Category Archives: Issues & Debates

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…

Introducing “The Power of Negative Emotion”

Issues & Debates, Review - books movies series,

How Anger, Guilt and Self Doubt are Essential to Success and Fulfillment

By Todd Kashdan & Robert Biswas-Diener
By Todd Kashdan & Robert Biswas-Diener

I bought this book from Kinokuniya bookstore, KL in September last year (price RM52.50, before 10% off for members). No doubt I picked this book up straightaway after looking at the title, as some of my regular readers would know that I’m not in favour of all those positive psychology, positive thinking, positive attitudes etc kind of approach.

One of the authors (RBD) is actually a positive psychologist – and what? He co-authored a “power of negative emotion” book? If you look through the list of books that he has authored, you will inevitably see either “positive” or “happiness” in most of the titles! So what made him write this book?

The centre point that it brings, I guess, is becoming “whole”. It is similar to ACT’s concepts (accepting the positives, negatives, everything; and make full use of them all), except that it has shown me the benefits of not being mindful and that we don’t necessarily have to be so mindful all the time.

I also like it that it’s evidence-based, many interesting research studies are cited. Despite that, I also realised that it can be biased from time to time, picking out only the points that support their views and not stating the full picture.

Overall I think it’s a good read, I’d say “anything moderate will be good for us” is quite a common sense. Such as eating fruits is good, but eating too much is never good; having stress can help to push you, but too much can collapse you; feeling angry can make you a more assertive person, but too much can cause problems etc. So the book doesn’t provide much of new perspective to me, and maybe to anyone who would pick up this book. Yet it’s a good book, because it makes you think about things you already know, and help (at least a little bit) to become whole.

“People who are able to use the whole range of their natural psychological gifts — those folks who are comfortable with being both positive and negative, and can therefore draw from the full range of human emotions — are the healthiest and, often, the most successful.“ (p. x)

精神药物的角色

Basic & General, Issues & Debates, Treatment Approaches, ,

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。

想睡得更沉更好? 不妨先让自己醒着吧!

Basic & General, Issues & Debates, Treatment Approaches, , ,

你无法入睡。粗略估计，在美国大约有30％的人长期失眠，一般的标准建议，就是养成良好的睡眠习惯，并尽量早点上床。如果（或者）这方法行不通，也还有几十种帮助睡眠的药物。

然而，根据科学文献 (scientific journal articles)，对于长期失眠最好的治疗方法，却是大多数人都没有尝试过，而且听起来有些疯狂：睡得更好的秘诀就是(至少在一段时间里)故意减少睡眠时间。

这就是所谓的睡眠限制疗法 (Sleep Restriction Therapy)，它是认知行为疗法专门针对失眠治疗(CBT-I, Cognitive Behavioural Therapy specifically for Insomnia)的其中一部分。这样做是为了减少你花在试图睡着的时间(比起你实际能睡着的时间)。

方法是这样的：用几个星期的时间，记录你真正得到的睡眠是多少个小时 – 比如说每晚可以睡五个半小时。下来，设定肯定必须起身的时间，通常是你最迟必须醒来又来得及去上班的时间 – 比如，早上6:30，所以，在睡眠限制疗法的原则下，你不让自己在凌晨1点之前上床。如果你在这段时间(1点多到6点半)成功地睡着了，你就可以开始渐渐地让自己早点休息，每次大约提早15分钟上床，直到你可以每晚熟睡完整的七八个小时。

当然，任何一个失眠者最不想做的事情就是故意剥夺减少自己的睡眠时间。然而大量的证据表明这个方法有效，而且根据一些研究至少跟药物同等有效(或比一些药物更为有效)。

当然 CBT-I 不仅仅是睡眠限制 – 它着重于改变失眠者有关睡眠的思想和行为，包括典型的建议，如在睡前一小时关掉手机等的电子设备，还有每天在固定的时间上床和起床。虽然这是一个优秀的治疗方法，但是患者一旦发现他们必须做的是特地的剥夺自己的睡眠时间，他们就选择放弃疗程。 这也是为什么这个已经被研究证明有效的方法没有得到充分利用的原因。当然这方法一点也不容易执行，尤其对失眠者来说要抵抗睡意，想睡时不去睡觉是非常困难煎熬的。失眠者往往非常在意他们睡了多少个小时，但是他们可能忽略了，睡了五六个小时不是问题所在，他们最应该驱除的，是躺在床上干看天花板辗转难眠的时间。

 

原文的英文版在这:

To Get Better Sleep, Maybe Try Staying Awake 

之前写过给失眠者的建议:

Insomnia & Poor Sleep

睡好眠清单 (.pdf)

Trichotillomania

Anxiety Disorder, Clinical Case Studies, Issues & Debates, Obsession & Compulsion

She started picking hair since standard 5 in primary school, and the problems got worse over the years, especially when she was under pressure. She had seen a few counsellors, also skin specialist, and was given injection on the scalp and prescribed medicine. Finally her parents decided to take her to consult psychiatrist, and within two months she got better with some SSRIs and anti-anxiety drugs. She then stopped taking the medicine. Her hair was growing again.

Few days ago the mother called up, saying her problem is back. When she was sweeping her room, she could see hair all over her bed, pillows and on the floor. The mother asked if we could provide phone counselling to help her (without using medication, as it was causing drowsiness).

This kind of request is not untypical here. Asian people (including myself) tend not to take so much western medicine, and avoid it as much as possible. I can understand that. But the girl’s trichotillomania (hair pulling) problem has a biological components.

Most mental or psychiatric illnesses have a biological component, whether it’s depression, anxiety, OCD, psychosis (obvious!) etc. Sometimes it depends on the type of illness, sometimes on the individual, sometimes it depends on which episode (which means for the same individual, she could have a biological trigger last year but this time it’s a pure psychological triggered episode), sometimes it’s a mix of both. For a person who suffers from very bad OCD, medication can probably reduce his symptoms of 30-50%, but still leaving symptoms that would still interfere with his life, so for this part he would need psychological interventions.

So I explained to the mother that she needs medication, pure counselling may relieve her symptoms to an extend, but not all of it. Because when something is wrong biologically, she would need medication to help her, whereas psychological interventions can help her to reduce her anxiety and stress, and to learn to cope with stress, mood swing, etc.

The best treatment for her would be both medication and psychological interventions, and a good combination is in fact the best and most effective treatment for a lot of people and for many mental illness and psychological problems, unfortunately nowadays this is not the kind of service provided anywhere.

拔毛癖

她从小学五年级开始拔头发，多年来问题一直恶化，特别是面对很大压力的时候。她看过几个辅导师，也见过皮肤专科，并接受头皮注射和处方药。最后，她的父母决定带她去咨询精神科医生，吃了一些SSRIs(抗抑郁)和抗焦虑药，在两个月内情况就好转了。然后她就自行停止服药，头发也慢慢长出来了。

前几天，母亲打了个电话来诊所，说她的问题又回来了。当她帮女儿打扫房间的时候，看见床上，枕头，地板上都有头发。母亲问我们是否可以提供电话咨询辅导服务来帮助她（不使用药物，因为药物使她很疲累）。

这种要求在这里绝对不是非典型的（意即典型!）。亚洲人（包括我）普遍不爱吃西药，能免则免。这点我可以理解。但这女生的拔毛癖不是简单的心理问题，她的起因含有生物因素。

大多心理和精神疾病的起因都有生物成分，无论是抑郁症，焦虑症，强迫症，精神病（显然!）等。有时它取决于疾病的类型，有时针对个人，有时取决于哪次病发（就算是同一个人，她去年发病可能是因为生物因素，但这次却是心理引起的），更多时候是两者混合。对于严重的强迫症病患，药物也许可以减轻他的症状的30-50％，但剩余的症状仍然会干扰他的生活，所以对于这部分，他需要心理治疗。

于是我向她母亲解释她需要来见医生和吃药，单纯辅导或心理治疗可以缓解她部分的症状，但不是全部。因为当头脑里的传输物质出错了，她需要药物来帮助她，而心理治疗可以减轻她的焦虑和压力，并学会应对压力和生活的变动，情绪波动等。

最好的治疗方法是结合药物+心理治疗，其实对于很多人和大部分精神疾病，结合治疗都是最好最有效的方法，可惜在现今这却不是多少地方找得到的服务。