Medications help people feel better, but do people disempower themselves when they give all the credit to medications during the healing process?
DR. HASHEM: Absolutely. That’s a very good point, actually. I don’t feel medication by any means is the only reason people get better or worse in certain cases. As we just mentioned, the perception people have about their condition is also paramount. Placebo is a perfect example. I read an article that said drug companies are having big problems with the impact of placebo because the placebo has such a strong impact in the healing process that placebo success rates often surpassed the success rates of the actual medication. The pharmaceutical company, Merck, tried to create an antidepressant they thought would be highly successful. Ironically, when confronted with the fact that they would be trying a brand new highly successful antidepressant, when they gave the control group the placebo they felt better strictly by the perception and the new medication could not be approved. We still don’t fully understand the effect of placebo or the ability of the mind to heal itself, so I would say perception by the patient is just as important as the choice of medication.
In a large study early on it was found that the group of depressed patients received only cognitive therapy with no medication improved as much as the patients on medication alone. I recall when Prozac came out it was found to be very helpful to a lot of people the issue of how long to stay on medication came up. In my experience I found that when depression is improved on medication the person actually change their interaction with their environment and people around them. This positive interaction feeds back into them positively. If you can copy that positive interaction and cognitive thinking and behavior and continue to do it without the medication you would be able to get off the medication.
So somehow you need to learn that you are feeding into the environment that is causing some of the problems you are experiencing. Your role in the environment is very important. In my experience, this method applies with disorders like depression and anxiety. Bipolar and schizophrenia on the other hand, are purely biological conditions. In these situations in particular, the mind over matter approach would not be the preferred method and would probably have little effectiveness. There is no doubt about it; I always encourage people to take steps in the way of cognitive function which will eventually take place of the antidepressant or anti-anxiety.
INTERVIEWER: Often people give up on their medications because they lose patience while waiting for results, since most people won’t feel better right away. How long does it take for most psychiatric medications to get into the system and start noticeably helping?
DR. HASHEM: This is a very important aspect of treatment. Interestingly, a national study was done by the National Institute of Mental Health, called the CATIE. This study dispelled a common belief among mental health staff that patients stop taking their medications primarily due to side effects. Actually, the study showed the number one reason patients stopped taking their medication is because they believe the medication is not working. The time in which a medication begins to become effective varies from condition to condition and from person to person. In conditions such as depression or schizophrenia, one theory is that receptors in the brain seem to change in patients afflicted with these conditions. The problem can vary from these receptors malfunctioning, to the presence of too many receptors or too few. In order to heal these receptors, the body takes time to repair them effectively. The medication itself may affect the neurotransmitters immediately, but that healing process in the body does take time to complete. This is where some individuals may become impatient
INTERVIEWER: So the healing time can also vary from person to person?
DR. HASHEM: Yes. Two of the main factors are person to person and from condition to condition. In my clinical observation, we generally tell the patients it takes about four to six weeks in order to see any noticeable effects. In the cases of some new medication such as serotonergics, which include SSRIs for depression, we observed some who saw improvement in three days, some people improved in a week, some people took two weeks, and some people took four weeks. But in general, the cardinal rule is not to give up on the medicine for at least four to six weeks. Now, another factor is the prescribed dosage of a medication. For example, many people are familiar with taking Tylenol. Commonly, most people take two Tylenol tablets for the normal headache. If you were to take just one tablet, your headache might not go away and you would believe the medicine doesn’t work. It’s the same thing with psychiatric medication. You can take one Prozac, and you may not get better. Your proper dose may be two Prozacs, or three, or four. The dosage normally goes up to 80 mg. So a rule of thumb, that is generally not used when medications are given up on, is that you should try a medication up to its maximum dosage for up to six to eight weeks before abandoning it. If after this you continue to not see results, then a medication can be deemed ineffective. I believe giving up before this, is a little premature. What will help people strengthen their faith in a medicine would be to think of their affliction as a cut on a finger. One day of covering it with a band-aid will not complete the healing process. Visualizing it like this helps when a condition is not visual like a cut or scrape. Unfortunately, nerve cells in the brain and the body are the slowest tissues to heal.
Dr. Hazem Hashem
INTERVIEWER: How do psychiatrists help empower people to accomplish their treatment goals?
DR. HASHEM: In the last few years, Psychiatrists have actually been cornered into just being medication prescribers. But we also my use the short time we have to give “cognitive therapeutic hints.” The most empowered patient is a patient who is knowledgeable about their condition. This is the foundation of empowerment. This is why I always encourage people to research on internet, look up their symptoms and read about the conditions, read about the medications, and read about the different side effects and things like that. In some cases, the doctor may miss to ask the right questions. This can lead to a physician missing important clues to a patient’s condition, inevitably resulting in misdiagnosis. When a patient says “I read about a particular condition and I feel it fit me perfectly.” I am happy to discuss and match their symptoms with the right treatment. Doctors should not feel insulted by that. Much to the contrary, it is very helpful for the person to know exactly what symptoms they’re dealing with. So I also ask people to put every symptom they have on a scale of one to ten before we start treatment and a number after treatment. Each time we readjust the dose or change a medicine. This way, you’re actually giving the doctor a good picture of whether the medicine has worked or not. If a patient is not aware of or doesn’t keep track of their symptoms, the medicine may have worked perfectly, but they deem it ineffective because they themselves were not aware of the changes taking place. So it is very important for both the doctor and the patient to recognize what has been achieved and what has yet to be achieved.
Knowing a patient’s preference is also helpful in the treatment. In some cases a patient might say,”oh, I heard horrible things about Zyprexa,” or Prozac or any drug for that matter. If the doctor continues to insist on giving that medication anyway, the patient may be reluctant to take it. Additionally, the patient will most likely give a negative report on the medications effectiveness since they already have a bad impression of the medication anyway. So it is very important for the patient to know what they are taking and to be educated on exactly how they are being treated
INTERVIEWER: Why do psychiatrists sometimes order lab tests?
DR. HASHEM: Lab tests are useful for certain conditions. Some depression, for example, can be caused by low thyroid function. The thyroid is a very important hormone producing gland located in the lower part of the neck. In this case, anti-depressants may be completely ineffective and lead to much frustration during treatment. Sometimes there are no other symptoms that can be observed to determine if a patient’s depression is caused by thyroid dysfunction. After discovering this, it has become standard to perform a test called TSH to check for this condition so we can begin effective treatment. For other medications, such as lithium or Depakote, it has been found that the effectiveness of the drug is based on how much is actually being absorbed into your system. You need a certain level of the medicine in your blood in order for the medication to be effective. Above that level, it may give cause side effects without additional benefit and below that range is ineffective. In the case of lithium, monitoring the level in the blood is very important. Lithium is excreted in the kidney. If you have a fast kidney, you will need more lithium than someone who has a slow kidney in order to reach the ideal level in the blood. This is why therapeutic treatment sometimes must also be complimented with lab tests to complete the treatment process.
INTERVIEWER: So as opposed to a specific doesage, one must look at how the medication is interacting with the individual’s body?
DR. HASHEM: Exactly. There is also another realm of lab work we use in order to tell is a medication is doing harm to a patient’s body or is creating an adverse reaction when mixed with another medication. For example, Depakote, Tegretol or other seizure medications tend to sometimes harm the liver at a very slow pace. We periodically check liver function and keep track of a patient’s blood count to make sure these harmful effects are not occurring. Commonly, with new second-generation antipsychotics like Zyprexa, Seroquel and Abilify, , it was found there was a high percentage of patients who developed diabetes and high cholesterol while on these medications. In those cases we will closely monitor weight, BMI, blood sugar and cholesterol.
INTERVIEWER: So reinforcement of other strategies - cognitive behavioral, physical, spiritual, etc. – is very important in the treatment process?
DR. HASHEM: Definitely. But in medicine we learnt not to say always or never. So in many of the cases of depression or anxiety, the cognitive and behavioral and the spiritual aspects of treatment are as powerful as or more powerful than the medication itself. This also has no side effects, obviously, because medication has side effects that you don’t want. Sometimes in the absence of this cognitive approach, no antidepressant can seem to work.
INTERVIEWER: What can people do to take more personal responsibility for their health?
DR. HASHEM: Complete awareness of your condition and treatment, in addition, a basic knowledge of what constitutes a healthy person. I actually like the spiritual aspect of thinking. The spiritual aspect of life gives us kind of reassurance, some degree of faith that takes away the sense of the depression. When you always feel that there is a higher power, you always feel that there is a hope and there is a reason. I think, spirituality also, in all religion and all philosophies, encourages you to be healthy. All the exercises in all the religions are meant to keep you healthy. A healthy body has a healthy mind and so forth. So to take more responsibility for your health is by being educated about health and being aware of what produces negative results in your body and your mind.
INTERVIEWER: And, last but not least, is psychiatry a science or an art or both?
DR. HASHEM: Well, I think psychiatry is primarily a science, and I would say it’s art that uses science. There are a lot of things that take this form, like computer graphics for example. It’s art that’s using the science. The reason is we are not going to use any medication without a scientific experiment or testing that proves beyond doubt that this medicine is really effective in this group of people. Unfortunately, to do that, they have to pick patients who have only mostly pure, single conditions and change the environment so it will be very specific to this condition and use this medication in that context and prove that his medicine works for this condition. On the other hand, humans are not created based on a textbook. God did not open the DSM to put the specific criteria in different people. All patients are a mix of different things. Nothing is exactly the same as the textbook. Nobody has one pure condition, or two or three, with all the other factors that get involved in that. So I would say that the science is actually the proof that each single medicine clearly has a function. The art is mixing all this together; matching medication together with people and conditions. This perfect balance cannot be taught and must be acquired through experience, observations, involvement, notions and feelings. That I believe is the definition of art.
Dr. Hazem Hashem is the medical director of Visions Unlimited and Wellness and Recovery Center North. He is also Chief Psychiatrist/Chief of mental health at Solano State Prison, and Board Certified in general psychiatry and Forensic