Monday, June 1, 2009

New Poll Results: Meds in Our Treatment - How Does "Smart" Factor In?

"How well have your meds worked for you?" I asked you in a poll I ran here through the month of May. Of the 168 who responded, only 14 percent of you answered, "very well." In other words, only a small percentage of you thought your meds worked like gang-busters. The overwhelming rest of you had reservations.

Thirty-six percent of you - about one-third - responded, "conditionally well." In other words, your meds may not be perfect but they were meeting your expectations. When you add in the "very well" group, fully half you reported satisfactory results with your meds.

So, can we put a positive spin on the results? Hold that thought.

One in five of you (19 percent) told me that your meds were "rather problematic." In other words, you're not happy with your meds, but you are experiencing some benefit.

Nearly one in five (17 percent) responded that your meds were "very problematic" and 11 percent told me your meds were "a complete disaster." Added together, nearly one-third of you have given an unambiguous thumbs down to your meds.

So, how do we interpret the results? Keep in mind this is hardly a scientific survey. Let's go negative, first:

The fact that more than eight in ten of you reported that your meds are not working "very well" - for whatever reasons - speaks volumes. Add to that the fact that the "complete disaster" group is running in a virtual dead heat with the "very well" group and we are talking very low levels of customer satisfaction.

In other words, if meds were automobiles, car makers like General Motors would be in bankruptcy. Wait, let me rephrase that. Uh, never mind ...

Now let's go positive. This means first seeing possibilities in the "rather problematic" grouping. Suppose, for instance, half of you in this group were to graduate to "conditionally well." Then 60 percent of you - nearly two thirds - would at least be reasonably satisfied with your meds. Suppose we could get similar conversion rates from the "very problematic" and "complete disaster" groups. Then three-quarters of you would be happy customers.

How is that possible?

The meds are constant in this equation. The two variables are you and your psychiatrist. First imagine a smart patient working with a smart psychiatrist. Now picture a naive patient placing his or her trust in a lazy psychiatrist. Are we likely to see dramatically different outcomes? I rest my case.

Okay, one example: You come to your psychiatrist depressed. He diagnoses you with clinical depression. The antidepressant doesn't work. In fact, it makes you feel worse. The psychiatrist tries you on another antidepressant, then another. You are starting to feel like you are crawling out of your skin.

Then your psychiatrist gets a bright idea - or rather a thought implanted in him by a drug rep the day before. Based on his conversation with someone way too dumb to get into med school in the first place but attractive enough to take up a career in modeling (whether male or female), he now decides that the answer to your problem is an atypical antipsychotic to kickstart the antidepressant.

A smart psychiatrist will know exactly the right situation to make this call, but in your case would probably never have to make it. Instead, after not getting a good result with your second antidepressant, she - the smart psychiatrist, that is - would probably revisit the diagnosis. It could turn out - on further enquiry - that you have bipolar or something in the bipolar spectrum. So she takes you off the antidepressant and puts you on a mood stabilizer.

If the mood stabilizer works, your "complete disaster" scenario has been turned around. Maybe not all the way. In all likelihood, in fact, you still have a long way to go. But now, at least, you are in a position to learn more, to move up to from being a naive patient to a smart one.

What a difference "smart" makes in the equation.


Anonymous said...

It's not necessarily a case of the medication not working, it's that the person never needed the medication in the first place. A drug can be over prescribed to the extent that it's number of "failures" masks the benefits it has to the few. Unfortunately the bashing it then takes for its lack of effectiveness can end up denying the drug to the ones who can benefit most.

John McManamy said...

Hi, Anonymous. Totally agree. And once again, it comes down to lazy psychiatry. Welcome to "Knowledge is Necessity" and keep commenting.

Louise Woo, CABF L.A. Area Support Group Coordinator said...

Hi John;

Two quick points to remember:

1. I think we'd all like to think that "laziness" is a treatable condition with psychiatrists, as if they could become "good" psychiatrists with a little effort. However, as with all varieties of MDs, I don't think this is generally true. Remember that joke, "What do you call the guy who graduates last in his class from Harvard Law School? A Harvard Lawyer."

Yeah, it's the same with doctors. Was yours at the top of his/her class? Probably not. Somebody had to be at the bottom and yet they are still licensed to practice!

As with any high-paid professional, I encourage people to FIRE your doctor if s/he isn't giving you real results. People hate to do this because they worry they aren't being "nice" or that there aren't any other doctors on their insurance plan.

I feel your pain, but would you keep going back to a restaurant where the food was bad or made you sick just because it was cheap and convenient? It is unfair, but a fact of American life, that the best doctors often LEAVE the insurance groups and are fee-for-service only. We all have to figure out how much our wellness is worth to us.

2. Once again, everyone needs to remember that antidepressants are misnamed. SSRIs (commonly called antidepressants) are most effective for anxiety disorders, not for depression. Go back and read Peter Kramer's classic "Listening to Prozac" or Baronde's "Better than Prozac." People should know in advance that unless you have distinctive anxiety symptoms, you're not likely to get much help from SSRIs.

Modestly-well-educated patients will get a lot better results from their doctors if they can discuss their own treatment options intelligently. We recommend Dr. Tim WIlen's "Straight Talk About Psychiatric Medications for Kids" to everyone -- parents and nonparents alike! It's a good, plain English explanation about all the meds commonly used for psychiatric illnesses. If you take any psychiatric medications and you don't know what they are/do, then you NEED this book! It will help you determine if your doctor has prescribed the "wrong" medication for your symptoms.

John McManamy said...

Hey, Louise. Very wise counsel. Riffing off your restaurant analogy: We are far more exacting in finding the right hairdresser - no way would we put up with someone incompetent. No way would we go back. We actually treat the outside of our skulls as more important than the inside.

But not if we're smart. As always, the best answer to dumb psychiatry are smart patients.

John McManamy said...

Hey, Anonymous. One more point to add to your perceptive comment. Let's stick with the antidepressant example. Let's say an individual complained about feeling depressed and wanting to commit suicide. A lazy psychiatrist (and a busy GP) would diagnose clinical depression and prescribe an antidepressant.

A diligent psychiatrist who keeps asking questions and listens to the answers might determine the individual is manifesting symptoms closer to borderline personality disorder. Perhaps an antidepressant is useful, but certainly not as sole treatment and probably not as a first option.

The obvious call would be to get this person into DBT or other talking therapies that work for those with borderline.

It is my strong belief that a lot of individuals diagnosed with bipolar have undiagnosed borderline - either instead of bipolar or comorbid with their bipolar. In either case, they are going to be frustrated with their meds.

I also suspect a fair number of those with borderline get misdiagnosed with depression.

So here is an example of what your were referring to: a whole group of misdiagnosed individuals, of which many should not be on any psychiatric medication.

Again, many thanks for bringing this up.

Anonymous said...

The other factor in the equation is when the patient bullshits the Pschiatrist - as I did for many years about the extent of my drinking. The general problem with Depression as opposed to say , diabetes, is that they can't take a blood test to tell exactly what's going on.

Anonymous said...

My first cousin has been prescribed every antidepressent there is. So have I and my psychiatrist is basically a pill dispenser. My cousin said she is now taking Ridalin along with Prozac and has noticed a great improvement in her problem with sleeping too much; lack of enthusiasm in her kids school activities is no longer a problem, now instead of looking at her cluttered house with despair she is able to tidy it up, etc. She said she doesn't get a high associated with drug abusers. What are your thoughts?

John McManamy said...

Hi, Anonymous. This sounds like a very happy ending, thanks to meds. When meds work right, they restore your brain so you are thinking clearly and feeling right. As to feeling right, the patient knows best.

There is a misconception that people on meds are addicted to them or are taking an easy way out. Far from the case. Drug abusers take drugs for exactly the opposite reason to patients - they want to get f---ed up. They don't want to be thinking clearly or feeling right.

It's wonderful your first cousin is doing so well. People without mental illness take their brains for granted. We don't. My brain has failed on me way too many times to take my brain for granted. To work with a clear head is the gift of life. Trust me on this.

Please convey my support and encouragement to your cousin.

Anonymous said...

What do you do for someone who has very limited success with many different meds for depression, won't get a second opinion because "they have been with this doctor for so long and don't want to start over" and don't think their insurance would cover a different doctor.