The Power Of The Pill

Thursday, July 16th, 2009

"It is going to be a medicine that fixes me. You just have not found the medicine yet."
I have heard this particular wailing invective from at least five patients this week. It is customarily followed by insult. I am told that I am not a good enough psychopharmacologist, or something like that.
The first thing I do is review the psychiatric diagnosis. I do this from zero. Sometimes the diagnosis is just plain wrong, and has been perpetuated without being completely reviewed. Sometimes there are medical problems, like thyroid problems or low-grade chronic infections that can account at least in part for the "untreatable" symptoms. These can be found and treated and the condition can get better. This usually flies in the face of conventional wisdom and patient belief, but I would rather be correct than conventional.
It used to be that nobody wanted to have a psychiatric diagnosis. My patients were relieved, even joyous, if I told them that they had a medical problem and did not require psychotropic medications. Now, there is a new kind of person who believes in psychotropic medication as if it were a religion. "You just find me the right one, and that is your responsibility, and when you do that, I will be just fine and you will have me on a program of prescription renewals, and I will be happy and well."
I have known, and written about, the importance of belief in being delivered from the agony of psychiatric illness. To have belief in a pill is not the worst thing in the world, and can help.
I had a job, once, where I filled in for an impaired physician, who was inclined to give out pills that I did not think, according to what I had expected were consensual guidelines on psychiatric medication, were in any way going to work. And they did work. Now a certain number of the patients in this clinic were immigrants from foreign lands, who had great and wonderful beliefs in the prowess of American medicine; and most precisely, American pills. I was amazed how well they were doing on pills I would have considered at least somewhat inappropriate. When there was no question of safety problems, I would try to leave people on these pills. The belief in the pills was making them better, not the pills, but I didn't care. Not as long as they had no reason to get worse and some serious reason to keep getting better.
It is a lot more difficult when someone believes that no pill will make them better. They can keep changing pills, sometimes being directed by well meaning doctors to take more dangerous ones, in an effort to ameliorate symptoms. In these cases, the psychiatric symptoms, anxiety, depression, or the like, seem to get better for a few days if at all, before the pill is rated as another failure and the shopping around just keeps coming.
These cases are a lot harder to treat. But belief is the strongest force in the world, and it is tough to fight.
The deep truth within these cases is that when no medication works, something else is going on that is fighting the biochemistry - producing negative chemicals and symptoms in the brain, I expect, faster than standard medication can correct things. Perhaps, I often find some kind of a post traumatic stress disorder (PTSD) type phenomenon. Something intense and impersonal. Generally something painful and hard to talk about. These things respond to psychotherapy.
To have a "perfect" medicine that fixes everything means a patient can remain passive and let the doctor do the curing. This is a seductive idea, consistent with views that doctors had in years past. It is no surprise that a lot of the patients who feel this way are a bit older.
Nobody ever said it was easy to be a patient. I have had so many who have observed or been party to things no human should have to live through, inhumanities. I know they don't want to relive them in therapy. I also know that psychotherapy can really change lives. I am partial to modern, intense, and quick working methods. I have learned (the hard way) that some people are just better off if the psychotherapy part is slower and gentler and that is just fine with me. The important part is that people try to get well and realize that their idea of how to get well might not be the idea of the doctor, who may have some experience in these matters.