Mind Over Meds

One day several years ago, I was reaching the end of my first visit with a patient, J.J., who had come to see me for anxiety and insomnia. He was a salesman for a struggling telecommunications company, and he was having trouble managing the strain on his finances and his family. He was sleeping poorly, and as soon as he opened his eyes in the early morning, the worries began. “I wake up with a list of things to worry about,” he said. “I just go through the list, and it seems to get longer every day.”

A psychiatric interview has a certain rhythm to it. You start by listening to what your patient says for a few minutes, without interrupting, all the while sorting through possible diagnoses. This vast landscape of distress has been mapped into a series of categories in psychiatry’s diagnostic manual, DSM-IV. The book breaks down mental suffering into 16 groups of disorders, like mood disorders, anxiety disorders, psychotic disorders, eating disorders and several others. As I listened to J.J. (a nickname that he agreed I could use to protect his privacy), it was clear to me that he had one of the anxiety disorders, but which one? In order to systematically rule in or rule out the disorders, I asked J.J. dozens of questions. “Do you have panic attacks?” “Do you get fearful in crowded situations?” “Have you ever experienced a traumatic event that later caused flashbacks or nightmares?”

Each of J.J.’s answers provided me with a clue, closing off one possibility while opening up others. At its best, when you are working with an intelligent, insightful patient, the process is fun, involving a series of logical calculations, much like working a Sudoku puzzle. Finally, toward the end of the hour, I felt confident that I had arrived at J.J.’s diagnosis. “I think you have what we call ‘generalized anxiety disorder,’ ” I told him. It may start with a defined series of causes, as was true for J.J., but then it spirals outward, blanketing the world with potential threat. J.J. worried about what the future would bring and experienced a predictable series of physical symptoms: insomnia, muscle tension, irritability and poor concentration.

“I’m going to write you a prescription for a medication called Zoloft,” I said, picking up my prescription pad. He asked what was causing his anxiety, and I began one of the stock neurochemical explanations that psychiatrists typically offer patients about low serotonin levels in the brain. The treatment involved “filling up the tank” by prescribing a medication like Zoloft, Celexa or Paxil.

http://www.nytimes.com/2010/04/25/magazine/25Memoir-t.html?th&emc=th

Gads I can't believe this pile of crap made it into the NYT, and worse that people will use it to villify medication. This kind of thing belongs in a publication for professionals, not for people to use as an excuse to not take their medication.

I didn't take it as a "meds are bad" article at all.

You start with the horrible title. Then you go to a psychiatrist who suddenly discovers he has been misdiagnosing his patients, and concludes that medicine, more specifically anti-depressants, isn't always necessary.

Well duh, if you're a good psychiatrist, you knew that from the beginning.

He was concerned about his whole field --psychopharmacologists--thinking that the split in the profession between those that provide counseling vs. those who give drugs was a false split, and indeed, leads to doctors making poor choices for their patients. He might admit to the "bad doctor"--but he slipped into this mode for lots of reasons that he got into in the article. He has statistics to back up the changes in the profession that caused him to be in this place. Maybe he should have realized this, but he was discussing a systemic problem in the profession.

I thought it was right on target.

It wasn't an anti-drug piece at all. He readily acknowledged that drugs could be just what a patient needs.

It reminds me of the saying--when you have a hammer, the problem is a nail. He has a hammer, because that is his tool. And, if a screw appears in his office, his answer is still the hammer. He is now questioning that whole premise. I think he'd like to add a screwdriver to his toolbox.

Not in a publication to the general population where there will be a number of people who will use this article as an excuse to stop their medication. It's irresponsible.

And again, a good psychiatrist already knew all of this. He is discussing what he believes to be a systemic problem, but it's really a problem limited to bad psychiatrists. No journal ever said that every single problem a patient presents with can be traced to brain chemistry imbalance.

What's scary to me is that Oregon is trying to pass legislation to let psychologists prescribe.

So I am not sure where you are getting that from (??)

It may make people think twice about going to a psychopharmacologist as a first line treatment, though. That could be a good thing.

Again, he was noting the historical trends in the business. The point is that, to the extent that psychiatrists become psychopharmacologists, the psychiatrists are increasingly becoming "bad" (your term, not mine).

I actually think it is important for the consumer to be aware of the trends in this industry when they are choosing treatment options.

I'm not sure about psychologists prescribing drugs either. Are there some blood tests, etc. that should be ordered regularly when people take SSRIs? I'm not even sure about that. I've heard of psychologists suggesting mood enhancing supplements. I'm not sure how common that is.

Some might be helped by medication.

But might the person rather find the cause of his anxiety?




I think anxiety might have a purpose in people. Somehow telling them something is wrong in the way they are acting or thinking, versus what they are seeing and feeling.

I have so little anxiety myself, that it is hard for me to think on it, but on the rare occasion that I worry about something, I know there are ways to very easily get rid of anxiety.


If you worry about your briefcase being taken, well you think 'is having it worth that risk', if it is, then you accept that, and no longer worry about it, because it is a decision of some risk you are willing to take.

If you worry about tommorow, just ask yourself, last month, when I spent all day woring about something, how important is that now. Usually not at all. Some people worry everyday about the next 10 minutes, but looking back they know that 10 minutes was not that big of a thing. So they spend all there time in worry, taking a longer look about things helps with that also.


But I agree manytimes mind help can be better then just drugs.

Well accept beer maybe. :D

Serious enough to keep me in bed for days at a time, and I had several severe panic attacks that crippled me. What got me through the initial, most horrifying stages of the disease were medications - Xanax short term and Effexor long term.

After that, it became a matter of using my brain to work out why the anxiety level was so high, how I could best combat it when I felt the warning signs, and how to "maintain" (for lack of a better word).

In these sorts of things, saying "mind over meds" or "meds over mind" aren't all that helpful. Every patient is different, and different combinations of different treatments will work for different people.

I don't disagree with that, and I hope it all works out well for you. Everyone has issues with something or another, and sometimes medication can help those things.

And as you said, also thinking about it, if it doesn't add to the difficulty.

Glad you found a way that works for you :)

very individual to the person being treated.

I was diagnosed with social anxiety and mild depression some years ago. My therapist recommended Prozac.

I'm hardly anti-medication (I take a number of medications for high blood pressure, low HDL cholesterol and a couple other health issues), but I resisted. I felt that my anxiety and depression had a specific root, and that I was seeing a therapist to address that root cause.

A couple years later, the root cause had been dealt with, and the anxiety and depression are no longer a problem.

However, I know people, people I care deeply for, who have chemical depression - actual neurochemical imbalances - now in both cases, there may be extenuating psychological circumstances that contribute to the depression issues, but the depression can be debilitating, and for them, medication is appropriate.

It isn't for everyone, but it very much depends on individual circumstances.

but unfortunately not all patients. Clearly, the mixed approach the author suggests is far superior, if only because spending more time over a long period of time will allow the doctor to reassess what those medications are and are not doing.

That's really the problem here, the prescribing physician is not doing the follow up work, usually because the insurance company balks at paying him for his time.

You can't just hand a sick person a prescription and turf him off to a paraprofessional and expect good care. It doesn't work that way.