The course of life is a mysterious adventure—bumps, challenges, and detours mark the road. At times, the mind becomes ill and strives for cures---one of which is psychotropic medication. People seeking psychiatric medication for themselves or their children often have the underlying fantasy that “God is in the pill.” Such a notion implies a miraculous restoration of balance and peace of mind depending on chemicals alone. Performance enhancing drugs are banned for athletes---but are given to children, adolescents, and young adults---often legitimized by a clinical, not hard-core measurable ADHD diagnosis. This is not true of all who need psychotropic treatments. Yet, for many of the “walking anxious” and restlessly dissatisfied, drugs are believed to be true restorers, if not enhancers. Regrettable fallout is thinking that mental problems, misbehavior, and learning differences can be "cured" by psychotropic drugs. The devil is in the side effects---if you look, often never discussed by physicians. Speed, fast pace, and hoping for “quick fixes” drive such misconceptions. Medications plus psychotherapies, to be sure, are such great expectations rationalized.
What is Mental Health?
Psychological well-being, adaptive competence, and an absence of mental disorder define psychological and behavioral wellness. A sound mind is functioning at a satisfactory level of emotional and behavioral stability and balance. This includes being able to enjoy life, creating balance among life activities, and achieving psychological resilience under stress. The integration of all these reflects a healthy mind.
The World Health Organization (WHO) states that mental health includes "subjective well-being, perceived self-efficacy, autonomy, competence, intergenerational dependence, and self-actualization of one's intellectual and emotional potential." WHO further states that realizing one's abilities, coping with normal stressors, productive work, and contribution to community echoes health. The new field of ‘global mental health’ is "the area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide".
What is Mental Illness?
Illness in psychiatry denotes disorder of emotional, thinking, and behavioral balance. A person struggling with his or her mental/behavioral health may face a variety of problems. These include stress, depression, anxiety, relationship difficulties, grief, addiction, ADHD, learning disabilities, mood disorders, thought disorders, and other psychological concerns.
Ideas of Cure in Medicine and in Psychiatry
The medical model is the conceptual framework that allopathic medicine has used for the last fifty years to guide its approach to patient care. It includes thorough history taking, physical and psychological assessment, laboratory testing results, clinical formulation, diagnoses, and a treatment plan.
The medical model is often contrasted with other models that make different basic assumptions also grounded on utility. Examples include holistic and alternative medicine, disability rights models, recovery and positive psychology perspectives, and the biopsychosocial approach used in psychiatry. The medical and these alternate models do not have to be mutually exclusive.
In most subspecialties of medicine, the core reference point is “disease.” Medical diagnoses seek to understand the pathophysiological mechanisms and etiological causes of disease. In turn, scientific attempts try objectively to isolate, analyze, and test therapies to treat these diseases. The end game is “cure,” if possible.
In psychiatry by contrast, psychological and behavioral signs and symptoms have been organized into clusters termed “disorders.” The Diagnostic and Statistical Manual of Mental Disorders, DSM-5, 2013, is the standard reference in psychiatry. When disorders are treated, goals are typical to manage the disorder so that signs and symptoms are diminished and a better quality of mental health achieved. The goal of cure in the sense of elimination may not be realistic.
Contrasting a strict medical model with the models used in psychiatry is useful but not definitive. Just as the history of medicine is long and complex, so too is the history of psychological medicine. In the latter, those most concerned with psychotherapies focused efforts on “talking” as the principal therapeutic technique. Treatment interventions were highly personalized and occurred over relatively long periods of time. Currently, those in psychotherapies spend several months rather than years learning about themselves. In the course of this, emotional coping skills, new thought patterns, and behavioral changes expand.
Over the last fifty years, professionals seeking the biological basis of psychiatric illness focused research on neurotransmitter and neurocircuitry study. Many significant findings led to the development of psychotropic drugs aimed at restoring the impaired biological substrates correlated with emotional disorders. At times, dramatic results have emerged. This and other factors have led to an escalation in drug prescriptions. Because results can sometimes be relatively “quick,” reliance on medication alone as the first-line intervention has arisen.
The Devil is in the Side Effects!
A rational approach to the treatment of psychological distress is one that is informed. Drugs have both effects and side effects. Typically, side effects are direct effects that are not desirable, and sometimes seriously problematic. Informed consent demands that a doctor discusses with patients the effects, side effects, risk-benefit ratio, alternatives, and giving no medication.
For example, a common diagnosis in children, adolescents, and adults is attention deficit disorder (ADD) or attention-deficit/hyperactivity disorder (ADHD). The conventionally prescribed first line drugs are the psychostimulant medications such as methylphenidate or the amphetamine derivatives. These increase vigilance, not learning as such, in up to 75%. Side effect occurrence and risks are substantial. A major pharmaceutical company marketing a stimulant reports the following (2015). Stimulants have a Black Box warning that states a high potential for abuse and dependence. Adverse drug reactions or side effects are decreased appetite 39%, insomnia 23%, irritability 10%, anxiety 6%, feeling jittery 4%, agitation 3%, restlessness, 3%, and affect lability (mood swings) 3%. Suppression in growth in height in children is reported in the literature. “Rebound phenomena,” an upsurge of irritability and hyperkinetic behavior, occur for a short time when the drugs wear off or are stopped. This may mislead parents into thinking that the child truly needs the drug rather than recognizing the situation as a withdrawal reaction, and medicine might not be needed.
Sensory Processing Disorder or Sensory Integration Dysfunction is not a DSM-5 diagnosis. It is typically given in educational contexts to describe children who are overly sensitive and reactive to sensory stimuli---problems with wearing certain fabrics, textures, noises, food peculiarities, and behavioral difficulties. Such children are said to be misdiagnosed as having ADD or ADHD and given stimulant drugs. One might speculate that it is the drug, itself, that is either causing or exacerbating such sensory problems.
Anecdotal reports from parents, teachers, and clinicians state that the child appears emotionally expressionless, affectively constricted, and not as “happy” (silly, light-hearted) as he or she had ordinarily been before the drug was started.
While these side effects are reversible, they all introduce clinically significant issues. These side effects often appear as new symptoms that are disturbing and troublesome. Often, the side effects, themselves need to be medicated. Insomnia, low appetite, and weight loss can be problematic in developing children.
While attentional difficulties and impulsive over activity may need medication, physicians do have options that have fewer side effects. For example, guanfacine is considered a second-line drug since its effects are less instant and dramatic than the stimulants. Guanfacine’s side effects, however, are also less dramatic. They include sleepiness 3.7%, sedation, 2.1%, tiredness, 1.6%, hypotension 0.8%. These side effects may or may not emerge in all children since their percent occurrence, in general, is low. Often, parents welcome a diminishment of hyperkinetic, over active behavior. In the Journal of the American Academy of Child & Adolescent Psychiatry, 09/22/2015, Wilens TE, et al. have recently shown that long-acting guanfacine is associated with statistically significant improvements in ADHD.
Dr. Alexis Feuer pediatrician at Weill Cornell Medicine and pediatric endocrinologist at New York-Presbyterian/Weill Cornell Medical Center recently presented a paper showing that stimulant medications such as methylphenidate (e.g. Ritalin, Adderall, Concerta, and so the like) are associated with low bone density in 8 to 20-year-olds. She says that if you do not accrue peak bone density during adolescence and young adulthood, you are at much higher risk for osteoporosis and fractures April, 2016).
Taking the Best of All That Therapies Have to Offer
The theme of this piece has been to show that psychotropic medications in isolation are not “magic bullets” that end unwanted psychological problems. Drugs are powerful tools that must be used intelligently and judiciously; and in psychiatry, they must not be used alone.
The role of psychosocial therapies has expanded in the last decades to include talking therapies and a wide range of behavioral therapies that aim to enhance performance. Individual, group, parent training, and family therapies are available. The field and subtypes are large and customized toward specific disorders to maximize effectiveness. In the case of ADD and ADHD, the role of a highly structured school program is indispensable. The Journal of Attention Disorders, 2015, 19 (10): 831-43 conducted a meta-analysis of multiple studies and found that parenting interventions are effective in reducing ADHD symptoms and comorbid conduct problems. When psychotropic medication is needed, psychotherapy and psychosocial enhancement interventions are essential to augment success.
People using mental health services often want more involvement in their treatment decisions than they are afforded, particularly decisions about the use of medications. The British Medical Journal concluded that "preference misdiagnosis" is a frequent problem among many clinicians, who erroneously believe that their unilateral treatment recommendations have adequately taken patient preferences into account.*
Pills are just one part of a large array of rational and realistic treatments that clinicians offer. Informed decision-making and asking doctors about least detrimental alternatives is a key part of every great expectation for help.
*O’Connor AM. "Modifying unwarranted variations in health care: shared decision making using patient decision aids." Health Aff (Millwood) 2004. doi:10.1377/hlthaff.var.
*Curtis LC, Wells SM, Penney DJ, et al. "Pushing the envelope: shared decision making in mental health." Psychiatr Rehabil J. 2010;34(1):14-22.
*Mulley AG1, Trimble C, Elwyn G. "Stop the silent misdiagnosis: patients' preferences matter." British Medical Journal. 2012 Nov 8;345:e6572. doi: 10.1136/bmj.e6572.
* Feuer, A. OR01-5 Use of Stimulant Medications and Bone Mass in Children and Adolescents: An Nhanes Study. Program: Abstracts - Orals, Poster Previews, and Posters
Session: OR01-Osteoporosis: What You Had, What You Lost, and What You Gain
Friday, April 1, 2016: 11:45 AM-1:15 PM.