Meds Compliance: Problem Meds
This is the fourth in my series on meds compliance. My last two posts looked at "The Problem Patient" and "The Problem Psychiatrist," respectively. Of course, if our meds worked the way the drug industry would have us believe, we would not be talking about problem patients or problem psychiatrists.
Today, I received a email with this heading: "Ban All Antipsychotics." A few days ago came "The Rise and Fall of Provigil." These are not isolated sentiments. In a widely talked about book published this year, "Anatomy of an Epidemic," journalist Robert Whitaker makes a strong case that we are better off without meds. He cites one study that tracked newly diagnosed schizophrenia patients over 15 years. Within four-and-a-half years, 40 percent of those who were off their meds were in recovery while the same could only be said of only 6 percent of those on their meds, a figure that remained steady in the years to follow.
Whitaker also cites studies (that I have reported on as a mental health journalist) noting a minimal difference between patients on antidepressants who got better and those on placebos.
Our meds, of course, are very dumb. The smart ones are still on the drawing board. In the hands of dumb psychiatrist (of which there is no shortage) working with a dumb patient, this is a recipe for disaster.
A major problem is that drug companies test meds to treat a diagnosis. Take the case of Provigil, which drew very bad marks two months ago from a European agency. The drug was approved a number of years ago for treating narcolepsy, and there were high hopes the med could be deployed to treat depression and related conditions, as well.
In essence, Provigil can be considered an amphetamine or ADD med with brakes. It works on the dopamine system to increase energy and promote mental clarity, but without the dangerous surges associated with the highs of uppers or of street drugs such as cocaine. Dopamine is also associated with pleasure and reward. You can see where the thinking is going: boot up the dopamine system and you may have an answer to depression.
Unfortunately, the Provigil trials for depression proved underwhelming. But did the fault lie in the drug or the way we think about depression? With very few exceptions, clinical trials fail to distinguish between different types of depression (and the same holds true for bipolar and other ills). Part of this has to do with the drug companies, who are seeking a license to print money based on marketing meds to very large patient populations. Part of this has to do with the DSM mindset, which militates against the psychiatric establishment thinking outside the box.
What is depression? Feeling sad? Unmotivated? No energy? Not thinking straight? A spiritual crisis? A stress-induced condition? An abnormal reaction to normal events? A normal reaction to abnormal events? A hibernation reflex gone bad? All of the above? None of the above?
Psychiatry just sees depression. The real answer is probably something way more complex and nuanced, with different biological causes demanding completely different treatments and therapies. Thus, there is probably a subpopulation of patients diagnosed with depression who would probably do very well on Provigil, but we'll never know.
For years, psychiatry treated unipolar depression and bipolar depression as exactly the same. A number of years ago, enlightened members of the profession woke up to the fact that we were dealing with entirely different phenomena, but this has yet to filter down to the rank and file. Many psychiatrists still operate under the assumption that if it is a depression, it needs to be treated with an antidepressant.
Thus: Problem psychiatrists prescribing problem meds to problem patients. It stands to reason a lot of us will go off our meds. There is only one way to break the impasse: Become a smart patient and find a smart psychiatrist. There are smart ways of working with dumb meds. Then the meds won't be so much of a problem.
More to come ...