Below is an outline I made of all the forms of bias that would have to be corrected in order to insure that people received the “optimum” amount of medication and emphasis on medication. This outline could use more work, it may be missing some things, and could use references being added, but I wanted to see what you all would think of it so far.
Barriers to Medication Optimization in Mental Health Treatment
“Medication optimization” is here defined as a state where individuals receive no less and no more medications than what is optimal for their long term health.
It has become apparent that huge numbers of people are receiving more medication, over longer periods of time, than what is optimal for their long term mental health.(Whitaker, 2010) What are the factors in the current mental health system that biases it toward greater use of medication than what is optimal? It is important that all of these areas be identified, since efforts to achieve medication optimization are likely to achieve only partial success at best if significant areas of bias remain unchallenged.
Bias exists both in what is communicated about mental health issues and treatments, and in how mental health services are structured and provided.
Since use of medication is commonly negotiated between professionals and consumers, and is also influenced by third parties, it follows that medication optimization is most likely to be achieved when professionals, consumers, and the public all have access to balanced information about mental health problems, medications, and possible alternative approaches.
Areas of bias in information include:
- What people are told about the nature of mental health problems
- What people are told about the likely effectiveness of the medications
- What people are told about the possible hazards of medications
- What people are told about the possibility for alternative treatments, and the possibility of recovery to a point where treatment is no longer needed
The bias in the flow of information is complex. One problem is that many professionals often are misinformed or uninformed about key issues. In addition to this, there also appear to be cases where professionals are fully informed about particular issues but deliberately choose to misinform consumers, in order to elicit behavior preferred by the professionals. In a recent example of this, psychiatrist Daniel Carlat freely admitted in a 7/19/2010 NPR interview that he tells his patients that SSRI’s work by relieving a serotonin deficiency, even though he knows this theory lacks evidence, because he dislikes the alternative of letting the patient know he has no idea as to how the medication might work. In yet other cases, professionals do not themselves spread misinformation but fail to communicate in a way that would counter misinformation that consumers have picked up from the media, medication commercials, etc.
Even if all parties are accurately informed however, the system can still be tilted toward excessive use of medication through the way particular services are or aren’t made available.
Areas of bias in the way services are provided include:
- The success of mental health interventions is usually measured in terms of short term reduction in targeted problem areas. The possibility that medication are creating new problems, and are actually making existing problems more chronic in the long term, cannot be evaluated by such measurements. Use of such measurements encourages the creation of more programs oriented just toward short term gains, regardless of long term costs.
- Primary authority in mental health systems is given to psychiatrists, whose income depends on prescribing medications
- Mental health crisis is usually handled by hospitals, and these typically use medications as their primary intervention.
- Mental health workers frequently lack the training, the financing, and the institutional support needed in order to provide alternative forms of treatment
- Psychosocial mental health services are frequently “managed” or limited, but medications are not
- There is often no service available to help people get off medications, or if it exists, it is often not well publicized
What follows is an attempt to outline, in some detail, the various forms of bias that commonly exist in our mental health system. Any thorough approach to medication optimization will have to address each of these forms of bias and create a balanced approach as a replacement.
Excessive emphasis on biological or medical explanations of the problem:
- Evidence that suggests mental health problems are likely to be related to underlying biological, biochemical, and/or genetic abnormalities is commonly exaggerated. Biological explanations reduce hope for psychosocial solutions, and increase the chances that people will see medications as likely to be the only possibly effective solution.
o People are commonly told that their problem is a “biochemical imbalance” despite the lack of evidence for any definite imbalance.
o People are told that their problem results from brain abnormalities,
§ despite the failure to find specific brain abnormalities that are consistently associated with specific diagnoses, and
§ despite the fact that many observed abnormalities may be the result of specific experiences like stress and trauma, and/or
§ despite the fact than many brain abnormalities found in studies may be the result of medications.
o People are told that their condition is “genetic” despite the failure to show that any sort of genetic predisposition is necessary in order to have a particular disorder – in other words, while some may have a disorder partly due to a genetic predisposition, others may have the disorder for other reasons, yet be told by the mental health system that their disorder is definitely “genetic.”
§ Evidence for the role of genetic predispositions is commonly highly exaggerated
§ The possibility that a person could continue to have a genetic predisposition to a mental disorder, but no longer have the disorder because of having learned how to live successfully with one’s genetic differences is often not identified. The consequence is the diminishment in hope for any solution outside of medication.
Denial or minimization of the possible role of trauma and other life difficulties:
- Evidence that suggests mental health problems may be result from life difficulties is commonly not mentioned or is minimized.
§ For example, especially for those labeled with “schizophrenia” and other “serious mental health disorders” the possibility that the cause might be childhood trauma, unusual or repeated life stresses, or understandable mistakes in belief and/or life strategies, is commonly not addressed.
§ In many cases, the possibility of a role for life difficulties in contributing to the mental health problem is explicitly denied – people are told that they definitely have something that is a “biological illness” or something to that effect.
o When mental health problems are seen as disconnected from life difficulties, then the possibility of addressing them by finding more effective ways of dealing with such difficulties is naturally neglected, leading to more reliance on medications.
Denial or lack of information about the possibility of full recovery:
- The possibility of full recovery to a point where there is no need for treatment, including no need for medication, is usually not discussed or is minimized. This commonly results in failure to make attempts at recovery, and this failure to make attempts can for some result in lack of a recovery that was otherwise possible and so a lifetime of unnecessary dependence on medications.
o Evidence for this possibility comes from recorded outcomes prior to the medication era, research into non-medication alternatives, data on outcomes in parts of the world where medication is used less, as well as the stories of those who have gotten off medications successfully.
Evidence for the effectiveness of medications is commonly exaggerated:
- Especially, claiming that the medications will “correct a biochemical imbalance.”
o People are likely to feel there would be something wrong with them if they neglect to take a medication that definitely corrects their “biochemical imbalance.”
§ The possibility that professionals are simply theorizing that an imbalance exists, even while the evidence shows that the medications create a distinctly abnormal biochemical condition, does not occur to the average person who has been educated to trust medical professionals.
o There is commonly a failure to acknowledge that medications that show some effectiveness for the average person may be completely ineffective or even worsen the mental health condition of given individuals, even in the short term.
§ The belief that a given medication or class of medications will necessarily be helpful for everyone with a certain mental health condition can result in a person staying on medications for years that never led to clinical improvement for that person, even when those medications are causing serious side effects.
- Medications are often credited for all positive changes that ensue once medications are started, without consideration for the possibility that positive changes may be due to placebo effect, or to other changes in and/or around the client.
Information about risk from medication is often either not communicated or is not attended to:
- The possibility and degree of likelihood of dangerous side effects is often minimized, or they may not even be mentioned by providers
o There is often failure to communicate the degree of risk that some serious side effects might be permanent, such as TD, diabetes, kidney damage from lithium, sexual dysfunction from SSRI’s etc.
o There is often failure to point out critical areas which have not yet been researched, such as the effect of antipsychotics on the developing brains of children and adolescents.
- When side effects do occur, there is often failure to notice them or failure to notice that they are connected to the medication
o When people experience side effects without being able to connect them with the medication that is causing them, they are likely to attribute them to their own “mental illness.”
§ Family members, friends, and professionals may also attribute the changes to the “mental illness”
- As a result, more medications may be given to control what are seen as symptoms of the “illness”
Possible withdrawal issues are denied, or at least not properly addressed
- Commonly, people are not warned about the likelihood of withdrawal reactions, including the increased likelihood of what will seem to be “relapse” when medications are discontinued abruptly.
o When people are not educated in the need to be carefully weaned off medication, their efforts to get off are much more likely to fail. And in the absence of information about possible withdrawal reactions and the high rates of relapse in fast compared to slow discontinuations, people are likely to mistakenly see relapse as proof of a need to stay on medications.
The risk that medications might worsen long term outcomes is seldom addressed:
- The possibility that medications will produce a short term (weeks or months) improvement in mental health problems, followed by long term worsening of those same problems despite continued use of the medication, is frequently not even considered, despite a preponderance of the evidence suggesting that this is the most likely scenario
o This means that even in cases where medication does lead to clear improvements in the short term, without destructive side effects, it is still possible or even likely that the medication is overall having a negative effect on the health of the individual
§ This is true even when efforts to quit the medication leads to a return of mental health problems – this may be a withdrawal effect, and in the longer term, there is a good chance that doing without the medication would lead to a stronger recovery than continuing to use it.
Information about alternative treatments, and/or the treatments themselves, are often unavailable:
- Often, people are not even told that possible alternative treatments exist, or the evidence for their possible effectiveness.
o Often, despite evidence that alternatives could work for many, they are not made available
o In areas where alternative treatments are available, people are often not given referrals to such treatment.
People in crisis are rushed onto medications before other options can be tried:
- Hospitals and crisis teams are usually oriented around the use of medications as the first and primary intervention, and alternatives are not even considered until later, if at all.
o This interferes with people having a chance to find out that the crisis might have been resolved without medications.
§ Because of the intensity of the crisis, people often feel compelled to try the medication which is the only choice offered at that point.
o Once the use of medications for difficult experiences has become an established pattern, it may be more difficult to switch to other methods.
Alternatives can fail to be effective because of the use of medications or too much medication:
- People, and even professionals, are often unaware that medications can impair therapy. This can be a result of the medication “numbing out” the emotional sensitivity required to participate effectively in therapy, or just because the person has learned to rely on medication as the resolution to psychological and emotional issues.
o So even when therapy is made available as an alternative, it may not be able to work because the person is too medicated to be able to benefit.
The possibility that “insight” might lead to rejecting medications is frequently denied:
- Too much emphasis has been placed on the possibility that a person may be rejecting a medication due to “lack of insight” into the usefulness of the medication, while too little emphasis has been put on listening to people’s voices and considering the possibility people know things about what works for them that professionals may not know.
Professional dominance by those who specialize in using medications:
- Mental health care has been dominated by medical professionals, who generally make money by, and who are expected by people to, prescribe medications.
o Other professionals have been discouraged from raising objections to the prescription of medications
§ Non medical professionals who do raise “too many” concerns about medications are sometimes challenged with accusations of attempting to “practice medicine without a license”
- While non medical professionals who support and recommend medications and send people to medical professionals to obtain them can be reasonably assured that no one will challenge their efforts
Medication effects can interfere with the ability to see problems with medications themselves:
- The possibility that a person will reject medications because of having some distorted perception or belief associated with a mental disorder is commonly emphasized,
o but the possibility that a person may stay on unhelpful or destructive medications due to a restriction of consciousness caused by the medication is seldom acknowledged.
§ This latter sort of effect has been called “spellbinding” or more technically “intoxication anosognosia.”
- Increased awareness of the possibility of this effect could lead to less assumption that failure of the consumer to complain means that everything is OK with medications.
Managed Care restricts psychosocial options but not the use of medication:
- Psychosocial forms of care are “managed” or limited in frequency and duration, while no limits are placed on the amount, type, duration or cost of medications. This of course encourages more reliance on medications.
Bias exists in the way mental health interventions are usually evaluated:
- Mental health interventions are frequently evaluated in terms of their effect on reducing the targeted symptoms or problem over a relatively short period of time, in days, weeks, or months at the most. There are two big problems with this.
o At the same time a medication may be reducing one sort of problem, it may be causing other problems. So better measures would weigh both benefits and harm.
o While medications may reduce a targeted symptom or problem, they may also create a drugged state that makes an actual resolution or working through of the mental health problem less likely, resulting in making the problem more chronic. This kind of effect is not measured in short term evaluations, but is critical to the future of people in mental health treatment.
Help in reducing or getting off medications is frequently not available or not publicized:
- While getting off medications has a good chance of leading to greater opportunities for long term health, it frequently leads to greater distress in the short term. Yet people are frequently offered only opposition, and no sort of assistance, from the mental health system if they decide to make such a change.
o Failure to get help in getting off medications can leave people feeling trapped on them, even while they feel medications are causing more harm than good
o Needless to say, the (arguably accurate) perception of being trapped by the system that claims to be helping is not conductive to good mental health.