Getting the right medicine, medication side effects, fear of being dependent on a medication, medications that stop working mysteriously… psychiatric medications evoke in us as many reactions as do psychiatric disorders… and psychiatrists.
What we propose to do on this page is to try to collect and organize information that we have found helpful in thinking about psychiatric medications. As with other parts of this website, this will most definitely be a “work in progress” as there is an endless supply of information on this topic.
We should begin with some of our beliefs about psychiatric medications. In general, we find them to be quite a bit less mysterious and magical than most people do. This is good and bad. They don’t have the ability to change who we are… as we sometimes fear they might, and sometimes desire they would. By and large, psychiatric medications are not “magic bullets” that take away problems so that we don’t have to think about them again. Adverse effects are pretty common, but in twenty years of practice, we have not (thank goodness) had any catastrophic outcomes… no one has had a reaction that didn’t resolve after the medications was stopped… although those things do happen with psychiatric medications as they do with any other medicine (including Tylenol and aspirin).
Medication “versus” Psychotherapy
One of the questions that we find we don’t know how to answer is the common question, “Is this a biological depression?” which often means, “should I take medication for this depression or is psychotherapy the answer.” The problem is that all depressions are both biological and psychological. Psychotherapy and medications both affect biology, they appear to do it by somewhat different routes. A recent article in the Archives of General Psychiatry demonstrated this with some dramatic brain scans. The implication is that they may be synergistic, working on the common problem of depression in different ways.
The important question is what is effective treatment. And, in general, comparing the two treatments, outcomes tend to be about the same. Medications tend to work a bit faster and are a little bit less expensive in the short run (the extra cost of more sessions for psychotherapy is generally more than the cost of medications, although not always), psychotherapy tends to be a bit slower and more expensive in the short run, but results from psychotherapy may be more enduring. Two recent articles in the Archives confirmed this finding.
We find that usually medication and therapy compliment each other (although the story is not as clear for anxiety disorders as it is for mood disorders). Medications are generally necessary for conditions that are more severe, but they are not restricted to use in severe disorders. Severe depression has a profound effect on the ability of the brain to learn and therefore may block the effects of psychotherapy, which may be why medications seem to work better in severe depression. On the other hand, medications tend not to be associated with the kind of enduring changes that can occur with psychotherapy.
Adverse Effects from Medications
Many patients ask us about the long-term effects of treatment with antidepressants and mood stabilizers. Over the years, we have grown increasingly comfortable saying that there do not appear to be major adverse effects of long-term antidepressant treatment. More recently, very good quality studies have begun to show that this is only part of the total picture in terms of brain effects.
A large number of studies now find that patients with chronic mood disorders have measurable cell loss and atrophy in certain areas of the brain associated with memory. These changes are similar to changes seeing in laboratory animals who have very high cortisol or cortisol releasing factor (CRF) levels (indicating high levels of stress). New studies find that individuals with depression have much lower levels of an important chemical called brain-derived neurotrophic factor (BDNF)7. It seems that neurons need to be exposed to this growth stimulator in order to grow in a healthy way and that depression, perhaps because of increased stress hormone levels, or perhaps for other reasons, is associated with reductions in this factor.
Many mood stabilizers and antidepressants appear to counteract both the increase in stress hormones as well as the decrease in BDNF. In other words, depression is associated with brain toxicity, and the best evidence is that antidepressants reverse this brain toxicity.
There certainly are adverse effects from psychiatric medications, just as with any kind of medication.
A couple of resources to check into. But when you surf the internet for information about medications, be aware that there is always going to be a bias towards negative information (if you feel great from a medication why post on the net?).
These books are a pretty good resource. And have the advantage that they are likely to be a bit more balanced in considering the pluses and minuses of medications…
Handbook of Clinical Psychopharmacology for Therapists
What Your Patients Need to Know About Psychiatric Medications
The Prescriber’s Guide (Stahl’s Essential Psychopharmacology)