Meds Compliance: Treating the Phantom Menace
Over the last six or seven weeks, we have focussed on the issue of meds compliance. This is a dialogue, a conversation, and thanks to you I am asking questions I never thought I'd find myself asking. Last week, for instance, in response to a comment by Donna, I queried whether in certain instances noncompliance or partial compliance could be acceptable.
That question, in turn, inspired this penetrating comment from Tabby:
If I have never had the symptom, not prone to having it, not currently having it, just because I have bipolar does not mean somewhere down the road I may develop it. Why add more chemicals to my system - that are known to cause damage to my organs, that can cause psychiatric symptoms of their very very own to manifest - when I'm not experiencing said symptom or ever ever have?
Tabby goes on to contrast the difference between the way psych meds and meds for physical conditions are prescribed. For instance, she says, with blood thinners, chances are the blood clot will not grow bigger. With cancer, we will be sick as a dog on the meds but we can expect the cancer to remit. Are we taking our psych meds with that same degree of certainty?
Thank you, Tabby, for raising the issue. This is huge. I am aware of the topic having been raised with statins. Here is a CBS-BusinessWeek take, from 2008:
"We have no evidence that taking a cholesterol-lowering medication like a statin will prevent them from getting heart disease," said Elizabeth Nabel, director of the National Heart, Lung, and Blood Institute. Dr. Nabel oversaw government guidelines that say don't consider statins in patients with low risk factors unless their bad cholesterol is over 160. That hasn't stopped the statin craze.
In the psychiatry field, I am only aware of the issue being raised in the context of "at risk" populations. For instance, if psychiatry gets better at identifying kids at risk for schizophrenia, should antipsychotics be given to these kids, even though the odds are good the illness may never manifest, anyway? You'll be hearing a lot more on this in years to come.
The issue also comes up in seeking to identify those "at risk" for suicide. Should we, for instance, routinely screen kids in school for signs of depression and various behaviors? Following from that, once we've singled out these at risk kids, what actions would we take?
Tabby's query strikes a lot closer to home, so let me give you a personal example: My bipolar I diagnosis is based on the one floridly manic episode I had 23 years ago. I only sought help 12 years after that, following a series of severe depressions, with no intervening manic episodes. So, should I be taking a mood stabilizer to prevent mania?
After all, I had a bipolar I diagnosis. Obviously, I was a case of mania waiting to happen.
Or was I? My one manic episode occurred during an unusual time in my life, soon after a move to a new country, to a new job, working crazy hours under a lot of stress, anxious to make a good impression, with little sleep.
The "kindling" theory of bipolar posits that your brain is sensitized to future manic episodes once you've experienced your first one. There is merit to this, but was it applicable to me? Consider: I experienced no further manic episodes over 12 years (discounting an antidepressant-induced episode following a misdiagnosis of unipolar depression). There was little or no likelihood of the situation surrounding my manic episode of ever occurring again.
But there were other factors to consider. My mood cycles did stray up into hypomania. I also experienced mixed states where I felt like taking the world by the neck and choking it. Therefore, I was not averse to taking a mood stabilizer to slow down my brain a little bit. Staying on the med gave me a feeling of safety and more confidence in venturing out in public, which proved extremely beneficial.
For a number of years, I was willing to live life within a moderately restricted emotional range. But over time, as I became fairly adept in mindfulness, stress management, and sleep management, I came to regard my personal coping techniques as my real mood stabilizers. My chemical mood stabilizer dose was at the low end of the recommended dose, but was it really all that low? The dose range was based on studies conducted on manic patients in crisis. I was not manic, nor was I likely to be. I was certainly not in crisis.
Why, I asked myself, was I on a dose that was never intended for people in my condition? Yes, my diagnosis was bipolar I. But that hardly meant I was at high risk for breaking out into mania. I did the math. I went down to a lower dose, then lower. I experienced a greater clarity in my brain. I experienced a greater range of feelings.
I also experienced personal challenges in being on a much lower dose, but laughing too loud in public is neither a psychiatric illness nor a condition that meds are meant to address. Five years later, still no mania.
So, yes, Tabby. I thoroughly identify. Even well before I lowered my dose, I was writing that I believed that psychiatrists erred on the side of over-sedating us, such is their fear of mania, which for many of us is only a remote possibility.
But I also well know that for a number of you that mania is very real in your life, as is psychosis. I also realize that even mild versions of either of these type of episodes may be enough to derail you. It also needs to be noted that a good psychiatrist will employ meds to treat the cycle, not necessarily to manage symptoms.
Lots of things to consider ...