Wednesday, February 15, 2017

Is there a Pill for That?

I'll start by admitting something; medications scare me. Not all medications and not in all cases, but many. Perhaps this diminishes my credibility as a psychologist who fancies herself quite scientific, but there are reasons for my atypical stance. Allow me to state for the record that I am not a prescribing physician, and what follows is my opinion, which mostly consists of: "Buyer beware".

 In the years since I have been practicing psychology, I have seen a startling number of serious, damaging reactions to medications. In addition, I have also seen no small number of similarly bad reactions to street drugs. Years of observing and reading have thus led me to a very conservative stance regarding attempts to pharmaceutically solve health problems, both physical and psychological, as well as the ones sitting on the border thereof. Some examples follow, after which I'll provide some details about how I work with my clients in light of my observations.

A man called me for help with a serious problem--one that had nearly landed him in jail. He was a peeping tom. Suddenly. The long story was that he had Parkinson's disease and was being treated with L-dopa. In those days, it was not yet firmly established that, due to its effects on the dopaminergic pathways, L-dopa can cause obsessive-compulsive problems. Some time soon after this, the news began to surface--something that ought to have been pretty obvious, that when you alter a neurotransmitter system, since neurotransmitters serve more than one function in the body, you have to expect some serious changes beyond the hoped-for effect. As good a therapist as I fancy myself, nothing I did would completely break this man's obsessive preoccupations, until the drug was stopped. He made therapeutic progress and stopped violating people's rights, but that was not the same as overcoming his obsessive thoughts. So here we have an example of a drug prescribed for a medical condition causing a serious psychological symptom for many years before he came to me and we figured it out. Did that drug help his other problem? Indeed, but the solution caused a more serious issue.

A friend of mine complained of sudden pain and cramping in his muscles during his thrice-weekly jog. He had to stop exercising, which caused him great distress, not to mention weight gain, depression, and other problems. It did not take him much longer to stop his statin medication, change his diet to control his blood chemistry, and get back to normal. Not everyone is this lucky--for some, statins cause permanent alterations in muscle and nerve tissue. For others, lifestyle changes do not make the needed change in cholesterol. The caution here is to read those scary leaflets that come with every prescription and pay attention to your own responses. If you are the unlucky one to experience severe side effects, often there is an alternative to the medication that is causing harm. Talk to your physician.

For several years, my office saw quite a few clients with anxiety that had developed after a course of steroid treatment was ended. These anxiety problems turned out to be much tougher to treat than other forms of anxiety. Eventually steroid treatments began to be tapered carefully and used with more caution, and that problem decreased dramatically. Score one for pharmacology. But, again, proceed with caution when taking steroids. While they can be lifesavers, nothing comes without a cost.

The same caution applies as well to acne medications; while some sorts of acne can be severe and disfiguring, and I would not want a suffering individual to go untreated, the internal medications that have been developed to help sufferers are known to cause anxiety. This can be very hard on the target patient, who is a teenager struggling with a difficult issue. Parents--be willing to monitor your teen and seek psychological help when needed. This is no small matter.

Proceeding to the other end of the equation, we can peek at medications prescribed for psychological issues. And we can find both sorts of side effects; the physical and the psychological. Anti-psychotic medications can cause movement disorders and perceptual problems, not always reversible. Antidepressants have been know to cause anxiety, manic episodes, lethargy, and sleep issues, to name a few. And research shows very little demonstrable mood-enhancing effect. Stimulant medications for attention problems can cause depression, appetite suppression, and sleep problems. These medications are most often given to growing children, for whom such side effects are non-trivial. Again, the message here is to approach psychoactive medications with caution, particularly for children.

I have seen several young adults who either were or had been taking several psychotropic medications. In each case, the psychological symptom that had sent them to the doctor was easily treatable with psychotherapy. In each case, the youth in question suffered suicidal thoughts that struck them as out of the blue until their parents brought them to me. One young woman had taken herself off of all of her pills without medical supervision. Another was simply following doctor's prescriptions when she thought of self-harm. The scary thing for me and for them and their parents was that in each case, the young person had a mild depression, some life stress, or some other life problem that once we got to work at it, was readily treatable.

In another vein, a long, long time ago, a patient, my first actual client, in fact, appeared before me at a rehabilitation hospital. I nearly fainted, being a psychology trainee and not expecting massive quantities of blood. This incredible man was in fact, a high-functioning heroin addict, or had been. His last dose of his drug of choice had caused a massive event depriving his brainstem of oxygen and nearly killing him. He had, indeed, been comatose in a hospital for months, without the normal precautions having been taken to maintain skeletal function, as it was expected that he would not survive. Clearly, they were wrong. So, several surgeries later, finally able to walk a little, I met my patient in a hallway, covered in bloody bandages. My job was to learn about his cognitive functions and help him rehabilitate. He would never again rise to the top of his profession. In fact, he would never work again, but he could think, and he could understand that even an addict with perceived control over his use could have a devastating reaction to a non-prescription drug.

Two other clients, both college students, had bad responses to relatively small experiments with hallucinogens. One, salvia, not even illegal at the time, and the other, psilocybin. The first developed bipolar disorder and disorders of thought, which have not remitted 10 years later; the other developed depersonalization. I do not know his long-term outcome. Again, buyer beware--street drugs develop a mystique, and are often purported to be harmless--just a good time, but not everyone gets away with that. For some, putting such powerful, reality-changing chemicals into the brain makes frightening and sometimes permanent changes in perception and functioning. How do you know if you will be the unlucky one whose brain does not recover?

My reaction to the sum of these and other anecdotes, is to approach all chemicals that work on a neurotransmitter system or a hormone system with a great deal of caution. After all, even antibiotics can be misused and cause harm, and they work directly on the offending microbe. These drugs that affect our complex, multi-functional, interwoven system of chemical information can change us in many interconnected ways. They ought never to be taken lightly.

It worries me daily that so many people worldwide take such medications as if they are relatively harmless. I learned on my first day as a psychology student: First do no harm. Rarely is a medication completely harmless. Physicians, patients, and pharmacologists must always weigh benefits against risks. The problem is that when the problem seems dire, you, the patient, are afraid to risk not taking the medication and often therefore, blind yourself to the harm it is doing.

I run into this often with chronic pain. Many types of chronic pain do not respond to opioid medications, but patients in pain are terrified to stop taking a medication even when they cannot in truth tell me that their pain changes a jot when taking it. Pain is scary, and chronic, unceasing pain is really scary. But that is not a good reason to take a potentially dangerous drug that is not helping, nor the chorus line of subsequent medications to enhance mood, reduce the side effects from the first two, aid sleep, and then, of course, get the gut to work again after the effects of all of the nervous system suppressants.

Now let's look at how I approach clients who come to my office.  First, I make sure to get a complete health picture, as well as a decent lifestyle snapshot for each client. This way I can get an idea of their overall self-care, major health issues, and what other treatments they are receiving. Even though I am a psychologist, I often discover an important datum about my client from such information. Is my client eating? sleeping? attending to hygiene? able to work? People come to me for such problems as depression, anxiety, phobias, gut issues, chronic pain, headache, and trauma.

I do not differentiate the mind from the body except insofar as I need a medical review when there are physical symptoms to make sure nothing important has been overlooked, because, of course, I never treat a broken leg nor a brain tumor primarily with psychotherapy, though after medical treatment has been undertaken, I can safely offer pain reduction and immune enhancement via clinical hypnosis, which has been demonstrated to improve patient outcome. On the other hand, I will treat an irritable bowel or a migraine with psychological methodology, after that physical exam, because it is effective and can lead to a cure, which medications have not been shown to do.

What about drugs, then? In acute pain situations such as that broken leg, pain meds can be of great benefit. Hypnosis can be very useful with acute pain as well, but not everyone is in a situation to take advantage of hypnosis in the ER. On the other hand, in chronic pain, hypnosis surpasses medication on many occasions, especially when the pain persists despite many attempts to medicate, and the doses seem to be abnormally high with little effect. There is new evidence that chronic pain that lacks a current medical source or is in excess of what the medical issue accounts for, does not respond to medications, but it does respond to appropriate psychotherapy.

When we get to high cholesterol, diabetes, hypertension, and other clearly medical ailments, I ask my clients to have clear discussions with their physicians. All of the medications to treat these issues have side effects. For some, behavioral change and psychological counseling will rebalance the body's systems and restore health. For others, either the imbalance is too severe or the behavioral changes will not help enough, or you, the patient, really prefer the medication, which is your choice to make. But, again, it is always good to have a frank discussion with your prescriber as to potential for harm, alternative treatments, and what the drug research indicates a far as safety and effectiveness.

In the realm of depression, the modern tendency to immediately prescribe medications worries me. Research does not really support the use of medications with most depressions. Good (GOOD!) psychotherapy is more effective, and medications carry known side effects which are often worse than the offered symptom relief, and they are notoriously difficult to wean off.

As far as anxiety, we have a completely different issue. Anti-anxiety medications are less side-effect prone than antidepressants, but highly addictive, with the added issue that taking a pill rather than dealing with the cause of anxiety often leads to long-term psychological dependence as well as lifestyle restrictions to avoid feeling anxious. Anxiolytics are indeed effective, but not quite safe, as far as the dependence they can create. Psychotherapy is known to be effective for anxiety and phobias.

This issue of understanding psychiatric medications and other medications that are not serving a clear purpose is vital to how I practice psychology. I see many individuals with physical symptoms, taking several medications, and not able to identify any particular improvement from the drugs, yet afraid to stop or taper any of them. These same clients might also complain of poor sleep, lack of appetite, grogginess, or gut problems. The fact that this individual is in my office means that the medical approach is somehow not helping, or not helping enough, but because nothing better has been tried, the medications linger.

When a psychological approach is shown to be effective, working with my client's physician to taper medications is part of the process. We are able not only to work on the original problem, but also the new fear of stopping the medications.

When there is a psychological diagnosis such as anxiety, depression, phobia, or trauma, once again, if the client is sitting in my office, it is often because medications have not worked. In these cases, research bears out my own conclusion that psychotherapy is the approach most likely to help. Once again, when my client experiences an improvement in symptoms, he then needs to confer with the prescribing physician to assist in the tapering of any drugs that have not shown positive effects, but in this case, psychotherapy can proceed and the potential for cure rather than symptom reduction is real.

One of the problems here is that is can be very difficult to distinguish, as a consumer, good psychotherapy from just having a pleasant chat. Many supportive, empathic conversations help you to feel calmer and happier. Psychotherapy ought to be aimed higher than that. Not a short-term relief from psychological or physical pain, but a long-term learning process in which you acquire new knowledge and new behaviors that lead to a better mood and a calmer frame of mind. It is okay to hold your psychotherapist to a higher standard; you ought to see improvement. While this can be difficult to measure, it is less vague than some might think. Set goals with your therapist, and go over whether they are being met. Ask for assignments. The completion of assignments is a major predictor of therapeutic success; it means both you and the therapist are engaged in a learning process.

Psychotherapy has been shown to be effective in treating depression, anxiety, phobias, PTSD, and many other problems with life. Specialized psychological approaches have been shown to be helpful with chronic pain, migraines, functional gut issues, and problems with the immune system. Please discuss all medications with your physician at length, and if medication is not the answer, there are a variety of alternatives depending upon your issue, including, perhaps, a visit to a psychologist.


Ananth, J: Pharmacotherapy of Obsessive-Compulsive Disorder, (1985) in ed: M. Mavissakalian, L, Michelson, S.M., Turner: Obsessive-Compulsive Disorder: Psychological and Pharmacological Treatment : Springer Science, NY. Chapter 5, p 177.

Antonuccio, D.O.; Danton, W.G. & DeNelsky, G.Y. Psychotherapy versus medication for depression: Challenging the conventional wisdom with data. Professional Psychology: Research and Practice, Vol 26(6), Dec 1995, 574-585.

Kirsch, I. (2010 ) The Emperor’s New Drugs: Exploding the Antidepressant Myth. Basic Books.

Sarno, J. (1990) Healing Back Pain: The Mind-Body Connection Warner Books.

Whitaker, R. (2010)Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, Random House.

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