February 28, 2023 at 4:30 pm #2167
Hi Howard and Alicia, I am wondering if you have had the experience that patients taking psychiatric medicines specifically gets in the way of doing this work? I have been taking the approach that I do not suggest changes to their medicines while we do the work together. When their symptoms are improving they can decide for themselves coming off of the medicines. However, I have some patients that seem very emotionally numb from their medicines and wonder if the medicines are actually hindering the work. Thanks as always. BeccaFebruary 28, 2023 at 9:39 pm #2169abatsonModerator
I have found that it is best to not address the psychiatric or pain medications during treatment. What I find is that as patients do the work, their danger signal begins to turn off and their pain, other physical symptoms, anxiety and depression begin to get better. This improvement and “evidence” that they are on the right track gives them hope and more motivation to continue doing the work. As their symptoms improve, they notice they are needed the “as needed” or rescue medications less. Over time, they can develop confidence to work with their doctor to gradually begin to taper off of the scheduled medications. If they are doing the work and aren’t have symptoms, they should not need the medication.
However, I have found that if this process is started too early in recovery, i.e. before they have learned to keep their danger signal turned off and developed the confidence that it will stay turned off, then the process of getting of meds will only serve to scare them, thus keeping the danger signal on and the pain going. They risk misinterpreting the slightest symptom as a return of the pain or depression and a sign that they can’t do without it.
Most of the time, I don’t find that these medications are causing a problem though I do encourage people to try reaching for the “pro’s” less often as time goes on , so that they can instead use the onset/worsening of pain as “an opportunity” to learn how to intervene on their own behalf with practices of self-compassion, self-soothing and somatic tracking. The pain is the material you need to practice your recovery. I tell them, “begin to view your symptoms as an opportunity for you to learn how to better take care of yourself in the face of life’s stressors”. “To the degree that you are still having pain or other symptoms, that is information for you that you still have not fully learned how to take care of yourself”. So again, the brain is helping you to understand this.
If the patient feels like the medication is causing emotional numbing and they don’t want to feel like that, then it is reasonable to taper off of the medication – I would consider this a side effect. However, if there is some benefit for them (and sometimes they don’t realize there is benefit until they are off of it!), then it might be best to wait until they have recovered more fully.
I hope this helps. Thanks for the question.March 2, 2023 at 5:15 am #2178
Yes, that is very helpful. Makes sense. Thank you!March 9, 2023 at 6:01 pm #2212jtakahashiParticipant
This is an essay that was published a while ago but I only just recently came across it. Interesting food for thought!March 12, 2023 at 2:44 pm #2217hschubinerModerator
Great article, Jonathan!! This is a really important perspective and one that I take in my Anxiety and Depression book. The two influential books on this are from Robert Whitaker in Anatomy of an Epidemic and Irving Kirsch in The Emperor’s New Drugs. Both should be required reading for all physicians, especially psychiatrists!March 12, 2023 at 7:57 pm #2218aoldenParticipant
Very interesting discussion! Here is another recent article that challenges the serotonin theory of depression. The authors of this meta analysis concluded, “there is no convincing evidence that depression is associated with, or caused by, lower serotonin concentrations or activity… Most studies found no evidence of reduced serotonin activity in people with depression compared to people without. High quality, well-powered genetic studies effectively exclude an association between genotypes related to the serotonin system and depression, including a proposed interaction with stress.”March 14, 2023 at 2:04 am #2227abatsonModerator
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.March 15, 2023 at 12:13 pm #2239aoldenParticipant
Hi Alicia I am really glad to hear your take on this. I, too, believe in SSRIs and other antidepressants and, as someone who suffers from depression/anxiety, I can personally attest to the fact that they work. At the same time, I wish we had a good biochemical explanation but I think what you said makes a lot of sense. Thanks for your comments!March 16, 2023 at 8:56 pm #2247
I appreciate your thoughts Alicia. I have also seen significant changes in patients, and incredibly severe symptoms can be helped by medicines.
But I’ve more often seen patients chronically on medicines that aren’t helping and the list and amount of medicines they take gets bigger and bigger without benefit. Where I practice, the psychiatrists only focus on medicines. I have a patient with tardive dyskinesia from his antipsychotics to treat his ‘hallucinations about his neighbor trying to get him’. The psychiatrist and his therapist had no idea about his trauma history that included his neighbor bullying him throughout his teenage years and his parents not protecting him. The mental health field seems to be very afraid of bringing up and addressing trauma, but rather teaching patients to bottle it up and they need to ‘compartmentalize it’ as one ‘trauma informed’ therapist told me.
I think you underestimate the placebo effect you have with your patients Alicia 🙂
This is an interesting Hidden Brain about placebos – at the end is a description of a patient getting better from IBS when consciously aware she was taking a placebo. https://www.npr.org/transcripts/718227789March 17, 2023 at 11:34 pm #2248mwoodsParticipant
An interesting conversation, where PATIENT BUY IN (and not simply the search for a prescriber) continues to be the lynchpin, in this, a patient group that is often very cynical, critical, angry, desperate and even litigious. The novel (especially after years and decades of sx persistence, disappointment, unnecessary meds, tests, procedures, surgeries, and diminished hope) and essential ingredients we might offer are time, patience, and this new approach… to the management of a significant proportion of GP patient complaints…that our teachers have developed and refined. This new treatment model sadly does not fit into the piece work payment schedule in current use in Canada. My strategy has been to take on a manageable number of such patients, allow more time than usual, and stick to that agenda. By logging time with the patient at the outset, and in fact establishing credibility through a different type of exchange than has been previously experienced (eg hand on the doorknob), trust grows, and an action plan can emerge, with a careful and complete history, rock solid (minimum essential) diagnostics, careful recording and a plan forward that moves slowly and sensitively. In other words, we co-invent a plan that can turn off the Danger Signal. I appreciate Alicia’s candour re going too fast with a new patient and seeing them walk away. Yep, been there. A wise psychiatrist once told me, “if you are working harder than the patient, its time to back off and re-evaluate”. I have (painfully) learned more to be a guide than Mr Fix It, where the rate limiting step is determined by the patient, not by me. I am excited about learning new treatment strategies here, to engage a challenging and despairing patient group. Often on the meds list is a mix of psychotropics (SSRIs, SNRIs, TCAs, BDZs, atypical antipsychotics, etc) and narcotics, such that the role of each of these in the pill salad is confusing (and certainly numbing) at best, requiring a very slow and shrewd meds reduction plan. Yes, patients (with coexisting anxiety and dependent traits) become very invested in the notion that this pill salad is what is keeping them going, and any disruption in that list will cause them to topple. If Trust in our Program can be carefully cultivated and maintained, then careful meds reduction can occur, but I think the care giver-patient relationship must be sound before one starts. If the picture is further complicated by age related cognitive impairment, then we must modify our patient expectations and support/share that reality with the caregivers. The pharmacologists (depending on the meds and doses and pt comorbid conditions) typically guide us in weaning off the narcs first. I have no doubt that a pattern of positive interactions between doc and patient can boost the placebo effect of meds like SSRIs (longer term) and BDZ (short term) as we await the onset of effect of SSRS’s, while continuing to pitch the idea that the patient understanding, housecleaning and rebuilding is the more powerful and enduring stuff for the longer term. Where I live, the community supports for patients like this are woefully lacking. The belief-fear-chronic pain loop joins the mood disorders/anxiety and addictions loops where often all 3 coexist in these patients. There can be no doubt that providing a solid grounding in psychoeducation, ruling out structural/tissue damage, ruling in MBS, based on circumstantial and confirmatory testing/clinical assessment offers more than these patients have ever known in understanding and reversing conditioned response behaviours. Attitude is everything (Gordon) goes so well with seeing sx relapses/flares as opportunities, to harness the power of the prefrontal cortex to calm the and limbic system. But only when the danger signal has become contained and the slope of the line becomes positive.
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