WHAT IS AN ARTICLE on meds doing in the Recovery section of this site? Read on ...
During the first months of 2009, I ran three successive reader polls on my blog, Knowledge is Necessity. Let's pick up on the action in my second poll:
"How do you rate your meds in managing your illness?" I asked my readers. The results, quite frankly, astonished me.
One half responded that meds were their single most important tool and one third that their meds were "important, but no more so than their other tools." In other words, four in five patients put meds at the top of their list, either as a solo act or with a dance partner.
Interpreting the Results
How Do You Rate Your Meds in Managing Your Illness?
50% - Single most important tool
Thus: 80 percent who rated that meds as important vs 14 percent who are actually well.
How Well Have Your Meds Worked for You?
14% - Very well
Thus: Half reported satisfactory results with their meds, but one-third gave a clear thumbs-down.
An assumption: Smart patients working with smart doctors could probably raise the satisfactory results level from half to three-quarters.
Let's go negative first:
The fact that more than eight in ten of you - yes, you - reported that your meds are not working "very well" - for whatever reasons - speaks volumes. Consider that most of those in the "conditional" and "problematic" groups are more likely headed down than up (based on very clear trial evidence that less than a complete response to meds is a very strong predictor of relapse).
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Add to that the fact that the "complete disaster" group is running in a virtual dead heat with the "very well" group and we are talking very low levels of customer satisfaction.
The only way we can put a positive spin on the results involves seeing possibilities in the "conditional" and "problematic" and even "disaster" groups. Suppose, for instance, half of those in the conditional group were to graduate to "very well." Likewise, suppose we could get similar conversion rates from the "problematic" and "complete disaster" groups. Then three-quarters of you would be happy customers.
How is that possible?
The meds are the one constant in this equation. The two variables are you and your psychiatrist. First imagine a smart patient working with a smart psychiatrist. Now picture a naive patient placing his or her trust in a lazy and indifferent psychiatrist. Are we likely to see dramatically different outcomes? One example:
You come to your psychiatrist depressed. He diagnoses you with clinical depression. The antidepressant doesn't work. In fact, it makes you feel worse. The psychiatrist tries you on another antidepressant, then another. You are starting to feel like you are crawling out of your skin.
Then your psychiatrist gets a bright idea - or rather a thought implanted in him by a drug rep the day before. Based on his conversation with someone way too dumb to get into med school in the first place but attractive enough to take up a career in modeling (whether male or female), he now decides that the answer to your problem is an atypical antipsychotic to kickstart the antidepressant.
A smart psychiatrist will know exactly the right situation to make this call, but leave it to you to get stuck with the dumb one.
Joke: What do you call someone who graduates last in his class at medical school? A doctor.
I'm only half joking when I say that psychiatrists are people not smart enough to be proctologists. Yet they are licensed to practice medicine. So here you are, stuck with a dumb psychiatrist who is putting you on an antipsychotic on the advice of his drug rep. Don't look at me that way - this happens all the time. If something good happens, attribute it to dumb luck - emphasis on dumb.
A smart psychiatrist would have questioned why you weren't responding to antidepressants in the first place. The most likely answer to that question is because you are actually dealing with bipolar or something in the bipolar spectrum rather than classic depression. At any rate, a smart psychiatrist would investigate and know how to interpret your responses. And she would have called in a family member to find out what you conveniently neglected to disclose (such as your tap dance routine at Uncle Ernie's funeral).
So instead of adding an antipsychotic to your antidepressant to treat depression, she might wean you off the antidepressant and put you on a mood stabilizer to treat bipolar. It may or may not work, but - trust me - smart is a better strategy than dumb. If it works, your "complete disaster" scenario has been turned around. In all likelihood, you still have a long way to go. But now, at least, you are in a position to learn more, to move up from being a naive patient to a smart one.
A smart patient working with a smart doctor. What a difference "smart" makes in the equation.
My Readers Weigh In
One of my readers, Annie, commented that:
It's not necessarily a case of the medication not working, it's that the person never needed the medication in the first place. A drug can be over prescribed to the extent that its number of "failures" masks the benefits it has to the few. Unfortunately the bashing it then takes for its lack of effectiveness can end up denying the drug to the ones who can benefit most.
I hear you, Annie. Meanwhile, Louise had this sober reminder:
Would you keep going back to a restaurant where the food was bad or made you sick just because it was cheap and convenient? It is unfair, but a fact of American life that the best doctors often LEAVE the insurance groups and are fee-for-service only. We all have to figure out how much our wellness is worth to us.
Which brings me to one of my old themes: We are far more exacting in finding the right hairdresser - no way would we put up with someone incompetent. No way would we go back. But for some perverse reason, we actually treat the outside of our skulls as more important than the inside.
Wrapping Up Smart Meds Strategies
Hopefully, you now see my point in putting a meds article in the Recovery section. To elaborate:
"Treatment" implies your clinician is in charge, not you. There is valid reason for this when you are in crisis or just coming out of it. Further along, clinicians talk about "shared decision-making," but they tend to interpret this to mean, they decide, you say "yes."
"Recovery" means that you are in charge. Whether you are seeing a yoga instructor or a holistic practitioner or a nutritionist or a medical doctor - they advise, you get to say "no."
In the recovery phase, meds are a complement to your recovery practices, not the other way around. The best evidence we have indicates that in no way should meds be regarded as the cornerstone of long-term illness-management, namely:
The NIMH-underwritten STAR*D trials of the mid-2000s found that over one year, only one in four of depressed patients got well and stayed well on antidepressants.
The NIMH-underwritten STEP-BD trials from the same period found that over two years only one in three patients with bipolar managed to get well and stay well on various meds.
Yes, you may need to be on meds, but only as part of a smart wellness strategy integrated with all your recovery practices. Your doctor is either too dumb or lacks the time to assist you with this.
In essence, when it comes to your recovery your doctor has abdicated all authority over to you.
Be smart, live well ...
Reviewed July 10, 2016
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