Overprescription | The Pillbox

Mental Disorders: Are We Over Medicating?

In 1948, the World Health Organization (WHO) defined health as “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.” However, mental illnesses are not seen in the same light as physical illnesses. People who get labeled with psychiatric diagnoses often carry a heavy burden of social stigma regarding those diagnoses, and are generally uncomfortable disclosing and/or discussing them openly.

In ordinary conversation, it is not considered strange to mention that you had an appendectomy or discuss how you’ve been dealing with your diabetes for years. However, saying that you’ve been manic-depressive for years or that you’ve been desperately trying to overcome panic attacks is something that typically generates a negative response, and raises red flags for some people.

Why is mental health perceived so differently than somatic and physical health?

My inspiration for writing this piece was a debate about mental disorders held at the Emmanuel Centre in London, entitled: We’ve Overdosed. Psychiatrists and the Pharmaceutical Industry are to Blame for the Current Epidemic of Mental Disorders. Psychoanalyst Darian Leader, and accomplished author on the issue Will Self, argued for the “overdosed” side, while Dr. Declan Doogan and Professor Sir Simon Wessely, president of the Royal College of Psychiatrists, argued against it.

Is it true that mental disorders are made up by big pharma? Or is it just that we have a difficult time accepting that our psyche can, indeed, be a subject (or object, depending how you see it) of pathologic deviance and aberration? And that such aberration could and should be subjected to medical treatment?

Some critics view mental disorders as illnesses that have no definitive pathomorphological substrates. Are physicians overprescribing these agents to satisfy big pharma interests? Do they purposefully try to make the psychiatric bible (a.k.a. Diagnostic and Statistical Manual of Mental Disorders – DSM) thicker and thicker in each subsequent edition by bloating it with irrelevant and artificially fabricated diagnoses?

No one is claiming that every form of deviation from the “gold standard” of behavior (if such thing exists at all) is and should be proclaimed as a psychiatric disorder. No one is saying that every psychiatric disorder needs to be treated pharmacologically. No one is denying that many psychotropic drug treatments, unfortunately, fail among some patients. No one is saying that some classes of psychotropic drugs don’t induce debilitating side effects.

However, as future physicians we always have to remember that we will have a person with a problem sitting in front of us. This person will be seeking our help. We only have what is available to help them. We can only fight with the weapons that we have. Yes, sometimes treatment in psychiatry feels like we are trying to kill a mosquito with a rocket launcher. But it is the only thing we have got and for some it can be a salvation, regardless of the collateral damage.

My psychiatry professor once said, “if there is an equivalent of hell on Earth, it would be in a soul of a depressed person.” I could not agree more.

Severe mental disease is not a joke. It is not something that can be solved with a thoughtful late afternoon conversation, by reading a line or two from Coehlo, or by reciting a poem by Neruda. Sure, activities like those are great adjuncts and can help ameliorate the situation to a degree, but people who are in trouble often need and demand much more from us.

Let’s not forget that when we’re talking about mental disease we are talking about the state of a diseased brain (physical) and mind (cognitive/psychiatric), which is most likely due to a neurochemical imbalance within the central nervous system circuits. This imbalance needs to be medically treated, especially in cases where it severely interferes with daily living. For some people, psychotropic medication is their only hope and the only chance they are going to get. For some people these medications perform miracles. We do not have a right to deny them such a possibility.

References

Angermeyer MC, Matschinger H. The stigma of mental illness: effects of labelling on public attitudes towards people with mental disorder. Acta Psychiatrica Scandinavica. 2003;108(4):304-9. doi: 10.1034/j.1600-0447.2003.00150.x.
Schomerus G, Schwahn C, Holzinger A, Corrigan PW, Grabe HJ, Carta MG, et al. Evolution of public attitudes about mental illness: a systematic review and meta-analysis. Acta Psychiatrica Scandinavica. 2012;125(6):440-52. doi: 10.1111/j.1600-0447.2012.01826.x.
Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. Jama. 2010;303(1):47-53. Epub 2010/01/07. doi: 10.1001/jama.2009.1943.
Arroll B, Elley CR, Fishman T, Goodyear-Smith FA, Kenealy T, Blashki G, et al. Antidepressants versus placebo for depression in primary care. Cochrane Database of Systematic Reviews. 2009(3). doi: 10.1002/14651858.CD007954.
Leucht C, Huhn M, Leucht S. Amitriptyline versus placebo for major depressive disorder. The Cochrane database of systematic reviews. 2012;12:Cd009138. Epub 2012/12/14. doi: 10.1002/14651858.CD009138.pub2.

Featured image:
Reeve041788 by Otis Historical Archives National Museum of Health and Medicine

The Opiate Epidemic: A tragedy for patients is a warning to physicians

As student doctors, we are entering the medical field in the middle of a raging wildfire: an “opiate abuse epidemic.”[1] The media would have us believe that addicted patients are perpetuating the problem of opiate misuse and overuse, but opiate misuse and overuse might only be a symptom of a larger problem: a medical culture in which physicians fail to practice good prescribing habits.

Overprescription and subsequent overuse of opiates is undoubtedly further complicated by the ambiguous disease process of chronic pain, a topic which deserves its own time and attention. Questioning provider prescribing practices, however, may be the only path forward in making sure that the tragedy of this crisis does not escalate further. In my mind, there are several features that characterize ideal, quality prescribing habits. First, quality prescribing should place an emphasis on patient education about the drug being proposed. A patient should also be screened for the risk of developing any side effects. Included in this should be a review of any other medication that the patient is currently taking, and potential drug-drug interactions. If necessary, a pharmacist should be involved in this evaluation. Finally, a plan between the physician and the patient to manage care should be established. For medications known to be highly addictive, this might involve a phone call a week later, and a follow up in-office appointment to see how the patient is reacting to the prescribed drug. If at any point these benchmarks for safely prescribing a medication cannot be met, then the treatment choice should be reevaluated.

It was curious timing that in the middle of this epidemic, on May 5, Hawaii House Bill 1072 quietly died in the Hawaii state senate.[2] Bill 1072 “Relating to Prescriptive Authority for Certain Psychologists,” was meant to allow psychologists to have medication prescribing privileges in order to compensate for the Hawaiian physician shortage.[3] At first, I was relieved to read that the bill had not passed the Senate. As a future physician, it’s unsettling to imagine another profession encroaching on the special modalities that we have at our disposal to treat patients, such as our prescribing privileges. But then I had a second thought. If the average physician fails to exercise high-quality prescribing practices, then perhaps clinical psychologists, who by definition study human behavior, might actually make better opiate prescribers than the average physician. In general, psychologists spend time listening and learning about their patients’ history and behavior patterns, offer counseling education, and meet with their patients on a regular basis. This model of health care encompasses many of the aspects needed for ideal prescribing habits, as previously described.

You don’t need a medical degree to understand that opiates are powerful drugs that have many side effects and can lead to addiction. What we don’t yet seem to understand, as a profession, is how to effectively communicate these risks, or evaluate the best patient candidates for the use of opiates. A 1992 study by Wilson et al. found that when physicians increased the time of their patient interactions by just 1.1 minutes, there was a statistically significant increase in the amount of health education that a doctor could incorporate into a standard visit.[4] While it’s difficult to get specific data about the average length of a typical doctor’s visit[5], a 2013 article from the New York Times suggests that the average new physician spends only eight minutes with each patient.[6] If you have ever participated in a standardized patient encounter as part of your medical school curriculum, you have undoubtedly experienced the struggle to perform a history, physical exam, and basic patient counseling in 14 minutes. When you take into account the level of patient screening and education that the prescription of opiates, or any narcotic, demands, it seems implausible that a doctor can satisfy the requirements necessary to safely discharge a patient with an opiate prescription in such a short span of time.

In response to the opiate crisis, the ultimate long-term goal for the medical community should be to better understand chronic pain, and devise alternative treatment modalities for this diagnosis. In the meantime, however, the medical community should view this unfortunate situation as a call to reevaluate the quality of our prescribing practices. Current and future doctors need to commit ourselves to being worthy of the privilege of the prescription pad, so that it remains a treatment tool and not a source of patient harm.

References:

http://www.cnn.com/2016/05/11/health/sanjay-gupta-prescription-addiction-doctors-must-lead/index.html
www.civilbeat.com/2016/05/2016-session-ac-for-schools-help-for-housing-and-homeless/#.VyzIubQqa3o.mailto
http://capitol.hawaii.gov/measure_indiv.aspx?billtype=HB&billnumber=1072&year=2016
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1881485/
http://www.ajmc.com/journals/issue/2014/2014-vol20-n10/the-duration-of-office-visits-in-the-united-states-1993-to-2010
http://well.blogs.nytimes.com/2013/05/30/for-new-doctors-8-minutes-per-patient/

Featured image:
Medication by Gatis Gribusts