I want to talk a little bit about psychotropic medications (any drugs used to treat psychiatric conditions or to affect our mind or mood) because there are a lot of people taking these drugs. While often doctors do their best to inform patients about these medications, the reality is that with the short duration of doctor’s appointments, and the fairly limited training that most GPs receive in psychological conditions, often this information is not as thorough as it could be. I’ve met and worked with quite a number of people who are taking medication of one form or another who do not fully know why it has been prescribed, when or if they will stop taking it, what side effects they might be experiencing from the medication, and so on.
Then there are the reports about psychotropic medications in the media, such as recent studies that suggested that common anti-depressants are little more effective than placebo. Finally, there’s still a lot of stigma for some people around taking psychotropic medications, and various messages that some health professionals push which are intended to combat this stigma but which sometimes are inaccurate and lead to mistaken understandings about medication. I want to address all of these points, but it will likely take more than one post to do so. I want to start by talking about some of the general principles around psychotropic medication, and dispel some of the misinformation that is floating around as well.
1. We do not know if psychotropic medications correct a ‘chemical imbalance’ in the brain, but they probably don’t.
The truth is that we do not fully understand how pretty much any of our psychotropic medications work. Although our understanding of the brain has improved dramatically with modern neuroscience tools and technology, we are still a long way off from being able to accurately explain the link between our brains and what we think and feel, let alone explain how specific drugs affect this. We do know that certain parts of the brain are typically associated with particular types of feelings, but given the 100 billion neurons in our brain this is kind of like saying that the Waikato is largely associated with agriculture. True, but it doesn’t really tell us much about specifically what’s going on.
Our understanding is not incomplete – we know that particular neurotransmitters are affected by particular drugs, and that this is probably related to the effect that these drugs have, but we don’t know exactly how this happens – which is part of the reason why psychiatrists cannot predict which antidepressant will work best for any given person, and it can end up being a process of trial-and-error.
We know now from research into neuroplasticity (the brain’s ability to create new neural structures based on our experiences) that many mental health issues likely arise from this process. Our brain essentially tries to adapt to difficult or challenging circumstances, often in ways that are helpful in the short term but create problems in the longer term. So while it is true that our brains do become functionally different when we are suffering from mental health issues or psychological distress, this is a very different process from the kind of chemical imbalance that might arise from, for example, having an iron or iodine deficiency that can be corrected by introducing more of these substances into your diet.
2. Even though we don’t understand why psychotropic medications work, they still do work.
Despite some studies showing that, for example, antidepressants on average are not much more effective than placebo, these medications do work and work very well for some people. Often research done around psychological conditions can be quite misleading, since research is done across a large number of people and yet from an individual perspective the question is not ‘does this work for the majority of people’, but ‘does it work for me?’ One of the bigger studies into the efficacy of antidepressants found that on average, they had an effect size of 0.31 over placebo. If we just look at this value alone, then it can seem fairly insignificant. However, digging into the research a bit further we see that this effect size varied from medication to medication, with some of the more commonly used antidepressants having effect sizes closer to 0.5, which is usually deemed to be ‘clinically significant’.
More importantly though, looking at the raw data from studies like this we usually see that this average effect size comes about from the fact that some people had a strongly positive response to the drug, while others had no response, or a negative response. That is, it wasn’t that it was mostly ineffective for everyone – it’s that it was very effective for some, and not so much (or detrimental) for others. A more meaningful number used in medicine is ‘Number Needed to Treat’ (NNT). This number basically says ‘you need to give this many people the drug in order for one of them to get a meaningful benefit from it’. In the case of fluoxetine (Prozac), the NNT seems to be between about 3 and 6, depending on the population and particular study. That is, if you give fluoxetine to 6 depressed people, one of them will probably improve significantly. If you’re that 1 person, this is amazing. Otherwise it kinda sucks.
But, and this is important, this is true for all psychotropic medications. Which means that if you’re one of the five for whom fluoxetine did nothing, maybe you’re the one in 7-9 for whom escitalopram is effective (I know, I’m talking about SSRIs a lot – because they’re one of the most commonly prescribed drugs for mood disorders in New Zealand).
So while any given drug can reliably be said not to work for most people, all of the most common drugs will work for some people. This is why it’s so important to find a GP or psychiatrist – if you’re going to take psychotropic medication – who can work with you to try different medications, pay attention to your response, and find alternatives when first attempts are ineffective.
3. Psychotropic medications do have side effects – and we need to weigh them up.
Because psychotropic medications can be effective, they can also do harm. This is important to understand – anything that can make a positive difference also has the potential to cause harm – the same is true of psychotherapy. I’ll talk more about the most frequent side effects of common medications in a later post, but it’s important to be aware that side effects are common with most psychotropic medications. Again, as with efficacy some people will experience them and others won’t – you won’t know until you try.
What this means is that prescribing and taking psychotropic medications needs to be a carefully considered choice based on the possible risks vs possible benefits. Ideally, doctors would have the time to talk through in depth with patients the possible side effects, and how they would feel if they were one of the people who did experience that side effect. Patients could then decide if it would be worth it to them for the chance of a medication that helps, whether it’s with depression, anxiety or anything else. Unfortunately in my experience this rarely happens – patients are often prescribed medication with little explanation, and although this information is readily available we don’t always know where to find it.
Ultimately, only you can know whether it is right for you to take psychotropic medications, and only you can know if they are helpful for you when you do take them. The best advice I can give anyone taking or thinking about taking medication is to really ask whoever is prescribing as much as you can about what to expect, possible side effects, the number needed to treat for that medication, and the possible benefits so you can make the decision for yourself with as much information as possible.
4. There is nothing wrong with taking psychotropic medications.
Although acceptance has grown for all kinds of treatment for mental health problems, there is still often a stigma around taking psychotropic medications. Sometimes this is seen as a sign that there is something ‘seriously wrong’, or that you’re not capable of coping on your own. People sometimes talk about medication being a ‘crutch’. Although this is often said in a derogatory sense, in another sense it actually is not inaccurate. A crutch for a broken leg is something that we use to help us manage something outside of our control for a period of time until our body heals itself enough for us to do away with the crutch. It’s a temporary measure, designed to support and promote our body’s natural ability to heal, and to go alongside other rehabilitative measures like physical therapy.
Psychotropic medications can perform a similar role – to help us get our life to a point that’s more manageable, so that we can start making the changes and taking the steps that we need in order to return ourselves to health. Sometimes medication can help us get to the point where we can get the most out of therapy, where we’re really able to use it. Or it helps us get out of the house, get exercising and start doing the things that lead to us becoming psychologically healthy once more.
If you have been considering taking a psychotropic medication and have thought or felt that it’s wrong, or that there’s something wrong with you for doing so, then these are the sort of thoughts and feelings that it can be useful to discuss with your prescriber, or with a therapist. Again, only you can know whether taking medications is something that you want to do, but if it’s something you believe might be helpful then it can be useful to explore and talk about your thoughts and feelings about that decision.