(Revised, June 15, 2006)
There have been several generations of different medications that have come into use in the last fifty years, and these have revolutionized the care of the mentally ill as much as antibiotics have revolutionized the treatment of infections. Prior to this time, people with major mental illnesses constituted the largest segment of patients in hospitals! Their care was largely "custodial," which meant that other than offering the basics of food and housing, little else was done. Actually, there were hundreds of pilot programs that sought to offer a bit more, from dance therapy to psychodrama, from lectures and classes to work therapy programs. But nothing really caught on in a widespread fashion until psychiatrists were able to offer the benefits of the new medications.
There were even a few psychoanalysts who claimed to be able to treat patients with psychotic disorders, including noted figures such as Harry Stack Sullivan and Frieda Fromm-Reichman. However, there is little actual evidence that this approach was effective. Nor is there much to support the work of the radical psychiatry approaches in the late 1960s, inspired in part by R. D. Laing. The major mental illnesses vary in intensity as part of their course, and phases of improvement might be attributed to the therapy offered. But for every case study that suggested improvement, there were scores in which strenuous efforts were not ultimately effective.
While the medications offered a much higher rate of improvement, and often dramatic improvements, the first two generations of medicines often were accompanied by side effects that worsened over time. However, each "generation" of newer medicines sought to offer the benefits of the previous medicines with fewer associated problems, and in fact, good progress has continued to be made. Therefore, starting around the 1970s, medicines began to be used far more widely for many more types of conditions– especially for manic-depressive disorder, major depressions, etc.. Whereas the main use of medicine prior to this was for schizophrenia or manic-depressive illness (now called "bipolar disorder"), the latest generation of medicines are now used more for depression, obsessive compulsive disorder, social phobia, etc.
Fifteen years ago or so, I taught the main points in this paper to psychiatry residents in training, but these ideas are also worth being known by patients and family members who may thereby become more informed, the better to make use of their time with their consulting psychiatrist. This paper won't begin to address the specifics of the different medicines, which seem to change maybe 5% per year–new ones coming into fashion, old ones being used by fewer and fewer professionals until they are dropped by their manufacturers. Rather, the following ideas relate to the psychological and social aspects of using medicine.
Empowering the PatientMost patients are somewhat intimidated by physicians. Some are confused by the problems that got them into the doctor's office, or unclear why they were referred by other helping professionals–other doctors, nurses, counselors, teachers, ministers–and even friends and family.
I encourage a breaking away from the fashion of the one-to-one session. Sometimes that's all a patient will accept. But often they'll be more willing, and perhaps even grateful, to know the doctor is willing to see them along with a relative or friend. This is good not only for helping with diagnosis (see another paper on this website about diagnosis), but also for really understanding the use of medicines.
Many people are more unclear and confused by what may to the professional to be simple instructions or explanations. First, the patients and their families are often pretty anxious, and this is also mixed with shame. (Let's not ever overlook the sense of shame and social stigma associated with any problem even partially labeled "mental.") Shame and anxiety make it hard to remember what has been said.
So the psychiatrist or physician needs to take some extra time making sure the patient feels comfortable and even empowered to ask questions and correct the doctor if a misunderstanding occurs. If a spouse, parent, adult child, or friend is acceptable to the patient, often they can help take notes. I've been known to invite patients to bring tape recorders into the session and to replay the tapes to remember what was said! This way when the patients forget, the friends or relatives can remind them. Also, the presence of a friend acts as a support. I sometimes make this support explicit by suggesting that they discuss what I presented to them either in the office our outside in the waiting area while I write up some notes; then I have them join me again after a few minutes and they have some questions that eluded them in the course of the initial presentation.
Seek the Family's SupportNot only having a "mental problem" has a stigma, but it is compounded if any suggestion of medication is introduced. This means to many people that the patient is weak, and taking medication would be a "crutch." (Oddly enough, there's no stigma to using a crutch for a broken leg.) But actually, what is meant is that the medicines are a substitute for self-help efforts. (There was a germ of truth here--which will be discussed in another paper–but it addresses the use of simple sedatives in the 1960s before the feminist movement!)
Because of these and similar issues, it's common that any suggestion that the patient take medicines is often undercut by a relative (usually not present) who thinks that medicines are bad for you, that "you don't really need it," etc. So it's important to get these folks' support, or at least to seek the support of other family members who will answer the naysayers. So, in summary, developing an alliance with the family may be one of the most valuable elements in a comprehensive treatment program.
An Ongoing RelationshipOne of the more important components in the "art" of using medicines in treatment is the openness of communications regarding side effects and the needs for fine-tuning the adjustments in dosage. Too often people are given medicines and expected to take them obediently, in spite of worries, side effects, etc. The doctor should offer and the patient demand the option of making a couple calls a week to clarify these issues and get reassurance and permission to go a little lower or higher without having to make an appointment and come in and be seen every few days. Indeed, sometimes it's difficult to come in even weekly–not just a matter of the modern insurance company demanding major justification for this frequency of visits (See my paper about the need for patients to become more politically active), but also that nowadays visits require taking off from work, and such absences are often difficult to arrange!
(In the past, doctors felt that their own working hours were more important than the working hours of their patients–but I wonder how true this really is.) In addition, doctors and associated professionals should become more aware of the sheer inconvenience of having to travel to and from the doctor's, pay for parking, wait in the reception room--all to be seen briefly and getting told something which could have been resolved in five minutes or less on the phone. Patients appreciate this.
The Costs of MedicationEven if the insurance company pays for the medicines (except for a nominal co-pay)– which is only for some types of insurance coverage–there's still a challenge of becoming increasingly cost-conscious. Some medicines have become very expensive –well, I was going to say "obscenely" expensive–and maybe that's true, too.
(Some of the newer medicines have a lower risk of side effects, so the pressure to use them arises also from the liability incurred by using anything less than the most modern and relatively risk-free, even though some of these drugs are very costly! It's a bit of a dilemma.)
The point here is for you as physician or as counselor who refers a patient to a doctor to work in collaboration giving medicines, or for you as a patient or family member of a patient: talk about the cost openly and before the prescription is written.
Some little tricks here: Call the pharmacy and inquire–do comparison shopping. The difference may be over $30/month! Ask if the medicine being considered can come in batches pre-packaged at the pharmacy with an associated price break. In the past this was a hundred tablets.
On the other hand, when just starting out, consider the possibility of having a smaller number prescribed–to make sure there is no allergy, or that the side effects aren't problematical. That way if there's a need to shift over to another medicine, there aren't two or three weeks' worth of unused medicines left–often involving a considerable expense.
Another way to save patients money is to use larger dosage tablets and have them cut in half by a pill cutter. Most pharmacies have them, they look like a little stapler, and they cost about three dollars or so. For example, let's say you want a patient to take a 50mg tablet of a given drug, "X." It turns out a hundred of the 50mg tablets cost fifty dollars. However, fifty of the 100mg drug X tablets cost thirty-six dollars. In that case you would save patients a significant amount of money by ordering the larger size tablets and having them break them in half. Of course this doesn't work with every medicine, but you'll be surprised how often it does work.
Regarding DosageA significant number of patients have initial reactions to medications which might be ameliorated had they begun at a lower dose, and also most patients like the idea of starting at the lowest dose and gradually increasing. Depending on the condition, consider the benefits of this strategy vs the possible disadvantage of time spent reaching therapeutic levels. A number of textbooks don't always note these lower dosages! For example, the medication imipramine comes in both 10mg and 25mg doses, and in some cases the lower doses are often sufficient. Certainly the dose can be more finely adjusted using the smaller tablets.
Another example is methylphenidate (Ritalin), used more commonly in child psychiatry. Using the pill-cutter, this medicine can be initiated at 2 1/2 mgs per dose instead at the 5mg tablet levels, and again there are children or young adults for whom this is sufficient. These lower doses are those which should be used initially.
Now, there are some conditions in which the problem is acute enough that larger doses are used to get a more rapid sedating effect, and then lower doses are used. However, in most situations, such as in milder forms of depression, it may be more important to have the effect delayed a week or two than to have the patient suffer through excessive side effects because his or her body wasn't able to "get used to" the medication that rapidly.
Adjusting the Dose or Timing of MedicinesSome patients are clearly stable on their medicine. However, there are often opportunities to make constructive changes.
Some patients are maintained at a level of medication that just gets rid of their symptoms, and compared to what they were suffering from at the outset, the answer to "How are you today?" may be "Okay, I guess." The point is that some people might be able to move ahead to feeling much better if the dosage was raised.
The trick is that people can be "titrated," which means that they can be tried on a little more, and then a little more, each week, until they get as good as they can or that they start getting some uncomfortable side effects–at that point, one backs off to one dosage level less. (It's like adding a little sugar to a recipe, and tasting, a little more, just a little at a time, until the taste is just right. And the sugar or syrup is added to the edge, so the whole batch doesn't become over-sweetened.)
Of course, it's good to double check– has this medicine been used before? Have higher doses been tried? Were there reasons why they didn't work then but might work now? (Perhaps there were unusual stresses that hadn't been dealt with previously.)
Consider the opposite category. Perhaps the patient is taking more than needed for optimal results? Could a trial of a slightly lower dose be proposed? Sometimes people get put on a dose that helped, but once they're stabilized, they really don't need as much as they did initially. It's not a matter of just suddenly stopping, or even of cutting the dosage, say, in half. Often the dose can be reduced by about 10-20%–that's usually safe. If it turns out that symptoms come back, the dose can be increased again fairly easily. For most chronic psychiatric conditions, there is time for leisurely trials of a few weeks on a higher or lower dose or some other way of taking them-- more in the morning or at bedtime, perhaps.
Patients and family are often appreciative of this option. In cases where there is resistance to such a trial, the problem may lie in the family's being reassured that they can call and re-adjust the dosage upward at any time.
On the other hand, family members may, if asked, report that decreases in medication in the past led to a relapse. Inquire carefully whether the decreases were gradual or drastic. (That cutting by a half may have happened, and that's too sudden.) So make sure there's good communication about adjustments either upwards or downwards in dosage in the past.
There should also be some instruction about recognizing that the type of medicine may need to be changed. Some people respond much better to medicine B than to medicine A, and others do better vice versa, or perhaps with medicine C. Or the response may be equal, but one of the medicines is associated with a particularly unacceptable side effect. Issues of timing of medicine, frequency of doses, cost, convenience, and many other factors become important topics for discussion. Doctors should help their patients discuss the details of medication.
For patients out there who are being prescribed medicines: If you're not happy with how the medicines work or have doubts about the usefulness of this treatment approache, please speak up! Do not do as so many people do–just say yes to the doctor and then throw the drugs away, or flush them down the toilet. It's better to disagree with the doctor. If he or she doesn't seem to have the time to talk about the issues, first, re-state your claim that you really need the time to discuss these issues! If that doesn't work, demand a referral to a different doctor!
Summary.It's not just knowing about the medicines that makes for the "art of medicine." The art consists of coordinating this knowledge with a capacity to engage the patient, include family members, explain fully, answer questions, be available for adjustments, explain again, answer more questions, consider economics and other inconveniences of dealing with the taking of medication, and weaving all this together with a continual openness of communications. Patients and their families and friends need to participate in asking for–demanding, even–this openness. It requires the courage to be frank, to admit what's going on, and to be patient in working out mis-communications. If both sides work at it, the result is a far greater chance of a positive outcome!
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