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We’re all familiar with the cartoon archetype of the psychiatrist as a bearded man taking notes on a pad while his patient lies prone on the couch. But these days, the patient’s more likely to be sitting upright in a chair, and the psychiatrist may well be writing a prescription, scrawling notes on a pad or typing into a computer. Psychopharmacology is the order of the day.
Got a problem? Take a pill. Doesn’t work? Try a different pill, or add another pill to what you’re already taking. The visit may be only fifteen or twenty minutes, and the newest term used for this type of care is “medication management.”
Yes, your psychopharmacologist may eventually find a medication that makes you feel better, and that’s a good thing. But medications treat symptoms, not what’s causing the problem. And in order to keep feeling better, you need to keep taking the medication. For some patients, continued medication is essential, depending on what types of emotional disorders we are speaking about. But for many, it may not be.
What’s in That Bottle?
When it comes to treating anxiety disorders, the go-to medications for years were (and in many cases still are) the benzodiazepines, first sold commercially in 1960 as Librium (chlordiazepoxide) and followed a few years later by Valium (diazepam). Over the years, more types of benzodiazepines have been added to the original list. Ativan (lorazepam), Klonopin (clonazepam), and Xanax (alprazolam) are currently among the most popular.
Due to the addictive potential of these “benzos” and subsequent withdrawal issues, they are listed as controlled substances. In addition, benzodiazepines can be dangerous when combined with certain pain medications, including opiates. So, many clinicians are moving away from these anti-anxiety medications. Recently some the SSRIs (selective serotonin reuptake inhibitors), long used in the treatment of depression, have been approved and used for the treatment of anxiety. The SSRI Prozac (fluoxetine) was introduced in 1987, later followed by Zoloft (sertraline), Paxil (paroxetine), Celexa (citalopram) and Lexapro (escitalopram).
Got a Problem? Take a Pill?
Prescribing a pill is the way many people want to cure their problem, whether it’s mental or physical. Many pharmaceutical products are truly life-saving, and can successfully treat a variety of mental and physical disorders and we should not forget that. But when it comes to treating anxiety disorders— including post-traumatic stress syndrome, generalized anxiety, and phobias—the many variations of Cognitive Behavior Therapy, including my own LPA method, can be even more effective. That’s because the approach is able to create lasting changes in how people think and respond. The patient develops the tools to come at the same old problem from a new perspective, and change the way he or she will behave.
Because so many medications are prescribed, one of the great problems in today’s psychiatric and mental health care system is the tremendous overuse of medication with the mixing and matching of psychotropic medication all too often not designated for the intended treatment. It’s not unusual to see a person taking three to five medications and not feeling any better, or even feeling worse from the multiple side effects. The lack of clear blood testing or imaging to detect psychiatric disorders leaves the diagnosis up to the clinician. All too often, subjective thinking, writing a prescription that’s easy, pharmacological influences, or insurance reimbursement considerations can dominate the picture.
As I see it, the over diagnosis of bipolar disorder for irritability or moodiness and the widespread use of antidepressants for unhappy people who are not clinically depressed is something the psychiatric profession has yet to deal with adequately. And some experts who study mood disorders and depression have pointed out that more than half of those treated with antidepressants fail to respond to the medication.
When a pill’s effects wear off, the problem remains. The only way to keep the problem at bay is to keep taking the pills. In some cases, getting off the pills can cause so much havoc to the brain chemistry that it creates even more problems for the patient.
Even mind-body problems, such as chronic insomnia, may respond better to Cognitive Behavior Therapy. In 2016, the American College of Physicians recommended CBT as first-line treatment instead of medication for many adult patients with chronic sleeping difficulties. And in my own patients, when they are able to tackle and overcome a problem that’s been keeping them up at night, guess what? They can get to sleep. Without the aid of a pill.
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The DSM and Its Discontents
DSM stands for Diagnostic and Statistical Manual of Mental Disorders. Along with codification and classification, this tome is regularly used to diagnose patients, sending many down the path of medications. Although the DSM is a necessary resource to codify and classify mental disorders, its current biological leanings have unfortunately tried to medicalize many social experiences and normal human variations, affixing labels to many conditions that appear to be more subjective opinions and reasonable guesses.
The DSM’s website calls it “the standard classification of mental disorders used by mental health professionals in the U.S.” A DSM diagnosis is a necessary requirement for most interactions with insurance companies, hospitals and clinics, pharmaceutical companies, lawyers and the court system. So you can see just how important these diagnostic definitions can be.
But that does not mean these definitions are always accurate. Nor are they comprehensive: in some cases, they leave out or misattribute key symptoms, because the DSM’s diagnostic labeling is often simplistic and one-dimensional. It does not take into consideration such essential factors as a patient’s environment, support system, or personality type in order to give an accurate assessment. We are all individuals—our lives, our emotions, our personalities, and how we may process information through our nervous systems are different. No two of us are the same, and each and every diagnostic label can differ from person to person.
Yet, while the DSM’s accuracy is debatable, countless patients or clients of mental health professionals are nevertheless categorized by its standards—so much so that it’s often referred to as the “bible” of psychiatric illnesses. But it is far from a bible of any sort. At best, it’s a guidebook. Some have called it a dictionary, as it attempts to classify multiple mental disorders, but includes far more subjective thinking than scientific validation. It takes a top-down approach, using a checklist of symptoms in a one-dimensional manner, as opposed to a bottom-up assessment, which would look at the multiple factors in a person’s life and background, and factor them as well as the symptoms, and then, on that, make a diagnosis.
Unlike the way medical diagnosis often works, the DSM format is a checklist. It does not include a multidimensional history of the symptoms, labs, imaging procedures (which, of course, do not exist yet) or possible causes of the disorder through biological mediators, or how each and every individual copes differently with these symptoms. All of these are key factors in making a good assessment and plotting a course of action in terms of care. But at the same time, as more labels are added with each new edition, the medicalization of many behaviors, some of which can be entirely within the range of normal, has entered the picture. And that’s where medications come back in.
For example, the DSM has given a new label to temper tantrums: Disruptive Mood Dysregulation Disorder. Also, excessive eating (defined as more than twelve times in three months but not necessarily clinically adhered to) is now called Binge Eating Disorder and a medication has been approved for it, even though we are surrounded by great food and many Americans overeat as a matter of course. For most problem overeaters, a behavior modification program centered around eating disorders is probably more effective and longer lasting. But we now have a psychiatric label with limited studies or research offered to the public, so this behavior is advertised as a disorder. And guess what? Here’s a pill to treat it.
The Over-Medication Epidemic
It’s been suggested that the pharmaceutical industry is having a greater and greater influence on the minds of those creating the DSM. In recent years, we’ve seen “epidemics” of Attention-Deficit/Hyper-activity Disorder (ADHD) and childhood Bipolar Disorder, leading to frequent management by medication. This enhances the “Big Pharma” goals of prescribing medication to handle most mental disorders, even though many mental problems can be resolved by problem-focused variations of the “talking cure,” and even more by CBT and my version, LPA.
Again, it’s undeniably true that some severe mental illnesses, such as the schizophrenias, bipolar disorders, and clinical depression, respond well to medication and require ongoing medication for effective management. And with good medication management, we are all safer, healthier, and live longer lives due to the advances of pharmaceuticals. But it’s also true that the need to expand and sell more products is an endless motivation for these corporate giants.
Here’s another example: grief. The current DSM-5 had planned to include grief, or bereavement, as a depressive disorder. That would have allowed primary care physicians (who by the way prescribe well over 50 percent of psychotropic medications) to incorporate bereavement as a medicinally managed disorder. In other words, if you were grieving, they might have prescribed a pharmaceutical cure. So much for going through a natural and healthy process of experiencing and processing loss.
Luckily, the outcry against this wrongheaded classification was so intense that it was dropped from the new DSM-5. And behavioral addictions, such as “Sex Addiction,” “Exercise Addiction,” and “Shopping Addiction” also proved controversial and are not included in the new DSM, although many on the DSM-5 panels would have loved to slap a diagnostic label on what might be normal life experiences or choices, based more on personal opinions than any sound medical/ psychiatric basis. The major mental disorders have yet to be validated by biological testing, and it’s disheartening to realize that the labels above that were proposed for the new DSM-5 would have been listed as disorders without scientific validation. To think that many Americans, who are easily persuaded to shop by advertisers and go on shopping sprees when their finances allow it, could be subjectively labeled with a mental disorder defies common sense.
All of this has come to the attention of the National Institute of Mental Health (NIMH), which has made it clear that the new DSM-5 is more a dictionary than a “bible” of disorders. The DSM offers a common terminology; its weakness, according to the past NIMH director, Dr. Thomas Insel, is validity. DSM diagnoses are based on clusters of symptoms, not on any laboratory measures, as in general medicine.
Same Problems, Different Approach
But fortunately, responsible clinicians do continue to use their own medical judgment to assess, evaluate, and treat mental disorders in a multidimensional manner. That means taking a detailed history, considering individual responses and adaptations, and including some biological, sociological, and learned factors and issues into an effective treatment plan.
Irritability and daily mood swings cannot be simply logged in as a bipolar disorder, the current “diagnosis du jour,” just to satisfy an insurer and support the use of medications. There is no reason to medicate someone for simply being frustrated or unhappy if they don’t meet certain well-established clinical criteria for depression or a mood disorder.
Mistaking PTSD for pure depression, which may be one aspect of PTSD (to cite just one example of many) may lead to prescribing a useless cocktail of medications that do nothing to fix the problem or underlying the symptoms. Finding the proper therapy is not simple. What may work for one patient may not work for another.
Psychopharmacology isn’t a magic bullet, as we have learned in treating depression, where often one or more medications may fail. Neither are psychodynamic therapies that meander around and around with no fixed goal in sight. But the CBT techniques of the great Dr. Aaron Beck have demonstrated excellent results in treating many forms of depression. His techniques also work as well as for many people who struggle with commonly seen problems—including phobias, anxiety, and often-unrecognized forms of PTSD—neither medications nor psychodynamic therapies are completely effective in helping to solve the problem.
Copyright 2018 by Dr. Robert London.
Published by Kettlehole Publishing, LLC
Find Freedom Fast: Short-Term Therapy That Works
by Robert T. London M.D.
Say Goodbye to Anxiety, Phobias, PTSD, and Insomnia. Find Freedom Fast is a revolutionary, 21st-century book that demonstrates how to quickly manage commonly seen mental health problems like anxiety, phobias, PTSD, and insomnia with less long-term therapy and fewer or no medications.
Click here for more info and/or to order this paperback book. Also available in a Kindle edition.
About the Author
Dr. London has been a practicing physician/psychiatrist for four decades. For 20 years, he developed and ran the short-term psychotherapy unit at the NYU Langone Medical Center, where he specialized and developed numerous short-term cognitive therapy techniques. He also offers his expertise as a consulting psychiatrist. In the 1970s, Dr. London was host of his own consumer-oriented health care radio program, which was syndicated nationally. In the 1980s, he created “Evening with the Doctors,” a three-hour town hall style meeting for nonmedical audiences—the forerunner to today’s TV show “The Doctors.” For more info, visit www.findfreedomfast.com