“Hey Doc, why are you using me as a guinea pig? I am not taking these meds!”
Anybody who has been around people who need psychotropic medications (drugs for mental illness) has heard this complaint. Psychiatrists can never be sure if the prescription they write will do the “magic” that is sought. It is normal practice for a physician to give a trail of one medicine for a few weeks (or months) and if it is not working, try something very different. Or even begin a “cocktail” of medicines that might just do the trick.
It seems unusually cruel that people who have issues trusting people are given medicine that is so unreliable. In American culture physicians are the most trusted of people. But when some of us feel so bad that we can’t even think straight, and we can’t trust anybody, we often go to a doctor who will write something on that special pad that might help, but might even harm! Why is the system so cruel?
To understand this, we need to understand a little bit about psychiatric diagnosis, and then a little bit about the medicines themselves.
Psychiatric diagnoses or the types and categories of mental illness is defined in a book called DSM (Diagnostic and Statistical Manual) published by the American Psychiatric Association (APA). This book is periodically updated and is currently in the fourth edition. The APA is an association for physicians who specialize in psychiatry. So they are interested in having their particular specialty be as similar to other medical specialties as possible. But there is a major, essential difference. Mental illness is not like most other medical illnesses. Most illnesses are defined by what causes them. Mental illness is defined by symptoms.
In most fields of medicine a disease is defined by the pathogen (the “bug”- virus, bacteria, etc.) that causes it. You have a sore throat so you go to the doctor to find out what you have. She takes a culture and tells you that you have strep throat. And she writes out a prescription for a medicine that will kill the strep.
The sore throat is a symptom. Before you went to the doctor you knew you had a sore throat. You did not know if it was strep throat or post nasal drip. Any symptom can have multiple or various causes. It is the doctor’s job to figure out the cause in order to prescribe a cure. Otherwise, you could just go and but some Cepacol.
But the DSM does not define mental illness according to cause. That because we generally do not have much of a clue about the causes of mental illness. (Except for one case, I will mention later.) So all of the categories in the DSM are defined by symptoms. A person has bipolar disorder because he or she acts like a person with bipolar disorder. A person is labeled schizophrenic because he or she has two or more of one set of symptoms and a certain amount of other symptoms. But nowhere is there a diagnostic test that is similar to a blood test, MRI, or throat culture. (This is also why people with major mental disorders usually have multiple diagnoses or the diagnoses change over time.)
All of the symptoms are behavioral. That means, we can look at the way a person is acting and apply the label that fits best. Of a seven year old has six or more features of inattention for at least six months, then he has ADHD. But do we know (or care) if it is caused by a malfunction of the brain or because the home is so unorganized that the kid rarely gets enough sleep? (Try staying focused on 4 hours a night of sleep.) Or some other reason?
Since psychiatric illness is defined by symptoms and not causes, the medicines are also given to address the symptoms and not the causes. That can be very good. If you need to control the symptom of hallucinations, it is fine to give anything that will work. If you need some immediate relief for your sore throat there is nothing wrong with a Cepacol. But it might not work, if the cause remains and can overpower the symptom. So if it doesn’t work, we can’t be sure why not. So the next best thing is to try the next best thing. Try a different medicine that might attack the symptom a bit more efficiently.
There is one category of psychiatric illness where we do know the cause. That is Post Traumatic Stress Disorder, and the related diagnoses. We know that there is a clear environmental cause. But that just makes the problem of prescribing medication even more complex. You cannot prescribe a retroactive anti-trauma medicine. (It would be wonderful, wouldn’t it?) Which is why there is no medical intervention for ex-abused people or people who have survived trauma. And when medicine is helpful, it is very difficult to apply that helpful experience from one person to another.
So if symptom relief is the best we can get, go for it. It can be much better than being with the symptoms. Without a cure, I’ll go get a Cepacol.