Reply To: Psychiatric medicines

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As an adult psychiatrist in practice with a demographic of high-functioning young to middle-aged adults, I often prescribe “anti-depressants”, mostly SSRI’s, bupsirone, SNRI’s or NDRI (bupropion). While it is true that science has not shown us the biochemical milieu behind mood states, nor how these medicines work, I can only say that I see benefit daily in my patients. I presume a large part of the benefit is placebo – they are suffering, they finally receive help and get started in therapy. However, therapy often takes a couple of month, or more, to get started, and I don’t believe I am that powerful of a placebo response. I get response rates >90% and quickly. I suppose it could all be placebo, but people don’t necessarily respond to the first agent they try. I think the article is confusing – a lot of overlapping and changing topics and discussions – over focusing on “sedating” meds like opioids (not used by psychiatrists), TCA’s (hardly ever used anymore) and benzodiazepines (hopefully, rarely used as a last or short-term result). To the degree, that a BZD is “sedating” vs. treating an underlying disorder directly, biochemically – I’m not sure that matters. If you have ever had severe anxiety and panic, I’m sure the patient does not care what the mechanism is – it works! However, my patients on BZD’s are not zombies; they are alert and can think clearly. Too high of a BZD dose will definitely sedate. If these medications cause side effects, we find one that doesn’t. There is no evidence that antipsychotics cause sedation as a treatment mechanism – the goal is not to sedate the patient – it is to stop the voices and paranoia and they do do this. Only in an agitated, violent patient, would you try to sedate them – so they don’t harm themselves or others. There is a mental state called mania and lithium and neuroleptics actually resolve it, stop it, so if you believe you are God and you are going to harm someone who gets in your way, lithium can bring you back to reality. So, it is a much more complicated story. I only know that these medications do safe lives and help people function so that they can work and have families and enjoy their life. It is always great when a patient feels confident to pursue their affective mood states and trauma through therapy, and I recommend this to every patient. However, I can’t jump on the bad wagon that all mental health meds are bad. I don’t know why they work, but patients are better and are grateful. More relevant to TMS/PDD however is that if you are highly anxious and BELIEVE these meds will give you side effects, they will !! It is not uncommon for people with chronic pain to also be very sensitive to medication side effects – nocebo affect.