This past week we attended the annual meeting of the American Psychiatric Association in New Orleans, Louisiana. Our cab driver said that he'd been all over the world, but New Orleans had the best food of anywhere. He might be right. Ah," the food! Much more interesting than the meeting! The oysters were incredible and so were the sauces. And we didn't even make it to the "cutting edge" restaurants, as told to us by a local psychiatrist whose passion is food and who attended the course we gave on Narrative hypnosis. By we, I mean myself and my colleague in the Coyote Institute, Barbara Mainguy, who is a hypnotherapist, among other credentials. We had hoped that other colleagues from the Coyote Institute could attend, but that was not possible.
Coyote Institute is a not-for-profit corporation founded for the study of change and transformation. Of course, coyote is the North American symbol for change and transformation. Wherever coyote goes, change happens. Coyote's original distribution mirrors his role as symbol which is the West Coast (all the way to Northwest Washington) spreading eastward to the Mississippi River, and filling the Great Plains of the U.S. and Canada. Today, coyote is the only species of animal who distribution is actually growing, so she must know something about coping with modern life.
Speaking of change and transformation, the A.P.A was markedly different from two years ago and even last year in San Francisco. The presence of the pharmaceutical companies has greatly diminshed. Some change has occurred, and we're not sure what it is, but the A.P.A. seems to have distanced itself from the inudstry. Unlike Washington, D.C.'s meeting, the buses were not panel to panel drug ads. No people rode segues distributing ads about drugs. We saw fewer industry sponsored symposia, and it was hard to find a pen.
I have written before about how unfortunate it is that drugs have become the mainstay of American and even world psychiatry. There is no question, that some people require drugs to remain stable. However, the idea that drugs are the first-line treatment seems preposterous. Yes, this is the state of community mental health in most of the developed world.
In my conventional psychiatry practice, most patients expect that medication will make them feel "normal". We have convinced them to believe this. We have convinced them that the vicissitudes of their emotional swings are entirely chemical and should and can be managed by chemicals. Sleep is the best example. Almost everyone wants something to make them sleep. Sleep is a a major income stream for the pharmaceutical companies, and one in which nothing really performs. A recent double-blind, randomized, controlled study showed that people sleep, on average, 4 minutes longer each night, when taking Ambien. Many drugs make people sleepy when taken at night, but this side effect usually wears off in 2 weeks. For example, quetiapine (brand name, Seroquel) and trazodone (brand name Desyrl) and mirtazapine (brand name Remeron) all make people very sleepy. These drugs are prescribed for their side effects, which seems like a questionable practice. The side effects wear off. The drugs no longer make people sleep. But people keep taking the drugs. Increasing the dose will bring back side effects for another two weeks or so, but how high can the dose go? A recent meta-analysis of controlled trials of sleeping agents found that nothing works better than over-the-counter diphenhydramine (brand name Benadryl), which itself doesn't work all that well.
We know how important sleep is. In a recent lecture on NPR about sleep, we heard that teenagers who get 15 more minutes of sleep, on average, every night, grades increased from "C's" to "B's". Schools with later starting times produce more people in the top 15% of standardized tests. In a study on teenagers, eighty percent of depression cleared up when people sleep. The symptoms of depression begin right away when we start losing sleep. Perhaps those extra four minutes of sleep with Ambien are worth something!
What is sad, is the expectation that we have created for patients that a pill should instantly put them to sleep. Of course, they have the same expectations about all their symptoms. When they feel sad, a pill should pick them up. When they feel angry, a pill should calm them down. When they feel hyper, a pill should make them mellow. Pills should exist for every unpleasant feelings. Pills don't appear to work this way. I think medications do have long-term effects, but these effects are seen over weeks and not hours. Perhaps there is no escape from the hour to hour fluctuations of our moods and feelings. I suspect we just have to learn to cope, which is not the message psychiatry has been giving people.
Sleep is a good example. The best evidence for helping people sleep goes to cognitive behavior therapy. CBT helps people learn how to manage their thoughts at bedtime. Here are some examples. I ask people to write down all their fears, worries, and anxieties before attempting to go to sleep. I ask them to write until they can think of nothing more to write. Then put that writing in a special place where they can review it in the morning. "Now," I say, "you have no reason to think any more about your problems. You can do or solve nothing more until the morning." Then I teach them to use mindfulness meditation techniques to still their minds. In addition, basic sleep hygience is important. The bed should be used only for sleep or sex. All other activities should take place outside the bedroom. If one cannot get to sleep in 15 minutes, one should get up and do something and then try to sleep again. Reading exciting novels or watching exciting television programs in the hour before attempting to sleep is also a mistake. Reading a textbook is a much better idea for that hour before sleep. Perhaps a cell phone instruction manual would work just as well or a software use manual. People have to learn how to do these practices. Our contemporary society does not teach this kind of common sense.
In psychiatry, I believe we need to emphasize much more what people can learn to do for themselves and with each other than what drugs can do for them. Most of the people I see in my conventional practice come because the drugs aren't making them happy. They believe that they just aren't on the right medications. Their desire is to find the right combination of drugs that will make them feel "normal". Of course, defining normal usually highlights an expectation for emotional life that is unattainable. We in psychiatry have also fostered this expectation in people.
How does this work in practice. Commonly in a community mental health center, patients come to see the intake worker, then have a psychosocial assessment with a social worker or another type of counselor, and then see the psychiatrist for medication assessment. Since the psychiatrists only job is to prescribe medication, everyone gets a medication. Larger, my sense is that these drugs are functioning as placeboes except for the more severe patients for whom the drugs appear to have some effect, as in reducing paralyzing fear. The psychiatrist then sees people for medication management and a psychotherapist sees them for everything else. This configuration arose because it maximizes income in both the U.S. and Canada. One study showed that it was more cost effective for the same person to have one hour sessions and manage both medication and psychotherapy, that that study had no impact on contemporary practice. Year ago, this was how all psychiatry was done. It fits my model for the use of medication, which comes from a book entitled Unbearable Affect. Drugs are best used to manage unbearable affect in the service of psychotherapy and other healing. People (human contact and support) are also effective for managing unbearable affect, and probably work better than drugs. People, however, are in short supply today. We don't have communities as much as we once did or as much as Third World countries have (this is why their outcomes for schizophrenia are better than ours, as found by the World Health Organization). Withoutdoing both psychotherapy and managing medication, it's impossible to steer this course. People do need some uncomfortable feelings in order to learn new skills. If the goal of perfection through medication could work, no change or transformation would ever occur. We would never address the contexts that produce the emotions and the instability that we feel.