinn, all established and respected researchers, are correct?

How can you possibly affirm that rat brains, without cognition, self-identification, are the same as human brains? What if the science is simply bad? It is not the first time, or only present example, of the medical profession insisting on the efficacy of bad science. My suggestion, Robert, is that psychiatry is driven not by evidence but ideology-which can be detected in its earliest manifestations.