My Thoughts on Psychiatric Medications

Today we discuss prescription psychiatric medications as they are used for major mental health conditions such as depression, anxiety, schizophrenia, bipolar disorder and ADHD,  and we outline 8 principles as to how they can be used in a safe rational way.

See 13th edition of the Maudsley guidelines here: https://www.clinicaltoolkit.co.uk/wp-content/uploads/2018/05/9781119442608.pdf

Audio-Essay by Dr. Alex Curmi. Dr. Curmi is a consultant general adult psychiatrist with a sub-speciality in addictions who completed his training in the South London and Maudsley NHS foundation trust. In addition to general adult psychiatry he is a UKCP registered training psychotherapist.

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Transcript

Welcome back to the Thinking Minds podcast. My name is Alex. I'm a consultant psychiatrist. Today I want to take some time to talk about psychiatric medication. Whenever I see psychiatric medication discussed publicly, it always seems to be in very simplistic terms. Those are terms like should you take medications for your mental health or not? Or can antidepressants cure depression? Most of the time people outside of mental health professions, but frighteningly, sometimes even actual professionals can take a blanket stance on this topic. And this is a stance which is often based on gut feeling intuition about the value of medications in general. These ways of discussing medication tend to lead down narrow conversational paths, without much room for discussion as to how to best use medications in a way that is safe or rational or effective. Rather, they can pit groups of professionals against each other in a kind of strange ideological struggle. For example, psychiatrists can look down on psychotherapists for not taking biology and biological processes seriously enough when dealing with mental illness. Psychotherapists can deride psychiatrists for being overly biological and not taking a holistic approach, and including a patient's psychological or social situation into account. Another complication is that psychiatric medications are very often not prescribed by specialists in mental health like psychiatrists, but rather by general or family practitioners by GPS. And this is not a knock against GP's, who are often doing their best in a really difficult situation. But the lack of expert knowledge when prescribing can definitely have a huge impact on patients, potentially. The end result of this is often I see patients in the clinic who, for example, have been on medication for years with no real benefits, but to continue to take it regardless, or patients who really should consider taking medication but haven't, or patients who have tried medication to help deal with their difficulties but have not tried any other strategies whatsoever. So that being the case, I wanted to outline some sound principles anyone could use when considering taking or prescribing psychiatric medication. 1s The principles I'll discuss in this podcast will be applicable to most mental health conditions such as depression, anxiety, panic disorder, ADHD, and even some of the more severe mental health conditions like schizophrenia or bipolar disorder. So hopefully, whether you're a psychiatry trainee, a psychiatric nurse, a therapist, a patient, or a friend or relative of a patient, or even just someone who's interested, you can get something out of these principles that could help you if you're in a situation where psychiatric medications are involved. And lastly, before we get into this discussion about medication, obviously none of the information provided here can be taken as advice for any one specific patient going through any one specific situation, but rather that person should consult a professional themselves. I'd also like to make you guys aware. As I've mentioned on previous podcasts, I'm now available for one on one psychotherapy sessions, and this includes online sessions, but also face to face sessions in the South London area. So if you have a relationship problem, a family issue, if you're dealing with a problem at work, or maybe you just want to learn more about yourself, you can now inquire about doing a one on one psychotherapy session with myself by emailing Alex Karimi therapy at gmail.com, and the email address is also in the description. 1s Okay, so here are some principles for prescribing psychiatric medication. Principle one. Have a clear rational goal. What symptoms are you trying to treat? This is important because it does underscore one of the main issues with psychiatric meds, which is that they are basically all ways of managing symptoms and not a definitive way of curing any particular mental health condition. Although it's worth noting that many mental health conditions can go into remission with time. This is a point psychiatrist can skirt around. In fact, a lot of the points I'm going to make today are points that psychiatrists can skirt around. But I think it's important to mention this is why sometimes it's necessary to take medications for long periods of time, even years, because reducing and stopping medications can cause symptoms to come back. For example, someone with schizophrenia who takes antipsychotic medication might notice if they stop, they might begin to hallucinate again or become more paranoid. Similarly, someone with bipolar disorder might find if they stop their mood stabilizer, they might have another manic episode or another depressive episode. 1s That being the case, it's always worth keeping at the front of one's mind. What are the symptoms we are trying to target? This is especially relevant because often mental health conditions may present with a cluster of different symptoms. For example, a case of depression can present with low mood, poor appetite, poor motivation, disturbed sleep, and suicidal thoughts. It may be that some symptoms are more disruptive of the quality of life for that person than others. Therefore, it's really important for the patient and doctor to have a conversation about treatment priorities, because some medications will be better at treating certain symptoms than others. For example, an antidepressant like Murtaza is more likely to be effective to treat poor appetite and disturbed sleep, while an SSRI, a serotonin reuptake inhibitor like fluoxetine, may be more appropriate if the patient is experiencing a lot of anxiety alongside depression. 1s So it's not just good enough to know what condition you're treating. And strangely enough, some patients are often even unaware of that. But specifically, it's important to know what symptoms you're trying to address. Principle two. Medication should be nested within other strategies. This is a point we make a lot on the podcast. There's almost no case in psychiatry I've encountered where medication was the only intervention that could help that patient. Aside from medications, a good clinician will always consider other strategies. These could include other biological interventions like improving sleep, improving nutrition exercise. It could include psychological interventions like therapy, meditation, or different standalone psychological techniques. For some patients, it includes basic social interventions like helping the person to get appropriate housing, helping them to get back into work, or assisting them with maintaining their relationships and friendships. One thing I've noticed is that doctors can often unconsciously overemphasize the importance of medication, because that is, after all, for many of us, our comfort zone. And they can subtly under emphasize the importance of other strategies. For example, if someone is depressed, we may spend 20 minutes talking about medication and five minutes talking about everything else. What does that communicates to the patient? Implicitly, it communicates that medication is the primary strategy while the others are merely secondary. Whether this is actually so depends on the details of the case, but often it's importantly wrong. For example, recent studies suggest that regular physical exercise is at least as effective as antidepressant medication to treat mild to moderate depression, even in conditions like ADHD, which actually respond really well to medication. Something like 60 to 70% of ADHD patients report significant improvement with medication. It's well understood by clinicians that medication should just be one recommendation amongst many as to how the patient can manage their symptoms, for example, by reducing their use of technology, by reducing their consumption of simple sugary foods, by minimizing distraction, or by learning organizational skills. Principle three. Try and give the patient a choice before they start. 1s In clinical situations, it's really common for doctors to come up with a recommendation for medication, more or less by themselves, and for that to be accepted by the patient without much of a discussion of different options. Although they may and should at least go over the possible side effects, this can lead to a number of problems. One problem is that it maintains the dynamic where the doctor is in a kind of paternalistic role, and the patient is merely expected to follow their recommendation. This dynamic is inappropriate because it subtly takes away the patient's autonomy and their basic ability to choose. And it's also inappropriate because it does not reflect the myriad of different treatment options that are normally available in a particular situation. This doesn't mean, of course, that the doctor should not be clear about what he or she might recommend, given that they have expert knowledge and experience. And they should certainly narrow the field of different options. But it does mean that the doctor should consciously facilitate the patient's choice making. And this should include, fundamentally the choice of whether or not to take medication at all. And then wherever possible, different choices between medications depending on the desired outcome, as I mentioned previously. 1s If you are a patient or a relative. You should be aware that assuming the patient has full mental capacity, it's always their choice as to whether they should take medication or not. And this is appropriately so, because it's unlikely that a doctor will be as invested in your health and well-being as you are a patient. Making the conscious choice to try a medication, rather than just following a doctor's lead, can make all the difference psychologically, because it encourages them to take more responsibility for their course of treatment overall. 2s Principle for. Prescribe or take medications in a time limited manner. 1s One of the biggest issues I see in my clinical work is that the patient is prescribed a particular medication, most often an antidepressant, and they just remain on it indefinitely, sometimes even for years, sometimes even when the medication is conferring no benefits whatsoever. As I mentioned in the introduction. Both the positive and negative effects of medication change across time. A medication that works now may not have much of an effect in the future, and bad side effects can crop up at any time. The patient can also develop medical conditions that mean it's no longer appropriate to take the medication. For example, if a patient on lithium develops kidney problems, or if someone on ADHD meds develops a heart problem. 1s Even in a stable situation. For example, someone with bipolar disorder is on lithium and they're not having any episodes of mania or depression. Their medication should be reviewed at least once every six months to have basic discussions about how effective the treatment is, whether or not they're having side effects, whether or not it would be sensible to either increase the dose of the medication, or possibly even reduce and stop the medication when things are more unstable. For example, a person is being treated for hallucinations and delusional thoughts with antipsychotic medication. Medication is sometimes reviewed as often as once a day in a hospital setting, or as frequently as once a week if the patient is at home prescribing medication in a time limited manner. It's one of the things that can ensure that the treatment remains patient driven, rational, and goal oriented. If you are a patient, you should make sure that you have the discussion with your doctor and that you consciously opt in or opt out to continue or stop a medication at regular intervals. 1s Principle five. Make one change at a time and give it time to work. This is a pretty simple one. Often people are prescribed two or more medications at the same time, or they're trying a number of different interventions to try and deal with their mental health. And it's important when making changes to medication that only one change be carried out at a time, whether that's increasing or decreasing the dose or stopping a medication entirely. And that adequate time is given in between changes. So that patient and doctor have a better idea of what effect each change is having. Prescribers should be aware of this, and I would be very wary of prescribers who don't follow this rule. For example, if someone is taking an antidepressant but they still feel like their symptoms are a bit out of control if they increase the dose of the antidepressants, while at the same time adding a mood stabilizing medication like lithium, which can also improve the effectiveness of the antidepressant if the patient's condition improves. It's difficult to know whether or not just increasing the dose of the antidepressant was enough, and therefore whether the mood stabilizer was necessary at all. With the exception of life threatening events, medication changes should be made in a slow and carefully planned manner. 1s Principle six. In some cases, medication will do more heavy lifting than others. As a rule of thumb, some conditions are much more likely to require some form of medication than others. These are usually the more severe mental health conditions like schizophrenia, other psychotic conditions, and bipolar disorder. This is not so surprising because these conditions often present with symptoms which suggest a more biological form of disturbance like hallucinations, delusional beliefs, paranoia, severe disturbance of sleep and appetite, and even disordered thinking and speech. Unfortunately, these are also the conditions where it's often harder for the patient to have what we call an insight into their condition. In other words, the awareness that they may have a mental health condition which is significantly impacting them. Some researchers even believe that in such conditions, the parts of the brain responsible for insight and self-awareness may be functioning less effectively than in people without the condition. That being said, patients with these conditions can often develop inside, but it can take longer. They may develop insight into their condition gradually over multiple episodes and possibly multiple hospital admissions. On the other hand, mental health diagnoses which present with largely psychological symptoms, such as, for example, emotionally unstable personality disorder, where the symptoms include things like fear of abandonment, emotional volatility, and difficulty maintaining relationships, among others. They're much less likely to have a solid, long lasting response to medication. This is reflected in our guidelines, which actually don't recommend medications for personality disorder in general, but rather recommend psychological interventions. Having worked in clinics specializing in personality difficulties. Typically, I find when prescribed medications such as antidepressants or mood stabilizers, these patients will report a temporary improvement for a brief period, usually around a couple of months, before returning to their baseline. Despite their ineffectiveness in these cases, doctors are often tempted to prescribe medications anyway because it's often difficult for doctors to feel like we're, quote, being effective unless we pick up the prescription pad. But this is an issue for a whole other podcast. Another good rule of thumb is that the more severe any condition is, the more likely is that medication may be beneficial. Necessary. Depression is a good example of this. Mild to moderate depression often presents with predominantly psychological symptoms, and can therefore be more amenable to psychological approaches with or without medication. But severe depression can present with the patient having difficulty moving, difficulty getting out of bed, even difficulty speaking. They may eat and drink a lot less. They can even hallucinate or form delusional beliefs themselves. As we discussed earlier, and almost no case would I recommend medications as the only means of improving someone's condition. But certainly the more severe the patient's presentation, the more likely it is that medication of some kind is a good idea. In extreme cases, even other interventions like electroconvulsive therapy can be used. 1s Principle seven. Expect unpredictability. 1s One thing that can't be overstated in psychiatry, but really in medicine in general, is that everyone's case is unique and that therefore everyone requires an individualized treatment plan. And this is not just a platitude. One of the biggest problems psychiatrists have is that it's very difficult to predict how someone will respond to a particular medication. For any psychiatric medication you can think of. You'll find patients who felt this treatment saved their life or greatly increased the quality of their life. And you will find patients who felt this treatment just caused a number of intolerable side effects and had no benefit whatsoever. To complicate things further, you will also have everything in between. When recommending a medication to a patient, I often warn them about this unpredictability, and I often find this helps patients be less disheartened when a particular treatment doesn't work or doesn't work as well as they hoped, and leaves them more open to trying other options. One of the hopes of neuroscience and genetics research in mental health is that we will come to better understand why patients with similar symptoms can respond so differently to the same medication, and this will help us match patients to medications better and hopefully avoid patients having to try multiple different medications. Unfortunately, we're not there yet. And until we are, we unfortunately have to rely on relatively crude treatment guidelines, which are less able to take the patient's individual biological characteristics into account. 1s As an aside, if you're curious about how these guidelines work, I've put a link to the 13th edition of the Maudsley Guidelines in the description, which is like the Bible of prescribing in the UK. It's outlines recommendations as to how to prescribe for all sorts of different mental health conditions, and cites all the research based evidence as to why those recommendations are made. So if you're curious to get some detail as to how psychiatrists make decisions about medications, this can give you quite a good idea. Unfortunately, the unpredictability does not stop there because, as we've mentioned before, not only do people respond differently to the same treatment, but a given patient can respond differently to the same medication over their lifespan. In other words, a medication which worked well in the past may stop working or produce side effects. This again underscores the importance of using a variety of strategies to manage your mental health. So as much as possible, medication is not the linchpin on which your recovery rests. In my experience, everyone's mental health is a continual puzzle that needs to be solved and things will not remain the same. It's generally better to accept and embrace that fact and embrace that. Figuring yourself out and managing your mind will be a dynamic challenge you solve across the lifespan. And although it's not always pleasant, it can be one of the things that makes life interesting. And our mental health difficulties, importantly, can be a window into what we need. What's missing from our lives or how we need to evolve or grow? 2s Principle eight. Our understanding of mental health conditions and medications is incomplete. 1s As implied in what we've just discussed in The Last Principle, there's still a lot of mystery, both in terms of what is happening at the biological level, in different mental health conditions, and how medications act biologically to improve symptoms. One of the things that makes psychiatry different from other medical specialties is that we tend to diagnose based on symptoms rather than causes, and that's not generally the case in other specialties. For example, if someone is diagnosed with tuberculosis, that diagnosis is pointing to a specific cause, specifically an infection from a bacterium called Mycobacterium tuberculosis, which is causing that patient's illness. What we do in psychiatry would be analogous to diagnosing that patient with tuberculosis with a cough, and grouping them with all the other patients who present with coughs. In psychiatry. This happens because the cause of mental health conditions are a lot more complex and incompletely understood. And so we diagnose based on clusters of symptoms. For example, if someone has five different problems with attention, five different problems with hyperactivity, if this is causing significant impairment in two areas of their life and if they started in childhood, we call this cluster of problems ADHD. 1s The obvious problem with this is that two patients can present with the same clusters of symptoms, but ultimately have different causes at biological, psychological, and social levels. Of these, the biological level is particularly hard to understand because actually, with a careful assessment, you can get quite a good grasp of someone's psychological and social situation. But as of yet, we cannot peer into someone's brain with sufficient clarity to understand what is happening biologically. As I mentioned previously, our scientific understanding of how the brain works and develops may get to the point where this can radically improve our diagnostic systems and treatment. But we're not at that point yet, and it's important for clinicians to be transparent with patients about this. 2s A good example of this is the dopamine hypothesis in psychosis. So this is the idea that increases in dopamine levels in certain regions of the brain are responsible for causing psychotic symptoms like hallucinations, delusional thinking. This makes sense for a few reasons. Dopamine is thought to be responsible for, among other things, generating a sense of meaning and salience from our environment. For example, for driving along the highway and looking for exit 450 and the sign for exit 450 appears on the side of the road. This thought to be dopamine release, which causes that sign to stand out in our perceptual field as very important relative to other stimuli in the environment which are muted, such as birds flying overhead or other cars or other signs. It's therefore thought that psychotic symptoms result from an inappropriate release of dopamine, which causes people to latch on to perceptual events and form delusional beliefs around them. For example, people with psychosis will often report stories like I saw the traffic light turn from amber to green, and that was when I knew I was supposed to save the world. Secondly, drugs that cause increases in dopamine like cocaine and amphetamines can induce psychosis in someone who's never had psychotic symptoms before. And thirdly, drugs that block the action of dopamine in the brain, which we call antipsychotics, tend to decrease psychotic symptoms in the majority of patients presenting with them. That being said, the dopamine theory of psychosis is problematic because not all patients with psychosis respond to antipsychotics. Antipsychotics are often only partially effective in relieving patients symptoms, and in these cases, which we call, quote, treatment resistant, the drug clozapine works well. However, clozapine has effects on all sorts of neurotransmitters, including dopamine. Many researchers think that psychosis or schizophrenia is probably not one condition, but rather a group of conditions with similar presentations. Just like you can have groups of diseases which will cause coughs with different things happening biologically in different patients. And this sort of problem doesn't just apply to psychosis. There are similar discussions being had about almost every condition, including ADHD, anxiety, and particularly depression. You may have heard of the study released a couple of years ago by Joanna moncrieff s research group Dispute ING. The serotonin theory of depression and the underlying theme here is that there's still a lot we don't know about the biology of these disorders. 2s Okay. So these are the eight principles I wanted to outline. Here are a few take home messages. When you're on a medication or prescribing a medication, take it seriously. Track its effectiveness over time and make active decisions about treatment. If something is not giving you any benefit, consider stopping it with medical supervision. Also, consider that some side effects can develop insidiously over time, and may only become apparent once you stop a medication. For example, many patients who take antidepressants reported this can cause a narrowing of their emotional range, and often they only realize this once they come off. 1s You want a doctor who can treat you holistically and dynamically, who can refer to other professionals appropriately, who can respond to different problems, and who doesn't see you as a category, in other words, as another case of depression or another case of bipolar, etc.. 1s Clinicians should be honest about the ongoing gaps in knowledge as to how medications work and the biology of mental health problems. And of course, the underlying theme with a lot of these principles is good communication between doctor and patient and other professionals is absolutely essential. 1s So I hope you found this discussion useful. As always, this is not the last word on this discussion. And of course, these are not the eight principles of psychiatric prescribing, but rather these are just eight principles which stood out as important to me. You can tell us what you think by emailing Thinking Minds podcast at gmail.com. This is the Thinking Mind Podcast, a podcast all about psychiatry, psychology, psychotherapy and related topics. If you like it, there are a few ways you can support it. You can give us a rating. Share it with a friend. Follow us on Apple, Spotify, or wherever you listen. Or if you want to support us further, you can check out the Buy Me a Coffee link in the description. And as I mentioned at the start, if you'd like to work with me one on one for psychotherapy, you can check out the email address in the description. Thanks for listening.