Friday, September 9, 2011

Would You Rather....?

You've probably played the "Would you rather...?" game - basically, you have to choose one of only two options. They might both be decent options...or both might royally suck!

For example:
Would you rather lose your keys, or your cell phone?
Would you rather be stuck for five hours on a broken elevator, or a broken ski lift? (obviously if you're afraid of heights you'd choose the first, and if you're claustrophobic, the second)
My clients get to play this game all the time...the stakes are just a little higher. For example:
Would you rather feel bad about yourself because you cycled back into  a depression...or because you're obese?  
Would you rather think people are trying to hurt you...or know they're laughing at you because you're missing most of your teeth?
Surely I exaggerate, right? Not really. In spite of the vast improvements in psychiatric medications over the last 10 years, serious side effects continue to plague patients, often leading stigma to multiply rather than decline with treatment.

For people who think medications are helping them, the top reasons for discontinuing medication are sexual dysfunction, and weight gain. Unfortunately, the vast majority of antidepressants (Prozac, Paxil, Celexa, etc) cause sexual dysfunction, while common mood stabilizers (Lithium, Depakote) and antipsychotics (Seroquel, Zyprexa, Risperdal) can all cause significant weight gain - with all the other health issues that go along with it.

What about the tooth loss? All of the above classes of medication cause dry mouth. While dry mouth is not usually uncomfortable enough to stop people from taking their medications, it significant increases the rate of tooth decay, and may contribute to inflammation or infection of the mouth's lining. When coupled with inconsistent dental care (due to hygiene issues, lack of insurance, or both), recipients of psychiatric treatment often experience tooth loss. Think about it: how many of your clients are missing teeth? Versus how many of your colleagues?

And all of this is completely ignoring the possibility of antipsychotics causing the development of Tardive Dyskinesia - motor tics, usually of the mouth and extremities, which is often permanent.

Sure, there are strategies for lessening some of these side effects. Diet and exercise may reduce the rate or amount of weight gain (but are hard for people even without any mental health issues). Drinking more liquids, and sucking on sugar-free hard candy can counteract dry mouth.

Nevertheless, we do our clients a disservice if we minimize the real dilemma of whether to take medication. Calling it "noncompliance" when clients skip or stop medication is both paternalistic, and an oversimplification of a complex and personal decision. Who am I to say someone "should" prefer obesity to hallucinations? I'm not sure I would be willing to make that sacrifice for "sanity!"

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