Introduction
Hi all! 😄
The time comes again. For 2 years now, at the same time each year, they have summoned me with a curt invitation…
No, it’s more like an order. It’s definitely an order.
The words are printed on the back of a piece of paper, laden with numbers and unpronounceable names. Yet on the back of this green sheet are the clear, concise words, and the words seem to glow as clear as day, and they read; “Please book an appointment with your GP to review your prescription before handing in your next repeat.” (or words to that effect)
So, earlier this week I responded to the summon & went to see the GP to review my medication. It’s been 3 years since I was first prescribed sertraline, a selective serotonin reuptake inhibitor (SSRI) type of antidepressant. The decision to start on the medication was mine, of course, but it took a lot of encouragement from my friends and family; when it was initially proposed, I wasn’t keen on the idea at all.
Psychiatric Medication
There are a range of psychiatric medications available, which can be used to treat a variety of different conditions. Psychiatric medications can be divided into 4 main types (1, 2), which are:
1. Antidepressants
2. Antipsychotics
3. Mood-stabilisers
4. Sleeping pills & minor tranquilisers (benzodiazepines)
Figure 1 summarises the various types of psychiatric medications and what conditions they are commonly used to treat.
Figure 1. The 4 main types of psychiatric medication, alongside the major medications within the groups where applicable & the conditions they are frequently used to treat.
Note that the names of the types of medications can be somewhat misleading; for example, although I take an antidepressant medication I have never been diagnosed with depression. My diagnosis was of anorexia nervosa, an eating disorder, so why was I prescribed sertraline? As we saw in figure 1, antidepressants can be used for more than just depression – they may also be used in the treatment of anxiety, OCD and eating disorders (1). We have to consider that, unlike in medications for physical conditions, medication for mental health may involve a degree of “off-labelling” prescriptions, where medications are prescribed for conditions that they are not precisely indicated for (2, 3).
Off-labelling prescription is not necessarily bad practice; our understanding of the underlying mechanisms behind psychiatric medication is poor, as is our understanding of the mechanism of action of psychiatric medications, and so medication is often prescribed based on the results of randomised control trials and less on our knowledge of how the drugs work (3). Unfortunately, sometimes even these trials are lacking, and in the case of anorexia nervosa there is poor evidence for the efficacy of pharmacological interventions, even using antidepressants such as sertraline (4, 5). Despite this, a study of 525 women with anorexia nervosa attending the Clinical Research Centre at the Massachusetts General Hospital between January 1997 and December 2009 found that 48.4% of the women were taking antidepressants for their condition (5). The prescribing pattern of doctors can be influenced by their own experience as well as the available evidence, so despite the lack of evidence, a doctor may prescribe a medication that is not indicated if they believe it may benefit their patient more than it does harm (3). On the other hand, it does appear that antidepressants have a therapeutic effect for patients suffering from binge eating disorder and bulimia nervosa, so the lack of evidence for their use in anorexia nervosa doesn’t mean they aren’t effective in the treatment of eating disorders (4).
To Take, or Not to Take?
Taking medication for mental health is something that many people with a mental illness are hesitant to do, and while it’s important that we educate people about the pros & cons of taking psychiatric medication, it’s also important that we respect a person’s decision to take it, or not to take it. Perhaps the most unavoidable of the reasons why people may decide not to take psychiatric medication is the risk of side effects & the symptoms that appear when the course of medication is stopped, which can be very unpleasant or even disruptive (5, 6)! Even in the case of side effects, different psychiatric medications come with different sets of side effects and risks of experiencing these side effects, and many people won’t experience these or may experience milder side effects. If this does happen, it’s possible to overcome these side effects by reducing the dosage or switching to another medication altogether, which you may respond better to (7). Other reasons that people may fear taking medication include the idea that (8, 9):
1. Taking a medication means that the disorder IS serious – often people with a mental health disorder don’t feel that their illness is serious enough, especially if it doesn’t manifest physically. Taking psychiatric medication feels like acknowledging that something is wrong, although it can feel easier to deny it.
2. Taking medication feels like cheating – recovery is hard, and there’s no denying it; it can often feel like taking medication is just a “quick and easy” fix. Perhaps we know that others can’t receive this medication and so to accept it would be a luxury, or perhaps we’re just not ready to take something that could potentially turn this thing around so soon. There were many times when I experienced a sort of “survivor’s guilt”, because as well as asking “Why did I develop this disorder?” I was also asking “Why do I deserve all this help?” I have always struggled with low self-esteem, in some respects I still do, and I found it hard to understand why people were so concerned, or why they wanted to help.
Even when my thoughts were extremely disordered, I recognised that the way I was living wasn’t healthy and that anybody going through this experience was worthy of help. Yet I didn’t think this of myself.
It seems like a completely bizarre way of thinking, yet I was able to turn those self-depreciating thoughts on their head; if others were worthy of recovery, then surely I must be too? Plus, being recovered wasn’t something I had to feel guilty about. There were people who could help me out from the hole I was in, and using my experience I could join them to guide others out from their own personal holes.
3. Recovery should be done naturally, or that they simply don’t want to take drugs – this one is perhaps more to do with personal choice, although it can also be strongly influenced by others too. Further on in this post I’ll be discussing med shaming, and this can really put people off taking psychiatric medication as they feel that they are weak for doing so. This links back into my previous point; that taking medication is not cheating. Recovery is hard and it is not a race, if something can help to make the journey easier for you that’s an amazing thing.
Many of my friends will know that I don’t drink alcohol, although recently I tried it for the first time and this solidified the idea that it wasn’t for me. My decision not to drink alcohol is mine entirely, based on a range of information, personal views and social experiences. I’m fortunate enough to have friends who understand my decision not to drink, and when I did drink I did it because I was ready & willing to try, not because I was pressured to. For somebody else, their first time drinking could be a great experience, and they may decide to continue and have more great experiences! The key thing is that trying things out may change your life, or it may just affirm your belief that this particular thing is not for you and you can continue to seek other new experiences with the comfort of knowing that you’ve tried and can move on.
Whatever the case, it’s crucial that the person taking the medication is aware of what the pharmacological treatment will entail, and is able to make a decision without feeling pressured. This pressure can work in either direction; somebody may feel pressured to take medication by friends, family or doctors that are pushing it on them, or they may feel pressured not to take medication. Imagine that you and a friend were hanging around, and suddenly they suggested playing a game. You’re not sure you can be bothered right now, but you might be up for it.
“Great!” they say, “Footie it is!”
Obviously, that’s not the best way to go about it. You weren’t sure about playing a game in the first place, and now they go and choose the game without considering your wishes. If you do go ahead and play the game, you might be less invested in the game than you would be if they had asked for your opinion first, and you could have agreed on a game you were both up for. We can apply this to psychiatric medication, as it appears that involving patients in their decisions where they have the mental capacity to do so increases their adherence to the medication (10).
On the other hand, imagine that both you and your friend agree to play a game of footie. Suddenly, somebody walks up to you both and says “Don’t you know football is bad for you? Haven’t you seen all those injuries people get when they’re tackled? You shouldn’t play sports like football, just go for a walk or something instead!”
Med Shaming
When it comes to medication this sort of behaviour is called med shaming, which comes in a surprising amount of forms! Med shaming isn’t necessarily something there has been much research into, but certainly anecdotal evidence from those who have been shamed for the medication they take suggests that it can sway their decision whether or not to take medication, and if they do take medication it can make them feel guilty or weak for doing so.
Figure 2. Some examples of content seen as med shaming, which can be very damaging for people taking medication/considering taking medication.
According to the BBC, med shaming occurs when “people criticise others and make them feel guilty for taking medication for their mental health” (11). There is a fear that med shaming may put people off taking the medication prescribed for them, and stopping medication in an uncontrolled manner without medical intervention can be extremely dangerous (11, 12). As much as it’s true that some people may be able to recover without ever touching psychiatric medication, using other treatment modalities such as psychotherapy and alteration of lifestyle factors such as doing more exercise and eating healthier, this isn’t the case for everybody. It can be very difficult for a person experiencing a mental health disorder to find the motivation to engage in therapy and change negative aspects of their life, and this is where psychiatric medication comes into play!
Remember that we said that psychiatric medication is not cheating? Sure, taking drugs that enhance your ability to perform in sports competition is known as doping, and provides those taking the drugs with an unfair advantage. But when taking psychiatric medication we are not competing with anybody, or perhaps we are competing with the mental health condition. If we can get the upper hand in that battle, that’s an amazing thing, it’s not lazy or weak!
Fortunately, I never experienced med shaming. My family & care team were very considerate about my decision about whether or not to start taking sertraline, and although they encouraged me to accept it they did not pressure or force me to do so. Perhaps the only person med shaming me was myself. There were so many reasons I believed I shouldn’t take the medication: it would make me numb, it might make me overeat, it might make me recover too quickly and I wasn’t ready. I didn’t want to accept the medication because I wanted to do this by myself, not with the help of some pills. That’s a very harmful way of thinking, as you close yourself off from the possibility of experiencing something that may act as a turning point.
In 2018, singer Kanye West appeared to suggest that he had skipped his psychiatric medication for bipolar disorder, claiming that since coming off his medication he was his “real” self (13, 14). In response, Pete Davidson (a cast member of Saturday Night Live) said that there was no shame in medication, and claimed that it had helped him in his own struggles with mental health conditions (14). These types of conversations are extremely important, as med shaming can often be unintentional and it’s important to emphasise that, as much as some people feel they are “numbed” by the medication or are troubled by the side effects, others can see a huge benefit. This all depends on the individual taking the medication, and referring back to the pharmacotherapy of eating disorders discussed earlier, it’s suggested that the poor efficacy of antidepressants in patients with anorexia nervosa is due to their low body weight & associated energy deficit (4).
Clearly medication works for some and not for others, and a number of (sometimes quite surprising) factors appear to play a role in this! If a medication doesn’t work for somebody and lifestyle modification does, that doesn’t mean they should discourage others from taking the medication, as the effect of the medication will differ from person to person. Likewise, if a medication does work for somebody that doesn’t mean we can plug it as the cure for everybody with that condition.
As well as medication, it’s essential that treatment for a psychiatric condition implements aspects of psychotherapy and encouragement of lifestyle modification as well as other methods of management – medication SHOULD NOT be used as a treatment on its own. So taking medication is clearly not the easy road, nor is it weak to take medication. The effect of the medication can only do so much, and it’s much less effective without integration of other aspects of the treatment plan which you also have to comply with. Medication isn’t the cure, but for some it may act as a catalyst for change.
What do we Say to (Medicinal) Drugs?
Hopefully in this whistle stop tour of psychiatric medication – in all its glory and with all its pitfalls – I have been able to convince you that taking medication for your mental health is nothing to be scared of or ashamed about. Perhaps it’s unnerving to find out that we know relatively little about psychiatric conditions and medication, but medical professionals will not put you on a medication that they think will harm you more than it benefits you. If you decide to take a medication that turns out to be inconvenient to you, it’s absolutely fine for you to speak to your prescriber to see how you can adjust the prescription, whether you reduce the dosage, switch to a new medication, or ditch the medication completely and search for new modalities of treatment.
Despite the fact that I feel medication helped me personally, I don’t take sides in the pro-medication vs. anti-medication argument. This post doesn’t aim to sway you in either direction, and I can only cover the basics from the perspective of a non-professional. Here, I aim to promote education about pharmacological interventions for mental health conditions, so that patients can make an informed decision about their treatment and feel content with their choice.
Taking medication can feel like a big moment and a big step towards recovery. It’s not a decision that can be made on the spot, and taking time to think it over is important; to consider what the treatment entails and to analyse the conflicting messages that prompt you to take or not take medication for your illness.
You’re not weak for taking medication, and you’re not slacking on recovery if you don’t take it. You have the right to choose.
All the best,
Luke 😎
References
(1) Mind. Psychiatric Medication. Available from: https://www.mind.org.uk/information-support/drugs-and-treatments/medication/#.XPZPN497m00 [Accessed 4th June 2019].
(2) Rethink Mental Illness. Medication – choice and managing problems. Available from: https://www.rethink.org/advice-information/living-with-mental-illness/medications/medication-choice-and-managing-problems/ [Accessed 4th June 2019].
(3) Taylor, D. Prescribing according to diagnosis: How psychiatry is different. World Psychiatry. 2016; 15(3): 224-225. doi: https://www.doi.org/10.1002/wps.20343.
(4) Davis, H. and Evelyn, A. Pharmacotherapy of eating disorders. Current Opinion in Psychiatry. 2017; 30(6). doi: https://www.doi.org/10.1097/YCO.0000000000000358.
(5) Fazeli, P.K., Calder, G.L., Miller, K.K., Misra, M., Lawson, E.A., Meenaghan, E. et al. Psychotropic medication use in anorexia nervosa between 1997 and 2009. 2012. International Journal of Eating Disorders; 45(8): 970-976.
(6) Mental Health Foundation. Medication for Mental Health Problems. Available from: https://www.mentalhealth.org.uk/a-to-z/m/medication-mental-health-problems [Accessed 4th June 2019].
(7) National Alliance on Mental Illness. Mental Health Medications. Available from: https://www.nami.org/Learn-More/Treatment/Mental-Health-Medications [Accessed 4th June 2019].
(8) Smith, K. L. 5 Reasons Why Suffering People Don’t Want to Try Medication. Available from: https://www.psychologytoday.com/gb/blog/full-living/201510/5-reasons-suffering-people-don-t-want-try-medication [Accessed 4th June 2019].
(9) Blurt Team. Let’s Talk About Medication Stigma. Available from: https://www.blurtitout.org/2018/06/07/lets-talk-medication-stigma/ [Accessed 4th June 2019].
(10) Haddad, P.M. Ten principles of good psychiatric prescribing. Medicine. 2016; 44(12): 745-747.
(11) Foster, L. Medication for mental health: Call to ‘end pill-shaming’. Available from: https://www.bbc.co.uk/news/av/health-46212595/medication-for-mental-health-call-to-end-pill-shaming [Accessed 4th June 2019].
(12) Davies, C. Please Stop ‘Pill Shaming’ People With Anxiety and Depression. Available from: https://themighty.com/2017/11/pill-shaming-anxiety-depression/ [Accessed 4th June 2019].
(13) Holland, K. How ‘Pill Shaming’ Hurts Those Who Take Medications for Mental Health. Available from: https://www.healthline.com/health-news/why-do-people-mental-health-disorders-stop-taking-their-medications [Accessed 4th June 2019].
(14) Charles, S. 'SNL' star Pete Davidson says, 'There's no shame in the medicine game'. Available from: https://www.nbcnews.com/health/mental-health/pete-davidson-says-there-s-no-shame-medicine-game-doctors-n917886 [Accessed 4th June 2019].
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