Page 1, 2, 3, 4, 5, 6
One study worth describing in greater detail, which illustrates these poor outcomes, involved patients with psychotic disorders.26 This study included 64 schizophrenia patients, 12 schizophreniform patients, 81 other psychotic patients, and 117 nonpsychotic patients. All these patients were assessed as inpatients and then reassessed 5 times over the 15-year study period. At 15 years, the percent of schizophrenic patients in recovery while on antipsychotic medication was 5% compared with 40% of schizophrenic patients not on medication. In a more recent report by two of the same investigators, the schizophrenia patients in their sample who were treated continuously with antipsychotics over 15- and 20-year periods showed considerable psychopathology and few sustained periods of recovery.27 They even noted that the sample of schizophrenia patients who were not treated with medication for many years fared significantly better and had much better outcomes than the sample of schizophrenic patients on antipsychotic medication.
While problematic medication-induced psychoactive effects cannot always be well demarcated in patients who have histories of poor lifestyle habits, problems with interpersonal relationships or social competence, difficulties in maintaining employment, and/or habitual substance use/abuse, the psychoactive effects of psychotropic medications in and of themselves add a significantly harmful "biological" burden that makes the capacity for change and recovery much more difficult. The most unsettling biological effects have to do with adverse brain changes (i.e., damage) that result from psychotropic medication. These have been well elucidated by many investigators. Examples include the extrapyramidal syndromes (i.e., akathisia, dystonia, parkinsonism, and tardive dyskinesia) associated with antipsychotic medication, psychomotor and cognitive impairment associated with long-term benzodiazepine medication, the depressogenic effects of antidepressant medication (especially long-term), and the cognitive deficits associated with psychotropic medications used to treat bipolar disorders.28–33
Here is a case that demonstrates the damaging effects of psychiatric medication. The patient is a very pleasant 25-year old male with pronounced tardive dystonia. During his first year of college (sometime in 2004), the patient began to withdraw from life, slowly losing contact with his friends and family. He also became agitated, requiring little sleep, and his thoughts and therefore his behaviors became increasingly more bizarre to his fellow students and diminishing pool of friends. He was eventually admitted to a nearby hospital and given a diagnosis of schizoaffective disorder. He was prescribed 2 mg daily of risperidone to manage both the psychotic symptoms and agitation. Within about 10 days, his condition stabilized and he was discharged back into the community with a referral to an outpatient psychiatrist and instructions to attend an outpatient program for mental health patients. Within several weeks of taking risperidone, he developed frequent episodes of facial grimacing and painful upper-body contractures, characterized by having his shoulders being temporarily fixed into a shrugged position with concomitant tensing of the neck muscles. When I last saw this patient, the facial grimacing (tardive dyskinesia) had lessened, but his painful contractures (tardive dystonia) involving the upper trapezius and anterior cervical muscles were occurring constantly. The patient was having these dystonic episodes numerous times throughout the day. They became so bad that he had to leave his job because he was getting unwanted attention from his coworkers and clients, which resulted in shame, increased psychological distress, and embarrassment. When this patient questioned the value of this medication to several psychiatrists, each one told him that the medication was necessary for his ongoing stability, without any concern or compassion for resulting physical impairments. This is alarming, but not so surprising. The patient actually believes that the medication is necessary despite the fact that he has been neurologically damaged for life as a result.
The increasing medicalization of mental health makes patients believe that their human struggles can be remedied by taking prescribed psychotropic medication (i.e., "popping" pills) instead of committing to the very difficult task of identifying and solving problems, and thereby making their lives better and more fulfilling in spite of setbacks and learning to become more tolerant of emotional discomforts. Middleton and Moncrieff discussed this in their provocative article that questioned the merits of antidepressant medication. They noted the following: "Symbolically, medication suggests that the problem is within the brain and well-being is dependent upon maintaining ‘chemical balance' by artificial means. This message encourages patients to view themselves as flawed and vulnerable and may explain the poor outcomes of treated depression in naturalistic studies."34
Another unfortunate consequence of psychotropic medication is that prescription drugs can be disempowering. Most clinicians providing care communicate to patients that the best thing they can do for themselves is to take psychotropic medication. This touted biological "fix" often makes patients believe that this is the most important component of their recovery. Too much emphasis has been placed on the essentialness and/or beneficial properties induced by psychotropic medication. This confuses patients and leads them to believe that other components (e.g., psychological and spiritual development, counseling, and regular exercise) designed to facilitate recovery are incapable of providing sufficient results over time. This often pushes patients in a "medication-only" direction and makes them less likely to use nonmedication resources that could be extremely beneficial. Thus, in many instances, the provision of psychotropic medication hinders recovery and undermines allostasis, particularly as a result of disabling psychoactive effects (especially, long-term), and by demotivating effects that result when medications are promoted as the most important elements involved in treating serious mental illness.
3. Psychiatric Diagnoses
What happens to patients when their signals of mental distress are labeled with psychiatric diagnoses? Some patients find comfort and solace in receiving a psychiatric diagnosis, since this legitimizes (in their minds) their suffering and provides succinct rational reasons for their misery. However, my clinical experiences have suggested quite the opposite. Patients often internalize their assigned psychiatric labels similar to patients who receive a diagnosis of diabetes or congestive heart failure. Typical doctor–patient interactions teach patients that their mental struggles are the result of some disease process requiring pharmacological treatment, or else the consequences will be disease progression, much like untreated diabetes. Patients learn to identify themselves with their psychiatric diagnoses, and their problems thereby become very specific, requiring precise psychotropic treatment.
When Mary went to her family doctor and received a psychotropic medication, she was told that her mental health struggles were the result of a biochemically "imbalanced" (i.e., diseased) brain. Instead of understanding Mary and her life problems, her family doctor disconnected Mary from them by assigning her psychiatric diagnoses and medicating her. Mary also became disconnected from her problems by believing in her psychiatric diagnoses with their assigned biological fix. The end result of this common clinical conundrum is that patients like Mary do little to enhance their lives beyond taking psychotropic medication, since the most valued and recognized approach to their treatment involves the "medicalization" of their human struggles.
Another unfortunate consequence involves the stigma associated with psychiatric diagnoses. When patients like Mary believe they have a psychiatric problem requiring a biological "fix" this implies an underlying defect. Stigmatizing patients only deepens their psychic injuries and makes them more recalcitrant to grow and change since their humanity and struggles become secondary consequences of their presumed mental defects. As a result, patients feel more vulnerable, experience more shame, and feel less tolerant of life stresses. This interferes with their motivation to solve problems and implement positive changes and reduces their capacity to stabilize (i.e., makes achieving allostasis more difficult to achieve).
4. Family and Friends
Having a good support system is a definite asset and an integral part of recovery. Many families and friends of mentally unwell patients provide loving support and helpful encouragement. However, it is not uncommon for families and friends to become obstinate when a patient exerts his/her own ideas about treatment. When Mark mentioned to his parents that he would like to eventually discontinue his psychotropic medications, they told him that he could only live with them as long as he remained on medication. This is a very common method by which families undermine progress in a loved one. When threats are used to manipulate a particular outcome, this usually results in more acting out (i.e., frustration and/or anger) or the opposite (the patient becomes more inward, depressed, and socially isolated). None of these outcomes are helpful, since they prevent an honest and frank negotiation about what the patient wants and how best to meet these expressed needs.
Another problem that patients experience is that family and friends become hypervigilant about the patient's day-to-day moods and behaviors. All people, not just patients, have normal ranges of emotional responses daily; these can vary from mild to very intense. Otherwise normal daily fluctuations by patients are often thought to signal mental distress and possibly destabilization. An angry patient with a diagnosis of schizophrenia is thought to be destabilizing and psychotic as opposed to being justifiably angry about something. The patient has to "walk on eggshells" and maintain, on a day-to-day basis, a very narrow range of emotional responses to life events. Inevitably, the patient cannot contain this narrow range (for such containment is abnormal) and will have moments where his/her emotional reactions can be sudden and even extreme when witnessed by family and friends. This often results in unnecessary pressures to take more psychotropic medication and/or to conform behaviorally in a manner that is unreasonable. Thus, threats and constant hypervigilance by family and friends do little to promote wellness or instill the confidence necessary to recover from struggles with mental illness. These factors undermine allostasis and deny patients the healing potentials and joys that loving and nurturing relationships can provide.
Psychosocial Strategies that Promote Allostasis and Functional Recovery
An individual's capacity to buffer the ill effects of allosteric overload arises from genetic endowment and life experiences.3 Allostasis can be strengthened by psychosocial treatments aimed at increasing an individual's resilience to the stresses of life. Many resources can be utilized to strengthen a patient's circle of care, thus affording better outcomes and greater possibilities to live with satisfaction and purpose. This is all predicated, however, on the patient's ability to recognize value in such treatments despite the fact that they are given mere lip service by the majority of clinicians, who typically focus only on prescribing psychotropic medication.
1. Access to Proper Shelter and Regular Meals
Some patients live in inadequate environments where they do not feel safe or comfortable. If their living situations remain problematic, this will only trigger further mental distress. I had a patient who would dissociate when he felt physically threatened by the neighborhood surrounding his apartment. Only when he moved to a new apartment could he find solace and comfort in his living quarters. That moderated the frequency of his dissociation. It is important that patients have access to a residence that provides comfort, safety, and stability. As clinicians, we need to ask our patients about their living situations and get in touch with their case workers or social workers to see what opportunities exist when there are problems with their residences. This seems like a lot of work, but it becomes impossible to move treatment in a positive direction when patients' basic needs for shelter are compromised.
Additionally, patients need to eat regular meals and have access to nourishing food. I have a patient who often runs out of money and then ingests sugar packets instead of real food. Sometimes he consumes more than 50 sugar packets in a day. This patient does receive enough money for his basic needs, but due to compulsive spending he often runs out prior to the month's end. In supporting this patient, I have encouraged him to access free meals and food banks. All patients, despite their issues and obstacles (whether self-imposed or otherwise), need to eat regular meals and should be encouraged to use free resources. When patients cannot access regular meals, their treatment and progress are thwarted until they can eat normally.
2. Psychotherapeutic Service Referrals and Forming a Therapeutic Alliance
Patients should be referred for ongoing psychotherapy to better understand aspects of their lives that might be impeding their growth and/or to receive emotional support. The most integral aspect of successful psychotherapy happens to be the therapeutic alliance. It is vital to the patient–clinician relationship that the psychotherapeutic encounter offers understanding, acceptance, a safe space without judgment or threats of hospitalization, and well-articulated and negotiated care. These "alliance" factors facilitate healing and will impart feelings of wellness while also reducing or moderating symptoms of mental distress. Research across several studies and meta-analyses has consistently shown a strong relationship between the therapeutic alliance and outcome (for an example of this research see Horvath et al.).35 In other words, the better the therapeutic alliance, the more likely that the patient will derive benefit from psychotherapy. These benefits are not just emotional but also physical, since structural brain changes have been associated with successful psychotherapy.36 When people experience a sense of belonging and have the perception of feeling supported and acknowledged, their brains will structurally change in a positive manner, rendering them less vulnerable to the stresses of life.
Among the many psychotherapeutic strategies available, I tend to refer patients to psychotherapists who also offer mindfulness-based approaches. Mindfulness practices teach patients to become more engaged in the moment while also allowing them to become more tolerant of emotional discomforts. Studies on mindfulness-based cognitive therapy have shown it to lessen excessive worry and emotionality.37,38 For a thorough discussion on the beneficial neural or brain mechanisms implicated in mindfulness-based meditation, the reader is requested to review the paper by Zeidan et al.39
Page 1, 2, 3, 4, 5, 6