Tag Archives: Medication

Medicine side effects vs the illness itself – Which is worse?

The illness itself, or the medication side effects – which is worse? Perhaps people who are taking medication can share their experience?

I’d always thought it’s the illness. Of course, it’s something that you don’t get to choose and can’t control. To many people, it just happened, then their lives changed.

So whenever people complained about side effects of medication (e.g. many anti-psychotics cause so much drowsiness that patient can sleep all day; or some antidepressants cause dry mouth, constipation etc), I’d tell them the gains are much greater than the losses, or that you get more advantages than disadvantages out of it. So tolerate with it, and it’s going to fade away anyway  (when patient gets better the dosage can be reduced, or maybe when their body get used to the drug then the side effects diminish!)

Till this morning when I saw this young girl. She was completely disorientated, perplexed, restless, with limited response, almost zero eye contacts and tremor hands when I held her. It’s not possible to hold a brief conversation with her, leave alone doing psychotherapy. I knew it’s a psychosis case, but in my mind i kept wondering why her presentation was like that. It’s hard to believe she was once a happy and easy going girl, doing well in the schools, despite her kind of difficult family background.

Then I recalled what her auntie told me in the emails – the medicine she was taking from the hospital following the first onset and admission couple of weeks ago. Suddenly it became much clearer. I have seen this quite many times, most of them are patients who were already taking medicine when they first came to us. It’s not the presentation of the illness itself. It is the side effects of the medication (you can perhaps email me to ask what drug it is; I think to many people, the answer is obvious) given by the GH.

If this were one of my family members, I wouldn’t want it. I’d rather to have her having difficulty sleeping, some hallucinations and being a bit paranoid – ok, this might be equally bad I can’t deny it. But It’s really difficult. Isn’t it?

What would you choose? Do you have any experience tolerating side effects of medicine that you take?

N.B. Don’t get me wrong, I’m not asking everyone to stop their medication due to the side effects. Most of the time I still think that medication would be beneficial and helpful despite the side effects. However, if you suffer from intolerable side effects (another common one from anti-depressants – sexual dysfunction, ranging from changes in drive, arousal, erectile/orgasm problems, satisfaction), do speak to your consultant, quite often there are substitutes.

Introducing “Listening to Prozac”

By Peter D. Kramer

By Peter D. Kramer MD

Last year I bought this book for RM5 from the Popular RM5 book fiesta (by now you probably have realized that I bought a lot of books there, and yes you’re right, I do spend time to go through those non-fictions and try to pick some treasure!). It is written by an American psychiatrist.

This is really a book that I’d strongly recommend, to … certain people, like me – who know quite a bit about psychopharmacology, but not enough, not much about their history – who have seen how all those drugs are used practically and in day to day life, but not read much about the facts and dark stories behind them. It is an old book I have to say, but I learnt so much about the older generation anti-depressants (tricyclic like Imipramine, Monoamine Oxidase Inhibitors which is not so common these days) and those that I’m so familiar with, i.e. the SSRIs (e.g. Prozac (Fluoxetine)!).

It made me think a lot about how those so-called legal drugs are prescribed, used and misused, how it can change a person from the inside (personality! how they see themselves all their lives simply changed after they started the medicine!), how vague the definitions of psychiatric diagnosis are, how tiny the difference between well and unwell could be etc etc. It may not be a book for everyone, I’m sure some might fall asleep reading it, but it’s probably the first time I’m reading such old book (published in 1993 -before I attended elementary school :P , some updates in early 21st centuries at the back) but still get so astonished and learnt so much!

Drug Use & Drug Abuse

More specifically, it is Psychiatric drug use VS Illicit drug abuse

If I have depression, or dysthymia, or an inability to experience pleasure (anhedonia), why do I need to take psychiatric drugs? I can take cocaine, amphetamine, heroin or opium too, they make me happy and feel high too. It reminded me of the patient who took his own life by jumping off from a building. He said gathering with his bunch of friends and taking those pills are his kind of pleasurable activities (case study here), just like women go shopping or people go gym. Yea, right, how about that? Take a few “pills” and I’m better?

Antidepressants like Prozac and Lexapro (the SSRIs) do not provide pleasure, it restores the capacity for pleasure. It is neither excitatory like cocaine nor satiating like heroin. The drug taker doesn’t crave Prozac and does not feel relief when it enters the system. The desired effect, a change in responsiveness to ordinary pleasures, occur gradually and is unrelated to the daily act of consuming the drug. So unlike cocaine which produces quick, strong but short-lasting “high”, people don’t “usually” get addicted to the SSRIs.

Drug addicts use stimulant drugs hoping to cope with intolerable feelings. Without medication, they may experience little enjoyment. Prescribed medication makes drug addicts who kick the street-drug habit feel less empty and better able to enjoy ordinary pleasures. For the addict, the hope is to enhance the ability to “postpone gratification”, something antidepressants may do by increasing the ability to imagine future pleasure. If and when ordinary pleasure becomes appealing (after a drug addict is treated with psychiatric medicine and begins to experience “ordinary pleasure”), it’s hoped that self-understanding and self-control will follow (no longer rely on illicit drugs to achieve “instant pleasure”).

So can we use anti-depressants (and some other medication) to treat stimulant drug addictions? I believe with a combination of behavioural therapies, and supports from the immediate family members, anti-depressants would work. But taking only anti-depressants without strong mental and motivation to quit and sufficient social supports is definitely not enough, not in long-term for sure.

Psychiatric Drug Abuse?

But anti-depressant drugs (focusing on SSRIs here) can also be abused. There are patients whose depression were treated with the SSRIs, once successfully weaned from the tablets, want to restart it, not because they are depressed, but because life seemed brighter when they were medicated. In psychiatry it’s a bit difficult to decide where treatment ends and depression starts again.. but doesn’t this seem a bit like taking illicit drugs? Same applies to people who take excessive anxiolytics (anti-anxiety drugs / tranquilisers) to make them calm and functional, how do we define when it’s legal psychiatric drug abuse?

There are people who feel more mentally sharp and agile, talk more fluently, and more socially confident when they are on anti-depressants, they continue to take it even when they don’t show any signs of depression at all. Unlike amphetamines which also make people more alert and productive but at the same time is addictive and causing paranoia, most of these SSRIs don’t lead to any significant side effects (and (if) any discomfort tend to go away after first few days). So does this make it morally and ethically fine to take anti-depressants to increase alertness, quickness of thought, and verbal and mechanical fluency, in the absence of illness?

 

P.S. SSRIs stands for Selective Serotonin Reuptake Inhibitors, which are newer drugs used to treat depression, but also work for OCD and anxiety disorders. Some commonly used in Malaysia include Lexapro (Escitalopram), Prozac (Fluoxetine), Zoloft (Sertraline), Luvox (Fluvoxamine).

N.B. This post focuses more on major and minor depression, dysthymia and anhedonia.

Taking psychiatric medication in long-term?

“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…)

精神药物的角色

摘自马大元医师的<心灵影像的力量>-

精神药物就像救生圈,当一个人掉进水里快要溺死了,这时如果指导他游泳的技巧,绝对是缓不济急。此时,他最需要的,是有人赶紧丢一个救生圈给他,让他尽快脱离溺水的痛苦与危险。

脱离溺水危机之后,这个人痛定思痛,开始下定决心学习游泳。一开始,因为没有信心,仍需一个游泳圈的辅助。等到学会游泳以后,游泳圈就是累赘了。。。你有看过奥运选手戴着游泳圈参加比赛吗?

精神药物的角色也是如此,在你最痛苦,无助的时候,可以提供最即时的协助。危机解除之后,治本之道就是学会情绪调适的技巧。在学习的过程中,游泳圈(药物)仍可以提供适当的辅助。等到你的情绪调适技巧熟练了,游泳圈(药物)就是多余的了!


很多人会以为吃了几个星期的药,比较舒服了,就擅自甚至不听劝告停药(在还没准备好的情况下,就放弃游泳圈了)。非常幸运的,可能这辈子也没再复发;比较幸运的,可能过了几年才回来了;但是大部分,在几个月内,面对重大生活巨变或压力时,就又再溺水,又需要游泳圈(药物)了。

另一种情况,病人开始服药后,就产生依赖性,习惯了游泳圈的便利与安全感的。有些倒是乐意,反正舒服,经济也能承担。有些呢,则会责怪医生责怪自己责怪家人,开始了这药,就停不下来了。问题是,药物是可以平衡头脑里的传输物质,但是你自己呢?你努力了吗?只单靠药物就能完全痊愈不再复发吗?

所以我特别觉得这篇<游泳与游泳圈>写得特别好。不能只靠药物,在觉得比较舒服后,就开始学习调适自己,调适情绪,调整生活步调,学习如何抗压,多做运动和参与有意义的活动等等。

The need to maintain with psychiatric medicine

He’s a long-standing patient with paranoid delusions, all the while maintaining with medicine and depot injection. Though, past 2-3 years, he started to reduce his medicine, and at one point, he stopped them all completely, didn’t come back for follow-up and injection.

Within half a year, he had relapsed, with agitation, insomnia, sensitivity and sometimes he could be violent. He isolated himself from the family, spending all the time in his room. When the parents talked to him, he either ignored them or responded angrily.

So the mother started to put the medicine in his dinner, over time he got more stable, at least willing to listen to family, going out with them, and having better temper.

Few days ago his sister called up, saying patient’s condition has got so bad, he was threatening, paranoid and picking on the mother, throwing away her stuff, very agitated and always scolding the family members, also he has spent all his time awake.

The sister said the mother stopped giving him medicine since three weeks ago, as patient was listening to some calming religious musics, and was so much better — better-tempered and didn’t appear sensitive or paranoid at all. The mother thought he’d recovered, decided that he didn’t need the medicine anymore.

Now with his very much deteriorated condition, the family members have no ways to bring him to see a psychiatric doctor and for injection, also no way to make him take the medicine. The mother has also been threatened so much that she was afraid her life could be in danger, and is in the dilemma of whether to move out from the house (which then means nobody can help him).

This is not to say that calming religious music, chanting or prayer, relaxation exercises, meditation etc couldn’t help with one with psychotic disorders, quite often they can be very soothing and calming, at times they can even prevent mild relapses, but they cannot be a complete replacement of medicine. It’s always practical to at least let the patient (with schizophrenia or psychotic disorders) to maintain with a mild dose of psychiatric drugs, so that the condition will be more manageable even when a relapse takes place. (though for patients with good insight of their conditions, especially those with anxiety disorders or depression [but not psychotic disorders], it’s possible to stop all the medicine and only take back when needed).

 

Post related to client’s consent to treatment: Schizophrenia & Consent to Treatment