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mental health mondays :: what's so bad about drugs?

this won't hurt a bit
years ago, i had a friend who was schizophrenic. i knew this, but i can't say that anything really leaped out at me that marked his behaviour as different. he was soft-spoken and a little bit eccentric, perhaps, but that made him seem a lot like the majority of people i knew. so his condition was just something of which i was aware, but it didn't seem to have much of an impact on our interaction.

then one day, i got a call from a mutual friend, asking me to come with her to see him, because he'd apparently opted to stop taking his medication. we talked to him for what seemed like a long, frustrating time, listening to his theories on why those who would force him to take medication were really just trying to force his brain to work along certain lines, to stop him from being able to think in ways that weren't orthodox. flaunting my recently acquired knowledge of the causes of schizophrenia [this was in the days before google, so not everyone knew everything], i reassured him that the medications were merely redressing a type of chemical imbalance in the brain, not forcing him to think in any particular way at all.

i remember that he looked at me without any sort of anger, but rather the way that teachers do when they have a student who's a little slow catching on. "that's what they tell you," he explained, "because you wouldn't accept just hearing that the way you were thinking wasn't what they wanted. so they tell you it's because you have a chemical imbalance, or whatever."

ladies and gentlemen, there is no response to that argument. at the time, of course, i smiled in my condescending way and indulged him- it's not like, even at his most unhinged, he ever seemed in the least bit dangerous- while quietly remaining convinced that i was right. i still don't think that my argument was wrong, but in retrospect, i do wish i'd taken the opposite approach and asked him that, given that he normally seemed happier and more relaxed than he did at that moment, what was so bad about the drugs that he felt he had to stop taking them.


in fact, my friend's case was not particularly odd. the issue of noncompliance is a big concern for those working in the field of psychiatry, one of the toughest challenges faced by both the medical profession and the friends and family of psychiatric patients. huge numbers of people with serious mental disorders- bipolar, schizophrenia- turn away from their medications every year in spite of the problems their conditions present. why?

a couple of reasons are fairly basic. the first is that, when you're on a number of medications [which many psychiatric patients are], it can be tricky remembering when to take what, particularly if you're caught up in having a life at the time. furthermore, people with mental disorders are often prone to cognitive issues to begin with- confusion, poor memory, etc.- so it can be even more difficult than usual to ensure that a person even remembers to take their meds. setting an alarm or reminder on one of the myriad electronic devices that we carry with us helps alleviate this problem, but it does rely on the person to make sure that the alarm is switched on, that they actually have immediate access to their meds when it goes off and that they're always going to be in a position to take them at that point. [many jobs won't let you even look at your cell phone if you're on shift and are inflexible about when you can take your breaks. "hey boss, i need to take my pills right now or everybody dies."]

second, of course, there's the fact that many people with mental illnesses live in poverty, because their conditions make them difficult to employ to begin with. we've already looked at the potential costs of mental illness, but it bears repeating: being crazy can be expensive. insurance plans, both public and private, can be strangely picky about which drugs they do and do not cover and doctors aren't always inclined to prescribe those medications that are covered. a friend of mine who has adhd was originally prescribed ritalin, but that was changed by his doctor to concerta, which is newer, has a more gradual release and is supposedly better tolerated. except that his public insurance plan doesn't cover concerta, it covers ritalin, which means that he was faced with a choice of paying $100 for a month's worth of concerta or going back and trying to convince his doctor [whenever he could get an appointment] to change the prescription. remember, we're talking about medication for someone whose brain is unfocused at the best of times. these are the challenges.

it's worth noting that one study conducted by durham university in the united states actually identified the inability to pay for drugs as the number one reason for noncompliance.

however, other studies have generally found that the main reason for noncompliance is that patients simply don't see the benefits. it's a bit of a conundrum and papers that study compliance issues repeatedly stress the importance of keeping patients on their medications, but there aren't a lot of hints on how to do that. and there are a lot of reasons why people decide to stop taking them.

the first, of course, is that they're convinced that they're ok now and they don't need the pills anymore. because that's how medications are supposed to work. you take your medicine until you feel better and then you get to stop. in this case, however, the medicine that you're taking isn't really making you better, but just masking the symptoms of your illness. so, yes, you might feel fine, but remove the medicinal cloak and you're right back to where you started. [or worse, since many psychiatric medications have harsh discontinuation symptoms.]

the other major reason why many choose to abandon their medications is what i like to call the "cure is worse than the disease" factor. the side effects of many psychiatric meds read like someone's social nightmare. almost all will make you gain weight, often a lot of weight. even the so-called milder ones, like ssri's will kill your sex drive. since most anti-psychotic medications are specifically meant to calm your mind down, most will also knock you out and make sleep your main goal in life. parts of your body can start moving uncontrollably and, yes, these medications can kill you via a condition called neuroleptic malignant syndrome, which is specifically linked to the sort of long-term use of psychiatric medications used to treat serious disorders.

am i the only one who thinks that this sounds like an awfully harsh list of things to ask people to endure?

it's all well and good to tell people that they have to stay on their medications, but perhaps it would help convince them if there was more serious work being done on developing drugs that have lower side effect profiles [although many newer drugs, like atypical antipsychotics, were at first understood to have fewer side effects, research is increasingly showing that that simply isn't the case and that they're every bit as rough as the earlier drugs they were meant to replace]. in addition, finding ways to manage side effects when they do occur needs to be paramount. the optimist's credo of "well it's better than the alternative" may work for some, but it's not really a practical long-term solution. i'd like to say that, ultimately, we should look for ways to manage illnesses without relying on medication, but i'm well aware that, for many, their brains are simply never going to be cooperative enough to guarantee that they'll be able to take care of themselves and interact with the rest of the world in their natural state.

as for my friend, the one who i started off talking about, i have to say that, following that episode, i sort of lost touch with him. to the best of my knowledge, his family intervened and had him hospitalised for a short time. although he was terrified of that possibility [it had happened before], the next time i ran into him, probably a couple of years later, he did seem to be in considerably better shape. he told me that he had been doing well, although he'd run into some legal trouble when a neighbour spotted a couple of marijuana plants in his place. he'd ended up pleading guilty to a misdemeanor and doing some community service and the experience was enough to permanently scare him off even thinking about pot for the rest of his life. [the system works?]

it didn't occur to me until much later to ask him if he'd ever pointed out to the police that marijuana was probably the least dangerous drug he had in his possession at the time.

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