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 psychiatrist Dr Sabina Rao.
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 depressed 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 them. 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 favor 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.