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!"

Meds? Therapy? Or Both?

A perennial question in the mental health world is, what is the "right" balance of psychopharmacology and psychotherapy? Obviously, the answer one gives depends on one's profession (are you a prescriber or a therapist?), as well as one's theoretical orientation (do you see psychopathology as the result of biology, learned behavior/ cognitive patterns, or unconscious drives/defenses?).

Clients also enter treatment with different opinions on meds vs. therapy, influenced by their culture and values, knowledge of treatment others have received, and exposure to media portrayals of treatment. Some are looking for a quick fix, and believe there is a pill that will end their discomfort (an opinion reflected in cultural and media messages). When the pill they are given doesn't eliminate their discomfort, they may think the prescriber is withholding something that would help them more. Some clients may not see medication as the be-all end-all, but may be opposed to talking about their feelings. Other clients don't see their difficulties as biological, and/or see taking a pill as an acknowledgment of weakness. And of course, there are people all along the continuum.

Where people fall on this continuum often influences where they first present seeking services. People who think meds are the answer are unlikely to contact a therapist first, while those who think meds are a sign of weakness wouldn't turn up in a psychiatrist's office. Of course, this self-selection doesn't apply if someone doesn't voluntarily seek treatment, and is instead hospitalized or mandated for evaluation. It also becomes blurred in clinics where psychotherapy and psychopharm. are offered as a "package deal" - as is true of most places that accept Medicaid and Medicare, and services affiliated with any hospital or health center.

Since people with more significant impairments often receive treatment at these kinds of clinics, prescribers have become legitimately concerned that clients (whom they typically see monthly, or less) may decompensate between visits, and the prescriber could be held liable. As a result, many - if not most - clinics require that clients engage in psychotherapy as a condition of continued psychopharmacology services.

As a result of this kind of requirement, the question of balancing therapy and meds is an ongoing issue for many clinicians. While it makes sense for prescribers to require clients who have not stabilized to engage in therapy, it may not make sense for therapists when clients are opposed to therapy.

I do believe that clients come in varying stages of readiness, and can get ready to engage in treatment as a result of coming to therapy. However, I also dislike being a "gate-keeper" for the prescribers, setting aside time weekly to see clients who are only interested in medication - and intent on making sure I know it. I also dislike the power struggle clients sometimes engage in over having to come to therapy: repeatedly cancelling or no-showing, dropping out of therapy while telling the prescriber they're still coming, or coming and sitting silently staring at the clock.

Some of these...reluctant...clients are reluctant because of the severity of their symptoms. They are at risk and do need to be monitored, and I can justify the time (to myself and the insurance company) as the best way to notice and respond to decompensation in a timely manner. However, there are also clients who have been in therapy for years, and feel that they no longer need it, but do still need to take their medication to maintain stability. Some of these clients may not be functioning as well as they claim to be - but many of them are really doing well. It doesn't make sense to me for people to remain in therapy forever, just because they need to take medication forever.

So, what is the right balance of meds and therapy - how do we determine, with prescribers and clients, who needs therapy, when and for how long? How do prescribers balance their own concerns about clients' functioning between visits, with the clients' expressed treatment preferences? And how do we get everyone on the same page?