Monthly Archives: April 2016

Taking psychiatric medication in long-term?

Issues & Debates, Treatment Approaches

“Do I have to take these pills in long-term? Do I have to depend on them for the rest of my life?”

This is one common question asked in the psychiatric clinic, especially during their first visit when they are prescribed with medicine, and again especially so in the Asians, who seem never quite keen to take western medicine (including myself).

I believe different consultant psychiatrists have different response to this question. More commonly, the answer is either, “not in long-term, but you will have to maintain stably for few months” (so before you are stable, it’s not taken into consideration), or, “yes, that will be better for you; though you should be able to maintain on a minimal dosage” (for some people, maybe just half a tablet of Lexapro 10mg).

And then they will continue to throw you with more questions… But today I just want to focus on this first question. And please take note that I have a background in clinical psychology, not medicine, and I had worked in a national forensic psychiatric ward (UK) for 3 years then in a private psychiatric outpatient clinic (KL) for almost 3 years too. (For differences between psychology and psychiatry, please see here)

I’d advise that you seek advice from your consultant. But if for any reason, you need a second opinion or some reassurance, these are a few points that you can consider…

  1. Are you in a stable state now? Do you and your closed ones around you think you are well? How functional are you compared to the time before you become unwell? (It’s obvious, if you are not even stable on the medicine, do you think you will be fine without it?)
  2. Is this your first episode? (I don’t think any psychiatrist would advocate long-term antidepressant treatment for people who have had a single episode of major depression; It may be different for people with anxiety or psychotic related problems)
  3. If this is not your first episode, how close is this episode to the previous one? How severe is this episode? Is it getting harder to manage, to return to your ‘normal’ state? (The general pattern was a decrease in the interval between episodes and an increase in the severity and complexity of the episodes, until finally rapid cycling set in. As time passes, it requires ever smaller stimuli (e.g. stress, a bit of change, an argument) to trigger an episode. The latter recurrences would typically include all the symptoms of earlier episodes, plus additional symptoms. So, if there has been a number of episodes, and it seems to get harder to manage and cope, you are strongly recommended to continue with the medication instead of withdrawing)
  4. Any early traumatic or stressful life events, e.g. physical/sexual abuse, separation from main carer, death of a parent, prolonged hospitalisation, marital quarreling, mental illness in a family member etc when you were young? (Those are not just memories, the incidents could also have altered your brain, leaving it more susceptible/vulnerable to stress, separation, rejection, loss etc. Click here for more details. Anti-depressant medications have been found to prevent further neural damage and block cell loss.)
  5. Are you someone who’s very sensitive and/or easily stressed? (It might suggest a vulnerability originated from the brain, please refer to 4.)
  6. Are you doing any psychotherapy? Are you responding to it? Does it help? (Not everyone responds well to psychotherapy. But as a psychologist and a psychotherapist I will have to add this point to the list! It is always good to learn more about the illness, to spot the early signs of relapse, to cope with stress and adversities in life etc. How can psychotherapy help after one’s stable with psychiatric medication? I have a post here in Chinese that explains it.)

Again I would like to emphasise the importance to discuss this with your consultant, whether you have financial difficulties, or maybe you think you are stable enough to stop or reduce, or maybe you think psychotherapy will help you in long-term. Sometimes it’s not a bad idea to have a second opinion, but that’s after sticking to one consultant long enough (a few months at least) and things still never improve.

 

A few readings that is related to the topic:

The need to maintain on psychiatric medicine (psychotic and related illness)

The more you worry about having to take medicine, the more you need to take them

Is psychotherapy for me? (Well, if you are now stable and really are not keen to continue with medicine, check here to see if psychotherapy may be for you)

Anti-depressant & Anti-anxiety Medicine (Maybe you are thinking to try to reduce some medicine without the advice from your consultant? See this first)

精神藥物的角色 (The role of psychiatric medication, in Chinese. It also tells you the role of psychotherapy after you are maintaining well on medicine)

In the news: Mum killed for asking son to take psychiatric medicine (No, don’t force them. If they are not willing to take the medicine, try to get professional advice to see what you can do to help, but don’t make them take it…)

Psychology Today: 7 ways childhood adversity can change your Brain (How those adverse experience make you more vulnerable…)

Introducing “Your Medical Mind: How to Decide what is Right for you”

Issues & Debates, Review - books movies series, Treatment Approaches

By Jerome Groopman MD & Pamela Hartzband MD

By Jerome Groopman MD & Pamela Hartzband MD

I bought this book for from the Popular RM 5 fiesta last year. In a way it’s not directly related to psychology or mental health, but in fact anything about human behaviour – it is psychology. And this book is about how patients decide their treatments.

It doesn’t tell you how to decide, or what is right for you, but it shows you clearly how your past experience and up bringing influence your attitudes and decisions. I’d say this is important to know (I’m a minimalist, and a serious doubter), so I learnt how to communicate with my doctors, so that I see how the dr’s background may affect his/her approach on the patients, so I can help the dr to help me better. In addition to that, I also learnt how to understand those figures that drs or papers like to present us with, it is an important skill to gain (so when the dr tells you taking X drug will help 30% of the patients who are similar to you, you know what it really means).

Few things that I learnt from the book:

  •  When you feel good, it’s difficult to imagine the choices and to forecast the decisions you will make when you are ill. Imagining that you have a disease, or that you have to live with X side effects, is not the same as actually experiencing them.
  • All of us initially overestimate the ultimate impact of illness and its unpleasant side effects because we tend to focus on the negative and neglect the numerous positives in our lives.
  • Many psychological studies show that we regularly underestimate our ability to adapt.
  • Much of medicine is still an uncertain science, existing in gray zone — not clearly black or white. So there isn’t a clear “best” approach.
  • Bernoulli’s Formula [(probability of outcome) x (utility of outcome) = expected utility]
  • Three approaches that researchers have devised to come up with a number for the impact of living with a side effect: (1) rating scale; (2) time trade-off; (3) standard gamble. (please see the book for details, but they are not interchangeable, so I don’t consider them as practical.)
  • A doctor’s good reputation can be built by … simply picking healthier patients, and avoiding patients with multiple medical problems (such as diabetes with kidney failure and heart disease), and thus will have better “outcomes”.
  • A person’s wishes about treatment often fluctuate over the course of an illness. Completing a living will or advance directive had no effect on whether they maintained or shifted their initial thoughts about what therapies they wanted. It is difficult to imagine what they will want and how much they can endure when their condition shifts from healthy to sick and then to even sicker.
  • Modern technology can support, at least temporarily, organs like lungs with a ventilator, the heart with a bypass apparatus, and the kidneys with dialysis. The liver cannot be supported by a machine but this vital organ can be transplanted.
  • Research among patients in the ICU found that doctors are generally correct in giving a prognosis for moderately ill patients, but they aren’t very good at predicting the course of the sickest patients. They erred on both sides — too optimistic and too pessimistic.
  • And many more…

給年邁父母的愛

Clinical Case Studies, Depression

其實很多時候我還蠻擔心接到他老人家的電話的，雖然我心裡很敬重他，但更多的，是心疼。

他是個七十多歲的老先生，是診所多年的抑鬱病患者，情況時好時壞，目前吃著的抗抑鬱藥物更已經是最大劑量。老先生已經退休，平時都在照顧中風臥病在床的妻子，給自己還有老婆打點生活的大小事務，有個兒子但不同住，關係也不大好，見面總是吵架，兒子去年剛離婚，也沒爭取到孩子的扶養權。老先生自己的身體不怎麼好，有骨刺，嚴重起來自己也是痛得徹夜難眠。

害怕接到老先生的電話，是因為老先生住得遠，平時要是病情惡化了，心情鬱悶不已，就會給我打個電話請我幫忙舒緩。而因為藥物已經是最大劑量，又真的不想因為增加沒什麼作用的藥物導致老先生得承擔更大的經濟負擔，所以平時只能儘量和老先生聊聊天減少他不必要的操心。而事實上，老先生尚算樂觀開朗，就算心情很煩躁鬱悶，也很少掛個苦瓜臉哀聲嘆氣，而且老先生的抑鬱很大程度是環境和一些他個人無法控制的因素造成的，所以藥物最多只能稍微輔助，起不了太大的作用（雖然對一件事的詮釋完全歸於個人）。

我知道我不該這麼想，但因為在這行久了，看多了，我常不自禁擔心老先生會不會覺得自己身體不好，又要照顧老夫人，和兒子關係又差（而且兒子還有許多要他擔心的事），抑鬱一發作，生活沒意義沒樂趣，一時想不開就走了。每次想到這，都會慶幸自己偶爾可以幫上一點小忙，更會明白老先生能撐到今天，很多能量來自於對老夫人的愛與責任。少一點愛，少一點責任心都不行。說得難聽些，換作是時下的年輕人（如我，雖然我也不太年輕了…），肯定早就撐不下去逃避問題去了。是的，我總認為上一代的人比較堅強，有韌性，有毅力，較能在逆境中生存甚至向上；這一代在太多保護與遷就裏長大，比較任性，欠缺責任心和堅持。

我心疼他，同時也生氣他的兒子，脾氣不好，行為不好，也不盡孝心，見面就是和老先生吵架。其實我也和這獨子有過一次接觸，感覺他生活很多狀況也自顧不暇，所以責怪他的心理很矛盾，因為其實兩父子顯然都很關心對方，有問題都不敢告訴對方怕對方操心，大概又是同樣的火爆脾氣，兩人說不上兩句就吵架了。

其實說穿了，很多老人家都一樣，寧可對外人聊心事講問題，也不要不敢對自己的家人自己的孩子說，因為孩子總是忙，因為孩子已經很累了，因為不要孩子擔心操心，因為和孩子說太多最後都變吵架，因為怕孩子嫌自己煩自己嘮叨（甚至怕孩子把自己送進老人院）… 每次和老先生的接觸，都會提醒我要對爸媽更好一些，更體貼他們一些（然後回家就忘得七七八八！）

P.S. 這是我第一用中文紀錄臨床個案（Clinical Case Studies），主要是因為我心裡有很多感受想用中文抒發；所以可能要請讀者體諒這文章可能寫得不太順暢（還要磨練磨練）