Monday, October 21, 2013

Meds or Therapy?


It's this funny thing, people talk about the rise in the use of medications like it's a bad thing (and perhaps it is) and the decline of psychotherapy by psychiatrists as also being a bad thing (and perhaps it is).  It's almost like a see-saw, and there is the thought by some that using medicine is a quick-fix, a way of avoiding looking at the more difficult issues that we as humans face in the natural course of human suffering.  It's funny -- as I started by saying -- because it seems like the combination of medications together with psychotherapy  may work best.

Let me address the quick fix thing.  First off, most psych meds take a while to work, they aren't quick fixes.  Second, we've all read that medication helps depression only 30% of the time, or the same rate as placebo, and this  because in clinical psychiatry it often takes a few tries to help someone -- switching medicines, augmenting one medicine with another, or trying some unconventional or creative cocktails. The study looked at a single trial of one medicine versus a sugar pill, not real life psychiatry.  And then we've got that *#$&~ DSM issue which boxes one in, says people have to "meet criteria" as though it's a totally real entity any more than diabetes is (-- see Psych Practice's post on just how scientific the diabetes diagnosis actually is) and there is the implicit criticism that if you take a pill for psychic pain that doesn't 'meet criteria' then it's just WRONG.  Can you imagine if you had a headache and wanted to take an aspirin to stop the pain, but you were told that since there wasn't an anatomical reason for the pain, taking that aspirin makes you a weak pill-popper?     

There are those who feel we should rely more heavily on psychotherapy, as though it's one or the other.  As though we know in advance who therapy will help heal of their mental  illness (we don't), or who therapy will help comfort during a painful journey.  I believe therapy is helpful to many people for many reasons: one is that for some people it provides tremendous insight and relief, though the two are not necessarily connected.  Another, is that by scheduling patient for hour-long sessions, it's so much easier to evaluate and understand them, to know the quirks of their personality and the patterns of their distress in relation to the nuances of their lives, and not just as a checklist of symptoms and side effects taken as independent variables apart from their environment and their perceptions of that environment.  You help them see their patterns, whether it's how they relate to authority figures or how they always feel worse (or better!)  when they stop their medicines.  Finally, when you're on a journey that may be long and painful, it's so nice to feel heard and cared about and like you're a human being whose emotions are important, and not like a person at the deli counter-- #16 today, "I'll have a script for Zoloft  please."    But as a cure, therapy doesn't always work, and we don't have a prescription for how long and how much therapy one needs, or of what type, before we can tell if a trial is adequate.  For medications, there are often some guidelines with regard to dose and time; for therapy there is not.  If you come for treatment of depression, how much therapy is enough to say we've given it a fair chance before adding medications?  Twice a week, 50 minute sessions, for two months or two years?  And what if the patient can't afford the cost of that and wants to try the $4 generic from Wal-Mart?  

So that you know where I stand: if it helps, go for it.  Meds (if the benefit outweighs the risk-- and yes that's important: sometimes the benefit does not outweigh the risk), therapy, light boxes, exercise, ECT, TMS, DBS, acupuncture, yoga, chocolate... I'm all for the reduction of discomfort for those who are seeking it, and I'm all for letting people heal as they will without the judgement of others telling them how to do it right. 

Hmm, I'm not sure what got into me today....