Sharing my journey through the mental health system, and especially my successful withdrawal from psychiatric medications, seems to have struck a chord with readers. Many have left comments stating their own desire to break free of pharmaceuticals. A few visitors have expressed reservations about my stance on these issues, because they have found psychiatric drugs helpful and life-enhancing.
The two positions (a belief in the value of medications and a desire to break free of them) are not mutually exclusive. There is no reason a person couldn’t credit drugs with saving his or her life, and still hope to someday be liberated from taking them. But there is obviously a tension between faith in pharmaceuticals and the desire to live without drugs.
The following text was cobbled together from my replies to the desires and concerns of readers. It explains at some length the fallacy in believing pharmaceuticals to be potent weapons against mental chaos. The next post will argue against long-term use of medications without trials of drug reduction, and also offer some suggestions for tapering off pharmaceuticals.
It is undeniable that people seem to get better on drugs. However, although there can be little doubt that the active agents in medications are sometimes responsible for the observed improvement, the placebo response and other factors need to be kept in mind. Pharmaceuticals are seldom prescribed in isolation. When someone presents to a psychiatrist for care and gets better after receiving a drug prescription, it is hard to dissect out how much of the recovery comes from the active agent in the pill, versus the support, encouragement, and therapy that go along with participation at a mental health clinic. Many people who get better on medication are recovering because of their mind’s own hidden powers, elicited in the context of a supportive environment, and not because of the pharmaceutical chemical.
One commentator pointed out that patients may try several medications without success, and then finally be given the ‘right’ drug combination, after which they get better. This sounds suggestive, and perhaps in these cases the pills are making a big difference. But in every real-world situation many other factors are at play, so it’s also possible that the supposed ‘ideal’ drug cocktail is merely a coincidence: it happens to be chosen around the time when improvement would have happened anyway. Only controlled, randomized research could settle this question definitively.
When placebo-controlled research is performed that adjusts for the myriad other variables in treatment, drugs never appear particularly decisive in their effect. In a typical ‘successful’ study, 60% of those who take a medication show some level of improvement, whereas 40% of those on placebo recover just as much. By these numbers, only one person in five who gets better on a psychiatric drug is doing so because of the chemical agent in the pill. Four out of five are improving for other reasons.
And of course the published research has been heavily biased to demonstrate efficacy. When all of the suppressed, failed studies are added to the analysis, the active agents in drugs look even less helpful. On the basis of careful review of both published and buried research, Psychologist Irving Kirsch has concluded that antidepressants depend almost entirely on placebo action for their effectiveness.
The tendency of the mind to respond to suggestion can hardly be overstated. Although the word ‘placebo’ carries a connotation of ‘fake,’ it really should awaken us to the healing power of expectation. In a future post I’ll explore placebo action more deeply. For now, I just want to highlight that medications may help us feel better for reasons other than the neurological effect of the synthetic chemical.
Having expressed some reasons for doubting the widespread perception that these drugs have nearly miraculous powers, I must emphasize that medications may be useful in the short run in many cases. Possibly they are also necessary on a more chronic basis at times. But given that research evidence supporting their value is weak, whereas their ability to cause serious side effects is undeniable, drugs should not be looked at as the most important, reliable, or safest tools available to aid those suffering psychic distress.
Note: in moving this text over to my other blog, Guideposts to Happiness, I made some revisions and divided it into two posts. Such edits in transfer are a common practice for me, but I usually allow WillSpirit! to maintain the original version. However, in this case the reworked presentation reads a lot more clearly, so I’m coming back to alter the format here. The section above appears on GTH with the same title, but it ends at this point. The essay below will soon be published on GTH under the title, “Drugs for Life?”
DRUGS FOR LIFE?
Although my last post argued against viewing psychiatric drugs as scientific miracle pills, it remains true that some patients experience decisive improvement on medication. I believe such individuals are fortunate. As my writings have made clear, I did not enjoy much success with drug treatment.
Lack of efficacy combined with dreadful side effects led me to taper off the medications, slowly and over several years. If the pills had worked for me over the long haul, I’d probably still be taking them.
Pragmatics, not ethics, determine my opinion here. I see little reason to argue against pharmaceuticals in those cases where life feels enhanced and neither adverse effects nor expense have proven troublesome.
Even so, as a physician I can affirm that limiting the number and dosage of medications to the minimum necessary for the desired effect is always a good policy. As a human, I can endorse occasional reevaluation of life strategies as a wise practice.
The pharmaceutical industry promotes the misconception that psychiatric drugs are, essentially, vitamins: permanently necessary for mental health. This is simply untrue. Some patients may need medications for life, but clinicians do us a huge disservice when they assume this without proof. The only way to know for sure is to occasionally try the alternative: professionally guided drug reduction.
Lacking helpful clinical advice, and often out of frustration, many patients stop taking pills in hope of living drug-free. Unfortunately, abrupt cessation of pharmaceuticals almost always leads to decompensation. Although the desire to discontinue medications is natural, quitting too quickly can cause profound deterioration if not hospitalization. Unthinking clinicians view the downward spiral that follows sudden drug cessation as evidence that the patient has an illness that requires chemical treatment, but it’s more likely a sign that the brain has become habituated to the drug and that the withdrawal was too rapid. Only by slow, careful tapering can a person’s condition on less or no medication be fairly assessed.
Pharmaceuticals too often get prescribed for years and decades despite a striking lack of controlled evidence for benefit with such prolonged treatment. At the same time, it’s all too easy to substantiate the harm drugs can cause when used for extended periods. Unfortunately, it is easier for psychiatrists to keep writing scrips than it is for them to undertake the difficult work of assisting with medication reduction. They also fear malpractice liability should a patient harm self or others (though this risk is probably minimal when tapering is done properly and with good communication). So countless patients end up on potentially toxic pills for life without ever getting a legitimate try at doing without.
Drugs can be helpful, especially early in one’s recovery. But after a time on medication, as one gains familiarity with calmer, more balanced mental states, one often feels ready to cut back on pharmaceutical support. It may make sense at that point to try measured reductions to see if the recovery remains stable with less intensive treatment. One might find that hypomanic energy (for instance) that once felt intolerable can now be managed or even used to advantage. Such a trial would be a personal choice that should made in consultation with clinicians.
Getting completely off medications once seemed impossible to me, but it turned out to be achievable. Most important to my success was learning to tolerate uncomfortable feelings without acting them out. Acceptance and Commitment Therapy (ACT) was instructive in this regard. Cognitive Behavioral Therapy also helped, as it taught me to avoid exacerbating psychic distress with distorted thoughts. In addition, mindfulness meditation practice helped me observe my feelings and thoughts without buying into them. Regular exercise, helping others, and like-minded social contacts were also vital in supporting this work.
For me, successful drug tapering hinged on my going slowly and remaining in touch with mental health professionals who supported my goal of drug reduction. Since I knew they shared my long-term agenda, I trusted them when they suggested I should increase the dose of a medication temporarily. I did this several times in the four years I spent tapering. I’d go up on the dose until some transient stress resolved, or the winter days got longer, or I simply felt stronger. I tried to avoid rigid refusal to take pharmaceuticals, but I never let go of my long-term hope of reducing the medication load as much as possible. In the end, I was able to completely stop, but if it had been necessary to continue on a low dose, I would have done so without feeling bad about it.
What matters is balance and contentment, not some misplaced philosophical purity. If medications bring a person to a better state, feel like the right choice at the time, and don’t cause harm, I see no reason not to use them. But it still makes sense to take a second look from time to time.
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