After talking for awhile about big pharma corruption, the distortion of research and academic psychiatry, and the overselling of psychiatric medications a bright social work intern who has been on our team for about six months pointedly asked me, “So, do you enjoy helping people by prescribing medications or by helping them in other ways?” I had to pause for a moment to think about it. “I don’t enjoy prescribing as much as I used to.” When I first started working as a psychiatrist out of residency, I took great pride in my ability to help people with medications. I could get the symptoms of more than 90% of people in the hospital well under control by the time they left. I even kept track. In the clinic if my patients didn’t use drugs and more or less complied with meds, I could get more than 80% of them much better. It felt like I was doing battle with illnesses and winning. That was enjoyable. But over the years, I see far more that needs help than just symptom relief and I feel far less like an all-powerful warrior.
I started wondering what it would’ve been like to have been a psychiatrist in the 1960’s when psychiatric medications first began being used in hospitals. Would it have seemed like magic to them? Or like “Awakening”? I suspect they weren’t dazzled by medication’s ability to calm people down and make them less acutely dangerous. After all they had lots of other ways of doing that already – barbiturates and other sedatives, seclusion and restraints, wrapping in wet sheets, ice and hot baths, ECT, lobotomies – although over time antipsychotic meds have basically replaced almost all those other things so they’re probably significantly better. Also hospitalizations were much longer then so I doubt that most people were acutely agitated and dangerous a lot. I suspect that the ward wasn’t as much of a battle zone as it is today. (If you want a view of inpatient psychoanalytically based treatment of psychosis from that era read the wonderful first person account “I Never Promised You a Rose Garden”). It’s only in today’s world that hospitals are only paid to reduce acute agitation and dangerousness by Medicaid and people are released after only a few days, usually with nothing else accomplished. Today’s acute hospitals have grown to value meds for their acute sedative properties, especially at very high dosages. (BTW – if you want hospitals to do something more humane than sedate and release in a few days, pressure Medicaid to pay for something else. All of my local private hospitals that accepted Medicaid and were more humane are now broke and closed.)
I’d bet that what really impressed those inpatient psychiatrists 50 years ago was that with meds they could communicate with and have a relationship with people they couldn’t connect with before meds. This is still the property of meds that I find most enjoyable today. Someone can be entirely isolated in their own world – of voices or paranoia, or delusions or depression or dissociation or panic or mania or obsessions or anorexia, etc – and by taking medications they can “come back” and reconnect with the world. I know a man now who only says, “It’s alright. It’s OK.” over and over, never bathes or changes clothes smelling horribly of urine and dirt, and is usually homeless when he’s not on meds. When he is on meds he can have most of a conversation, live somewhere, eat, change clothes, bathe, and have friends more or less. That’s pretty satisfying. But he always refuses meds when he has a choice, so after a few weeks out of jail or a hospital he drifts away again. That’s pretty heartbreaking.
I remember when I was a first year inpatient resident at USC and I went to see a panel presentation that included the legendary R.D. Laing. He seemed to be on a different plane than everyone else. I couldn’t tell whether he was enlightened or psychotic or a charlatan. He talked about schizophrenia becoming healed when everyone on earth was reconnected and when the Earth was aligned with the moon and the planets and the sun and the stars. He said the key was loving the person with schizophrenia. After the panel, I went up to the microphone and said, “I’m trying to do that, but don’t find it so easy to love people who are really psychotic and who I can’t understand and whose emotions don’t seem to be connected to what we’re talking about. How do you get through to do that?” He told me to keep trying. It would work out. It seems to me that medications have often helped it work out; helped us to connect and share love.
Most of the time now I don’t prescribe either to reduce agitation or dangerousness or to help people connect with other people and life; I prescribe to help reduce suffering. People come to me suffering with a whole range of problems. They’ve usually had experiences where a psychiatrist made some diagnosis, described their suffering as the symptoms of that diagnosis, and prescribed pills that really did reduce their suffering. Maybe not as dramatically as the ubiquitous commercials on TV, but they felt better, often a lot better. They want to be back on meds. Sometimes that first successful psychiatrist is me. It’s pretty enjoyable to help people feel better. Isn’t that what a doctor is supposed to do?
Three of the top selling categories of pills are pain relievers, anti-anxiety pills, and antidepressants. I think that all three of these are “anti-suffering pills”. When we’re suffering for almost any reason, we’re likely to feel pain, anxiety and/or depression and want relief. The problem, in my view is that if we externalize our suffering and make it a symptom, then our response is to just fight to get rid of it. But we might be getting rid of an important part of ourselves at the same time, leaving us more damaged instead of relieved. I’m particularly disturbed that in DSM-5 we’re eliminating grief and making it more of Major Depression. Grief is important suffering. It’s how we know we loved. It’s how we honor our loss. It’s how we rebuild our hearts to love again. It’s not just a depressive symptom to be eliminated so we feel better. That feels to me like it’s making us less human. If instead we stick with our suffering and work through it, learn from it, find meaning in our suffering and gifts in our wounds, we will recover stronger and more human. It’s not that I want people to suffer, but I think separating ourselves from our suffering and medicating it to eliminate it isn’t really recovering any more than locking it away and trying not to think about it is.
When I’m at my best, I’m both prescribing meds and helping people work through their suffering. Meds can often be very helpful in reducing overwhelming suffering to where it can be worked with. Meds can be a tool of recovery and not just a tool for symptom relief. It’s generally not the case that the more a person is suffering the more likely they are to work through it; more often it seems to me it’s the opposite – we need some hope and sense of power over our suffering to really dive in instead of avoiding it.
When antidepressants were first developed, psychotherapists thought that taking meds would make therapy less effective because the person wouldn’t be motivated in their therapy if their depression was helped with a pill. When they did the studies, it repeatedly came out that depressed people more often did better and improved more with a combination of meds and therapy than with either one alone. Somehow, we’ve stopped emphasizing that combination over the years. Too many people are on meds alone. Many of them are getting meds from primary care doctors without ever getting mental health evaluations or therapy. The new integrated care paradigms mostly call in mental health professionals if antidepressants don’t work. “Responders” will never know what else might be going on or what else they might have benefitted from if their PDQ-9 score goes down with a trial of antidepressants. They’ll just get refills.
I guess I do still enjoy prescribing meds to help people – to help them become less agitated and violent so they aren’t restrained, seclude, or locked away, to help them connect to other people and life, and to help them have some relief from their suffering so they have some hope and belief in themselves and motivation to find the strength to work through suffering and recover. Like most things in life, though, that’s a lot less simple pleasure than it used to be when I could just be a warrior fighting illnesses with medications. Life seems a lot more complex and interrelated to me now and I feel a lot less powerful than I used to, but when it all comes together and I can feel someone really recovering and my meds helped along the way; yeah, I still enjoy that.
