What is the prognosis?

 

I met a new patient the other day who described a long history of anxiety and depression that had recently become severe. She had seen two other psychiatrists in the previous year and came to see me because she was not getting better; in fact, she was getting worse. She described symptoms that ranged from anxiety and mild depression to severe panic attacks and social withdrawal; symptoms that were almost certainly caused by the high doses of alprazolam she was prescribed (Xanax). She described a common pattern: a person has relatively mild, manageable anxiety and is prescribed a benzodiazepine. After a few weeks, the 'benzo' is no longer effective due to a process known as 'tolerance,' and to make matters worse, if the person misses a dose, the discontinuation symptoms FEEL like severe anxiety and panic, prompting the person to take more of the benzo. To get a response, the dose must be increased, which causes the withdrawal symptoms to worsen, resulting in a downward spiral of increasing anxiety and medication use. This is a difficult pattern to break because the patient must reduce and taper off the medication (11 buy kalma Mylan Xanax Australia) that was previously providing relief while also tolerating some anxiety and insomnia.

 

I feel bad for the patients in this situation because they would have been better off if they had never sought treatment for their anxiety in the first place. But my new patient's situation was even worse, and what had happened to her was not uncommon. As her 'anxiety' worsened, the psychiatrist who was treating her increased the number of medications she was taking. She was given Depakote, but it did not help her. Then we were given risperidone. Then there's lamotrigine. All of these medications are sedative in some way, and when she complained about being too drowsy, she was prescribed the stimulant Adderall, followed by modafanil. Because the stimulants made her shaky, the original benzo was increased.

 

Medications such as Depakote, lamotrigine, and risperidone have a place in psychiatry; all three are mood stabilisers used to treat bipolar disorder, among other conditions. A person must have a history of'mania'—a period of 7 days (shorter if the person is hospitalised) when the person is'revved up,' with less need for sleep, increased risk-taking, racing thoughts, and other specific criteria—to qualify for a diagnosis of bipolar I (the more serious form of bipolar disorder). Some credible evidence suggests that the diagnosis of bipolar disorder has been overstated in recent years, particularly in children. Over-diagnosis of depression would not be a bad thing, given that the medications primarily used to treat depression, known as 'SSRIs,' are relatively safe. However, the same cannot be said about over-diagnosis of bipolar disorder; medications used to treat bipolar have a number of serious side effects ranging from sedation and tremor to weight gain and diabetes!

 

When I asked her about her diagnosis, she was perplexed. 

She had not been informed that she had bipolar disorder, so she had no idea why she was taking so many medications. She had no idea that some of the medications were only prescribed to treat the side effects of other medications. And she had no idea that the medications could cause a variety of systemic illnesses and conditions.

 

I'm not sure what to think of THAT kind of psychiatry. On my radio show, I frequently discuss the importance of patients and psychiatrists spending TIME together; time to get the diagnosis right, or in this case, to come to SOME diagnosis! Too often, medications appear to be prescribed out of desperation; an overburdened, short-on-time prescriber adding medication not in accordance with a sound treatment plan for a careful diagnosis, but rather using medications to blunt symptoms like firefighters in a helicopter dropping water on a fire.

 

Medication is not required for all psychiatric conditions, but it can be beneficial and even necessary in some cases. When medications are used, I encourage all patients to ask about the diagnosis being treated, the options for medication and non-medication treatments, and the effects and side effects of any medication that is prescribed. That understanding will most likely take some time, but it should be an essential part of every psychiatric relationship.