The Right Rx

I am willing to bet all my possessions that everyone reading this knows someone, or even is someone, who has some chronic medical condition for which medication has been prescribed.

This need not be a terribly serious health crisis, but simply some medical condition that can worsen if not treated, and which perhaps cannot be cured. I am thinking of things like hypertension, diabetes, thyroid disease, high cholesterol, conditions we expect to be controlled by medication. There are even less common illnesses that can be controlled with medication, such as epilepsy. We think nothing of such situations, we applaud those who take control of their health by following doctors’ orders with medication and lifestyle changes, and we expect that at some time in our lives, any of us might have to be treated for a serious medical condition.

But how do we see psychiatric illnesses? Do we see most of them as chronic, manageable illnesses, or as frightening conditions diagnosed only in those who howl at the moon? We may accept that someone needs support after a stressful time, such as a death in the family, but there is still a stigma attached to mental illness that seems to have no "cause." We expect that those are the people who talk to themselves, fall into the depths of despair, or go into manic rages and shoot up a post office. And of course, we all know that mental illnesses cannot be managed and treated, that those who have such illnesses are doomed to a life of pain. Right? Maybe not.

The past couple of days I was at a conference focused on current treatments for illnesses such as depression and anxiety disorders. The points that were hammered home by all the speakers were these:

• Psychiatric symptoms such as depression and anxiety are as prevalent, if not more so, than most "physical" illnesses.

• Psychiatric illnesses have a negative impact on the physical well-being of those being treated for other conditions, such as cardiac disorders or cancer.

• Psychiatric illnesses almost always occur in pairs or groups — we almost always see other disorders in those diagnosed with an anxiety disorder, for example.

• The earlier the onset, the worse the prognosis.

• But the earlier the treatment, the better the prognosis.

• Many psychiatric illnesses are chronic and need to be treated as such.

• Multiple therapies work better in general, just as they do with more strictly medical diagnoses.

We need to start seeing psychiatric illnesses in the same way we see something such as high blood pressure. They are medical conditions that we can expect to recur and that need to be treated with a focus on the long-term. Studies cited by the presenters indicated that women with terminal breast cancer lived longer if they gained emotional support from a counseling group, individuals treated for their first depressive episode, even briefly, had fewer relapses and better recovery than those who were untreated, and if at first we don’t succeed with medications, we should try combinations. One presenter mentioned that the typical treatment for heart failure includes eight different medications, yet when it comes to something as complex as the brain we give up when something doesn’t work and expect to medicate with only one drug. This is probably not realistic. Add to this that so many people with psychiatric disorders have co-morbid substance abuse disorders, and we start dealing with altered brain chemistry that may only respond to a psychotropic cocktail.

Unfortunately, until mental illness loses its stigma, which it is starting to, many people won’t even seek treatment, and those who do may be ashamed, frustrated, and too confused to stick with a regimen if improvements are not seen immediately. Thankfully there has been more awareness in recent years with celebrities writing books and telling their stories on "Oprah." No matter what Tom Cruise may think, Brooke Shields did a huge service when she came forward about her postpartum depression and need for medication. Her book chronicles her own confusion, humiliation, fear, pain, and resistance to treatment, and may help many other people struggling with the same feelings.

Other celebrities, such as soap star Maurice Benard, have come forward with their struggles with bipolar disorder (formerly called manic-depression), a terribly debilitating and hard to treat mood disorder. Patients with bipolar disorder are often the most frustrating to treat and the most frustrated themselves as drug after drug fails to alleviate symptoms, or something intended to address the depression causes a manic state. Because of the pain they are in, those with bipolar disorder are known for lack of medication compliance, and, sadly, a high suicide rate. Luckily, the right medication or combination can stabilize their moods enough for them to function normally. I am working with a patient right now who came to me after a brief hospitalization for a suicide attempt. In our first session her mood was low and she was overwhelmed. Less than a week later she exhausted me with her tales of baking all night, walking around her town for hours, intense amounts of exercise, and starting several projects such as sewing new curtains, writing a short story, and painting a city scene. I immediately knew we had to get her an appointment with her psychiatrist to adjust her medication, as she had cycled all the way to a manic phase. I am happy to say that less than a year later she is not only working full-time (she was able to keep her job, although she took a couple of short leaves), but just started going back to college. Her moods have been stable for months and she is aware of her red flags and what to do if any turn up.

She is a success story, but for others it is not so easy. Only about a third of all patients with depression will respond positively to the first treatment tried. Some won’t respond to any treatments at all. If a heart patient didn’t respond to the first medication given, we would never dream of giving up; we would go back to our bag of tricks and try something else. We have so many psychotropic medications to choose from now, many with minimal or no side effects, and we need to start taking psychiatric illnesses as seriously as we take cancer and heart disease. Let’s put it this way: there are about 40,000 deaths from breast cancer each year, and 30,000 from suicide. To put it in perspective, there were 58,000 deaths throughout the entire Vietnam War. There is one suicide attempt in this country every minute. That is a serious public health issue.

One major difficulty that causes discouragement among people is that many of the psychiatric medications take some time to work. Some need to build up for weeks before an improvement is felt. This can make someone give up and stop taking the medications, but it is important to continue. As one person said about how Prozac worked for him, "It was like someone all of a sudden turned the lights back on." When it works, it works.

As I said at the beginning, we all know someone with a medical condition that requires ongoing treatment. If you or anyone you know may have a psychiatric illness that needs to be addressed, please don’t hesitate to seek treatment. And if the first treatment doesn’t work well, don’t give up. Mental illness can affect anyone, not just those who are too ill to function or who hallucinate. Very high- functioning people such as Abraham Lincoln had episodes of debilitating depression. Imagine if they had Prozac in 1860!

Dr. Barbara Kapetanakes owns the Sleepy Hollow Family Resource Center.

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About the Author: Dr. Barbara Kapetanakes