When is Psychiatry Effective?

[calebprime]

calebprime wants to speak of his experience re: misdiagnosis, histrionics vs. genuine suicidal ideation, treatment of children, and other matters, but needs some encouragement.

Also, very hard to speak of personal matters without revealing too much.

In other words, being sincere and speaking with the authority of one's own experience is very, very difficult.

I'll throw something out for starters: Since I've known 4 or 5 M.D's personally, one thing I've noticed is that they speak in a completely different way when they are thinking of you as an equal vs. when they think you are a patient, or a gomer. When they let their guard down, they speak much, much more cynically about the whole process.

For example, one highly credentialed M.D. (who I shouldn't identify) said that ect definitely causes severe memory loss and that personality theory is roughly akin to astrology....

I honestly don't even know how to discuss this...

 

[Dave1001]

It's standard for the region in question. In this case, my wife is in Nova Scotia, and I reviewed the timeframes with BC and they're identical, so it may be a Canadian standard. Medication is gradually reduced for bipolar i in 6-month timeframes. It is possible that after a series of increments, the patient is totally unmedicated.

Okay, to keep going back down that trail, what is the protocol for determining that someone with BP1 and BP2 should have their medication start being gradually reduced? Let's say someone is diagnosed with BP1 or 2 and is prescribed medication at a certain dosage of medication. If they are doing well and suffering no adverse side effects, why would the physician start gradually reducing dosage? What would be the point of it? Is this something they are supposed to start doing if the patient has gone a certain amount of time without an episode? In short, what is the protocol regarding this?

P.S. Thanks for sharing so much information in this thread.

 

[blutoski]

For example, one highly credentialed M.D. (who I shouldn't identify) said that ect definitely causes severe memory loss

Not a secret. Rare, though. Define "severe."

and that personality theory is roughly akin to astrology.

I've never heard of "personality theory." What's that?

 

[blutoski]

Okay, to keep going back down that trail, what is the protocol for determining that someone with BP1 and BP2 should have their medication start being gradually reduced? Let's say someone is diagnosed with BP1 or 2 and is prescribed medication at a certain dosage of medication. If they are doing well and suffering no adverse side effects, why would the physician start gradually reducing dosage?

Right. That was what my earlier post was outlining. If the patient's stable for, say, 6 months, then reduce dosage slightly and monitor for relapse. The patient would have the option of staying on the current dosage, but most look forward to reduced dosage because it usually reduces the side effects.

What would be the point of it? Is this something they are supposed to start doing if the patient has gone a certain amount of time without an episode? In short, what is the protocol regarding this?

I wouldn't go so far as to say they're isupposed to, because each region will vary in terms of standard treatment policy. However, the long-term goal is always to get the patient off medication, so I would be surprised to see regions that would leave a stable patient on their dosage without periodically trying lower values to see how the patient responds.

This is not just about bipolar: it would apply to most conditions.

One problem that may arise is if a patient has a history of being stable at, say 25mg and consistently failing at 20mg. A psychiatrist may be reluctant to reduce to 20 in a patient who is stable at 25, because of past experience.



Another problem that comes up with anecdotes from relatives is that unfortunately, patients are not always honest with their friends and relatives about their history. They are often embarassed about their episodes or noncompliance to therapy.

Just one example from last week: my wife had a patient who was punching people during group therapy. He was given a two week cooling off period, as it was threatening the progress of every member of the group. She overheard him on the phone explaining to his sister that the hospital was cancelling his therapy for budgetary reasons. A doctor is not allowed to get involved in these private relationships, so who knows what the sister thinks about the system?

 

[calebprime]

In the last hour, I realized that, being new to forums--this is my first--it was simply misguided of me to participate. It's not a matter of critical thinking or the facts. It's a matter of not having the emotional stamina to discuss personal stuff. One can't discuss one's friends, the doctors one knows, oneself, etc. etc. without giving too much away. I'm not trying to be coy. Chalk this up to inexperience. I'll follow the conversation with interest.

By "personality theory" which was an infelicitous phrase, I meant the fuzzier parts of the DSM-IV. I was not inventing a technical term. I meant the theory of personality. This was actually the term used by a famous psychiatrist/neurologist, etc. in a written communication to me.

If ya can't stand the heat, gotta get out of the kitchen.

Take care.

 

[Dancing David]

I have thought about it and mentioned it in previous posts. I think this is problematic because it is outside of medical supervision. Much better that a psychiatrist supervise someone going off their medication in my opinion. I think this problem has at least as a partial cause the fact that many patients don't perceive a way to be reevaluated as not having a chronic/persistent mental illness, so they decide to unilaterally quit psychiatric treatment when they think they no longer have such illness.

Can anyone direct me to good readings on people who were initially incorrectly diagnosed with a chronic/persistent mental illness, and later had their diagnoses changed by psychiatrists and were taken off medication?

chronic/persistent mental illness

The term chronic or persistant is not part of the diagnosis, it is a social convention to describe the course of treatment for people who don't go into remission of thier symptoms. And that does not even consider the vast majority of people who seek counseling only without medication. remission of sysmtoms is another issue, I currently have low levels of symptoms that might be considered to be within base line, but I am compliant with my medication. Is that remission or successful treatment? I was off my medication for a year and a half due to lack of insurance, i would rather not try again for at least two more years. But I do consider that there will be a time I try going off the medication. My main concern is that i still have early waking in the spring and summer and infrequent panic attacks.

As for going off medications sorry anecdotes only, but there is a belief in the mental health field that only thirty percent of the population need continuing medication beyond three months for depression.

I have known many people who went into remission of thier depression, and I know two people who went off thier ADs with thier doctor's cognizance.

But that does not mean that they were misdiagnosed. Only schizophrenia is 'chronic' by definition, depression is not always considered to be long lasting, bipolar is a matter of debate.

If you want to find sources of information of what people percieve as the errors of psychiatric treatment, they abound on the internet. look up the term ADHD or 'childhood bipolar' on google, and I am sure 'psychiatry misdiagnosis' will provide a wealth of data.

 

[Dancing David]

I've heard of that being done for some types of anxiety and depression, but I've never heard of that being done in a mainstream way for bipolar disorder, for example.

All the literature I've read has said that someone diagnosed with bipolar disorder should continue to take their medication for the rest of their live, including during periods of "remission".

I know of again about thirty percent of people who are diagnosed with bipolar disorder going off thier medications on a regular basis. It is very hard for family or friends to convince individuals with bipolar disorder to seek treatment. And there are huge numbers of untreated individuals living succesfully with bipolar disorder. Many successful small bussness people, and all sorts of functioning people are living with untreated biploar disorder. People who sleep less than five hours a day and work twelve hour days can be very succesfull.

But then I have also seen many people who crashed and burned after being off thier meds for a while. The co-occurence of alcohol dependance or amphetamine abuse can be quite problematic.

Bipolar is also the current diagnosis de juer is is way overdiagnosed by GPs.

 

[Dancing David]

definitionally, wouldn't "Single Manic Episode" not be bipolar? Also, it wouldn't be in the larger category I mentioned being concerned about, people diagnosed as having chronic/persistent mental illnesses.

Again the term chroic/persistant is not part of the diagnosis, it is a social convention solely. Many people live with totaly untreated mental illness and do not seek treatment, so no less it is a moot point. Only the individual themselves can make a decision to ongoing treatment.

The course of bipolar disorder is believed by psychiatrists to be progressive, but there is not the data base to substantiate that belief.

And Bipolar Type I, Single Manic Episode is a possible diagnosis. Although the confounding factors would be hard to eliminate. I used to use Bipolar NOS, when it seemed that it might be the first episode, because often people are 'not accurate historians'. But then I was just making an 'assement' not a 'diagnosis'.

 

[Dancing David]

calebprime wants to speak of his experience re: misdiagnosis, histrionics vs. genuine suicidal ideation, treatment of children, and other matters, but needs some encouragement.

histrionics vs. genuine suicidal ideation

WOW that is a very dangerous area and fraught with risk, a clinician in an interview can only assess the presentation of suicidal ideation. You can not make assessments as to the potential for it being solely behavioral in nature( IE attention getting or exageration). To due so places the clinician in a very liable situation at best and the client at potential for harm.

Even with a history of flaming borderline personality D/O and no history of prior attemps, a person who states they have current suicidal ideation and a plan is automaticaly at high risk. Crisis workers who judge intent are likely to end up with dead clients. In a sitaution where the client states they have current suicidal ideation and a plan they need to go to a safe setting, the liability then falls on the psychiatrist.

When I was trying to gauge suicidal ideation there were clues i would look for, like asking them, "what will happen if you go home?" if they say 'watch TV" and not mention the desire to kill themselves then they are most likely not having actual suicidal ideation. But any crisis worker is familiar with people using the hospital inappropriatly, it is the doctor's job to decide when they are safe to discharge.

 

[Dancing David]

In the last hour, I realized that, being new to forums--this is my first--it was simply misguided of me to participate. It's not a matter of critical thinking or the facts. It's a matter of not having the emotional stamina to discuss personal stuff. One can't discuss one's friends, the doctors one knows, oneself, etc. etc. without giving too much away. I'm not trying to be coy. Chalk this up to inexperience. I'll follow the conversation with interest.

By "personality theory" which was an infelicitous phrase, I meant the fuzzier parts of the DSM-IV. I was not inventing a technical term. I meant the theory of personality. This was actually the term used by a famous psychiatrist/neurologist, etc. in a written communication to me.

If ya can't stand the heat, gotta get out of the kitchen.

Take care.

The problem with the non-developmental aspects of Axis II is the overuse of it! The DSM states very clearly that none of the personality disorders can be diagnosed in the precense of the symtoms of Axis I. So it is very overused.

 

[Piggy]

I have personally lost THREE relatives to suicide because they were on anti-depressent medications that caused SEVERE mental side effects.

What would have happened if they hadn't taken the meds?

I understand about side-effects. Right now I'm off meds because my previous medication became ineffective after a few years, and a subsequent medication had unacceptable side-effects.

But that first medication saved my life. It came down to "Do something about this or check out". Which was not an easy choice to make, but I decided to try therapy. I mean, why not? If it didn't work, then it's back to "check out". Nothing lost, really.

To my surprise, the meds made it so that I could get up and go to work.

Where I was at before, food had no taste so I wasn't eating much. I had no motivation to do anything, and the chain of questions "What happens if I don't..." had stopped ending anywhere that mattered to me. OK, so if I don't go to work then I lose my job, can't pay the rent, lose my home, can't eat.... OK.

The meds at least made me stop asking the first question. Even if I was emotionally flat, I could at least just get up and shower and dress and go, and I started enjoying food again.

Plus, I had a great doctor who said he would be my Sancho Panza and he was. He helped me get my mind right.

I had other doctors later, but none really helped me like he did. They were too soft. And besides, I'd already answered the really important stuff.

And actually, I don't think there's anything they can do for me. They can't change the fact that life is pointless and meaningless. Purpose and meaning and love, it's all just chemicals in people's heads, and my brain doesn't make that mix of chemicals. That's all. I've never in my life wanted children, don't understand why people feel the need to have company to see a movie or eat at a restaurant, and can't imagine how anyone tolerates having other people living in their house all the time.

I sincerely believe that when I'm depressed I see things most clearly, btw.

One of the best things I ever did was to stop trying to be something I'm not. I decided to stop beating myself up for not doing what I was "supposed" to do, what was supposed to be healthy, and admit that I don't give a damn about being around people. So I just dropped it. No more trying to make friends or be social when I couldn't care less. No more dating or relationships.

Best move I ever made. The frustration and anger subsided enormously.

I'm not happy, but I don't really care about being happy.

So I'd have to say that my first doc worked -- a reality therapist, very down to earth and no BS. We tried several meds and wound up with one that splinted my brain well enough.

Now I've come to understand myself much better and I have coping methods and I just accept that this is the way I am and anyone who doesn't like it can take a hike.

 

[blutoski]

What would have happened if they hadn't taken the meds?

Piggy: cabelprime has explained that he's finding the thread emotionally difficult due to the loss of relatives.

I'm suggesting that we hold back on replying directly his original post, in order to give him an opportunity to benefit from the continuation of the thread, but without feeling challenged.

 

[blutoski]

In short, what is the protocol regarding this?

I've located the APA's treatment guidelines for patients with bipolar, as of 2002. I've seen other versions in the UK dated 'final' as of 2003:

PRACTICE GUIDELINE FOR THE TREATMENT OF PATIENTS WITH BIPOLAR DISORDER (Second Edition)

 

[blutoski]

Piggy: cabelprime has explained that he's finding the thread emotionally difficult due to the loss of relatives.

I'm suggesting that we hold back on replying directly his original post, in order to give him an opportunity to benefit from the continuation of the thread, but without feeling challenged.

Having said that: your post was very valuable, thanks. Sorry if I seemed to be asking you to stop posting on the topic. That's not the case. You're an expert, in my book.

 

[rightbrain]

Here I'm talking more about medical practice than what people actually do. I'm sure a significant number of people are diagnosed as bipolar off a checklist, are presecribed a pharmacuetical and are told they will have to take it the rest of their lives, but unilaterally decide, without doctor input, to stop taking the drug when their life situation & mood improves. Some of these folks never need to take pharmacueticals again -they were probably incorrectly diagnosed as having a chronic mental illness instead of a temporary depression.

What makes you sure of this? On what facts are you basing this opinion?

It is true that bipolar may seem like a "trendy" diagnosis, but until recently, it was underrecognized in much of the population (particularly children). Bipolar, depression and ADD run strongly in my family (two of my close family members have been hospitalized for bipolar episodes), so I have some personal experience with this.

Doctors vary widely in competence, obviously, but any responsible psychiatrist isn't going to diagnose you with bipolar because you have a spot of "the blues."

It's true that this is an observational science involving a lot of self-reporting, but mental health checklists are a sophisticated collection of many-layered and redundant questions with various "checks and balances" that have been refined over decades of clinical experience. To be diagnosed as ADD, for example, the child, parents, and teachers answer a battery of questions.

Undertreatment of mental illness can have horrific consequences. Fifteen percent of bipolar sufferers kill themselves--between 25 to 50 percent attempt suicide at some point. And they often kill themselves not when they're depressed but when they're manic--i.e., when they're "feeling better" and decide not to take their meds. Bipolar folks can often have long stretches of "feeling normal" but can "crash" suddenly, which is precisely why those meds are prescribed for life.

 

[Skeptic Ginger]

As a general reply to this topic:

I have personally lost THREE relatives to suicide because they were on anti-depressent medications that caused SEVERE mental side effects. If they were referred to counselors rather than psychiatrists, there is a good chance they might be alive today.....

You cannot be certain there is a cause and effect here. There are a million things one can blame. If an association between antidepressants and suicide is observed you have to do more research before concluding that was the cause.

While the association has been observed, careful observation under research protocols has failed to determine if the antidepressants played a role in suicide other than with adolescents and in that case the evidence is very weak. You have to figure in the fact depressed people have a greater risk of suicide when they are beginning to recover. Prior to recovery, the severely depressed are often unable to bother with suicide, they have severe motor retardation.

 

[Piggy]

Having said that: your post was very valuable, thanks. Sorry if I seemed to be asking you to stop posting on the topic. That's not the case. You're an expert, in my book.

Oh, no problem, I understand. But btw, I'm not an expert. All I know is my experience. And my experience is highly unusual. I'm not your typical depressive. I think of myself as a "successful sociopath". Not all people with social pathologies (e.g., can't form relationships, can't empathize with or comprehend others' emotions and motivations) turn into killers and stalkers. But most of us wind up in jail, on the street, on the dole, in institutions, or in an early grave. A very few are able to focus their energies and become highly successful -- being forced to closely observe others' behavior in order to discern information that most folks intuit, they can become consumate students of their fellows, and may become, say, excellent writers, marketers, or politicians. And giving short shrift to relationships (which takes up so much time and mental energy for most folks) leaves more time for work.

 

[rightbrain]

As a general reply to this topic:

I have personally lost THREE relatives to suicide because they were on anti-depressent medications that caused SEVERE mental side effects. If they were referred to counselors rather than psychiatrists, there is a good chance they might be alive today.

I am very sorry for your loss. But cause and effect can be notoriously difficult to determine in cases like this.

There are many factors involved. People who are initially diagnosed as depressed may actually be bipolar--and antidepressants can trigger mania in bipolar, which is why it is very important for the person to be monitored closely by a psychiatrist when first being prescribed these meds. Severe mania can even have elements of psychosis.

Unfortunately, it is not always easy for a doctor to determine initially if a person suffers from unipolar or bipolar depression. This is why antidepressants now carry a warning label.

People who are prescribed medications do not always take them regularly.

And, as I pointed out in my previous post, people who kill themselves often do so when they are feeling "better" and have the energy to carry through with the suicide they have been thinking about for a long time.

While antidepressant-related suicides are truly tragic, I believe psychiatric medications have saved far more lives (including those of at least two people in my family) than they have taken. Therapy is also very important. For most mental disorders, the medical establishment recommends medication and therapy as the most effective treatment combination.

There is a problem with the close ties between doctors and the not-all-that-honest pharmaceutical industry, so it is important to become an educated patient. But there are plenty of lousy therapists, too, and plenty of people in the alternative health industry who badmouth prescription meds even as they exaggerate or even lie about the science (or lack thereof) supporting their alternative remedies.