Do I Enjoy Prescribing Medications?

After I had talked for a while over lunch at work about “big pharm” corruption, the distortion of research and academic psychiatry, and the overselling of psychiatric medications, a bright social work intern fairly new to our team pointedly asked me, “So, do you enjoy helping people more by prescribing medications or by helping them in other ways?” I had to pause for a moment to think about it. “I don’t enjoy prescribing as much as I used to,” I replied. As a psychiatrist just out of residency, I took great pride in my ability to help people with medications. I could get the symptoms of more than 90% of people in the hospital well under control by the time they were discharged, usually after a week or two. After I left residency and went to work in a community mental health center, I estimate that more than 80% of my patients got much better if they didn’t use illegal drugs and more or less complied with the medications I prescribed. I was doing battle with illnesses and winning. That was enjoyable. But over the years, I have seen need that far exceeds the need for symptom relief, and I feel far less like an all-powerful warrior.

Sedation

What was it like to be a psychiatrist in the 1950s and 1960s, when hospitals began using psychiatric medications? Did they seem like magic, or was it like the movie Awakenings, where the newly developed l-dopa miraculously brought Parkinson’s patients back to life? If so, why isn’t “the miracle of Thorazine” portrayed in any movie? And why was Thorazine called a major tranquilizer instead of an antipsychotic back then? I suspect those psychiatrists weren’t that dazzled by medications’ ability to calm people down and make them less acutely dangerous, either. After all, physicians had lots of other ways of doing that already—barbiturates and other sedatives, seclusion and restraints, wrapping patients in wet sheets, ice and hot baths, electroconvulsive treatment, lobotomies—although over time antipsychotic medications have replaced almost all of those things and are probably a significantly better option. Also, hospitalizations were much longer then, so I doubt that most inpatients on those chronic back-wards were as acutely agitated or dangerous as acute inpatients are now. I suspect that the ward was not as much of a battle zone as it is today. (For a view of inpatient psychoanalytically based treatment of psychosis from that era, read the wonderful first-person account I Never Promised You a Rose Garden.)

Connecting with People

Acute psychiatric hospitals today are basically funded to reduce acute agitation and dangerousness and to release people after only a few days, usually with nothing else accomplished. As a result, today’s acute care hospitals have grown to value medications primarily for their acute sedative properties, especially at very high dosages. (By the way, if you want hospitals to do something more humane than sedate and release in a few days, pressure Medicaid and insurance providers to pay for something else. All of my local private hospitals that accepted Medicaid and were more humane are now bankrupt and closed because of denied payments.)

I’d bet that what really impressed those inpatient psychiatrists 50 years ago was that with medications they could communicate with and have a relationship with patients they couldn’t connect with previously. This is still the property of medications that I find most enjoyable today. Someone can be entirely isolated—in a world of voices or paranoia or delusions, or depression, or dissociation or panic, or mania or obsessions, or anorexia—and by taking medications can reconnect with the world. I know a man now who only says, “It’s all right. It’s okay,” over and over, never bathes or changes clothes, smells horribly of urine and dirt, and is usually homeless when he’s not on medications. When he is on medications, he can have most of a conversation, live somewhere, eat, change clothes, bathe, and have friends more or less. That’s pretty satisfying. But he always refuses medications when he has a choice, so after a few weeks out of jail or a hospital, he drifts away again. That’s pretty heartbreaking.

When I applied to medical school, I already intended to become a psychiatrist. In my essay I wrote that I wouldn’t treat people against their will and I wouldn’t over-rely on medications the way they did at the state hospital. But my first day of psychiatric residency consisted of signing holds to keep people in the hospital against their will to force them to take medications. A good deal of my training there was focused on desensitizing me so I wouldn’t remember that I betray my ideals every time I forcibly treat someone. I’m glad that I failed that lesson. I work at a community-based treatment agency, the Village, that combines the best of assertive community treatment teams and rehabilitation clubhouses so I rarely have to forcibly treat anyone. Each time that I do, I struggle and agonize over the decision. I’m grateful for those feelings. I never want to be able to oppress people without sharing some of their suffering.

I remember when I was a first-year inpatient resident at the University of Southern California and I went to see a panel presentation that included the legendary R. D. Laing. He seemed to be on a different plane than everyone else. I couldn’t tell whether he was enlightened or psychotic or a charlatan. He talked about the healing for schizophrenia coming when everyone on Earth was reconnected and when the Earth was aligned with the moon and the planets and the sun and the stars. He said that the key was loving the person with schizophrenia. After the panel, I went up to the microphone and said, “I’m trying to do that, but don’t find it so easy to love people who are really psychotic and [whom] I can’t understand and whose emotions don’t seem to be connected to what we’re talking about. How do you get through to do that?” He told me to keep trying, it would work out. It seems to me that medications have often helped it work out—helped us to connect and share love.

Alleviating Suffering

Since medications have become less onerous over the years, most of the time now I don’t prescribe to reduce either agitation or dangerousness or even to help people connect with other people and life; I prescribe to help reduce suffering. People come to me suffering with a whole range of problems. They’ve usually had experiences where a psychiatrist made some diagnosis, described their suffering as the symptoms of that diagnosis, and prescribed pills that reduced their suffering, maybe not as dramatically as the ubiquitous commercials on TV, but people felt better—often, a lot better. They want to be back on medications. Sometimes that first successful psychiatrist is me, and it’s pretty enjoyable to help people feel better. Isn’t that what a doctor is supposed to do?

Three of the top-selling categories of pills are pain relievers, antianxiety pills, and antidepressants. I think of all three as “anti-suffering pills.” (Perhaps the current escalation in deaths by overdose of these pills should be considered people dying of unbearable suffering.) When we’re suffering for almost any reason, we’re likely to feel pain, anxiety, depression, or a combination of these and want relief. The problem, in my view, is that if we externalize our suffering and consider it a symptom, then our response is to just fight to get rid of it. But we might be getting rid of an important part of ourselves at the same time, which might leave us more damaged than relieved.

I’m particularly disturbed that in DSM-5 we’ve eliminated grief and folded it into major depression. Grief is important suffering. It’s how we know we loved. It’s how we honor our loss. It’s how we rebuild our hearts to love again. It’s not just a depressive symptom to be eliminated so we feel better. That feels to me like it’s making us less human. If instead we stick with our suffering and work through it, learn from it, find meaning in our suffering, and find gifts in our wounds, we will recover stronger and more human. It’s not that I want people to suffer, but I think separating ourselves from our suffering and medicating it to eliminate it isn’t really recovering any more than locking it away and trying not to think about it is.

When I’m at my best, I’m both prescribing medications and helping people work through their suffering. Medications can often be very helpful in reducing overwhelming suffering to something more bearable that can be worked with. Medications can be a tool of recovery and not just a tool for symptom relief. It is generally not the case that the more a person suffers the more likely he or she is to work through it; more often it seems to me it’s the opposite—people need some hope and sense of power over their suffering to really dive in instead of avoiding it.

When antidepressants were first developed, psychotherapists thought that taking medications would make therapy less effective because people would not be motivated in therapy if the pill helped with their depression. Studies of this topic at the time repeatedly showed that depressed people were improved more successfully with a combination of medications and therapy than with either one alone. Somehow, we’ve stopped emphasizing that combination over the years. Too many people are on medications alone. Many of them are getting medications from primary care doctors without ever getting mental health evaluations or therapy. The new integrated care paradigms mostly call in mental health professionals if antidepressants don’t work. Medication “responders” will never know what else might be going on or what else they might have benefited from if their nine-item Patient Health Questionnaire score goes down with a trial of antidepressants. They’ll just get refills.

Healing, Harming, and Recovering

Today’s health care system forces clinicians to focus on efficiency instead of on building enough trust so people will share their suffering with us. I enjoy people telling me that I’m the first person they told about being abused as a child or beaten by her husband, or about feeling guilty for using drugs, or about a secret abortion or rape or prostitution, or about the cancer being hidden from the family—the list of common human tragedies goes on and on—more than I enjoy prescribing medications. I really enjoy when people say that talking with me has given them relief or that I helped them gain a new perspective; I am gratified when they say they got some feeling of hope and power over their suffering. Those moments feel like real healing to me.

I think that “Do no harm” is an illusion. I likely harm everyone I come into contact with. Those I care about the most I probably harm the most, starting with my wife and family. Every interaction has unintended negative effects. Prescribing medications is no exception. We tend to focus on avoiding unintended biological effects, like weight gain or emotional numbing or diabetes or passivity. I’m often more vigilant than the people I treat in trying to reduce and avoid side effects. They will often passively live with side effects they don’t even mention to me unless I actively pursue information from them.

But what about emotional and psychological harm? How much harm does it do when I give someone a psychiatric diagnosis or a prescription? Maybe that’s why adolescents sometimes express more suicidality after they’re given an antidepressant prescription. Maybe that’s why so many people never return after they get a psychiatric prescription. I feel especially good when I have compassionate conversations with people and can anticipate how my diagnoses and prescriptions may harm them emotionally and psychologically and help prevent some of the damage before it ever occurs. I don’t take it for granted that patients will return to see me. I feel that I have to earn their return.

I guess I do still enjoy prescribing medications to help people—to help them become less agitated and violent so they aren’t restrained, secluded, or locked away; to help them connect to other people and life; and to help relieve some of their suffering so that they have some hope and belief in themselves and some motivation to find the strength to work through suffering and recover. Like most things in life, though, it’s not the simple pleasure it used to be, when I could just be a warrior fighting illnesses with medications. Life seems a lot more complex and interrelated to me now, and I feel a lot less powerful than I used to, but when it all comes together and I can feel someone really recovering and think that what I prescribed helped along the way—yeah, I still enjoy that.