Wednesday, April 10, 2013

My feelings about psychiatry as of this moment

I have a growing ethical dilemma with psychiatry.  I believe that the field, on whole, has a huge bias against treatment that the patients might enjoy.  So strong is this bias that they will fail to treat serious illnesses even when the life of the patient is at risk.

This is one of those things for which I can't find any studies.  If anyone out there can, pro or con, let me know.  This is all based on personal experience and a series of thoughts I believe are fairly original (or at least original for me).

The specific thing that moved my mind in this area is a friend of mine might kill himself.  For years he has struggled with serious illness, rages and suicidal depressions.  He is being treated but he faces two challenges: the government doesn't want to admit his problem is totally debilitating and his doctors are out of treatment options.  While his treatment has helped with rage, it hasn't done as much with depression and he has a whole host of pretty awful side effects.  Since his doctors are at their wits end, he's looking forward to living his whole life this way and he says it's awful.  He's thinking about taking it into his own hands and killing himself.

As I believe in euthanasia, I have to admit that maybe it's time for him to kill himself.  If he finds life unlivable as it is and there is no serious chance that it will be improved, how can I honestly say that he should continue living?  Yes, I would be crushed by this but . . . I've had friends kill themselves and at least this time I'll know why.  I won't be thinking that maybe there is something I could have done.  I would miss him forever, but I would heal.  There is very good reason to think that he will not.  I'm not that selfish.  I very much want him to live, but would understand if he died.

This made me think, "There's got to be something."  And . . . there might be.

There are actually a host of drugs that could potentially help him -- opiates, ketamine, LSD, MDMA, cannabis and chemically related drugs with names like 5-MEO-MIPT.  All of them have shown themselves to be useful in various studies of depression and anxiety, in particular, though none of them have had the kind of study their effects deserve.  It is superficially easy to find studies that are very suggestive that these drugs might work where others have failed.

The only problem seems to be that they are thought to be recreational drugs.  They make the user feel pleasure.  However, this is not a reason to deny prescription because, in other areas, that isn't the case.

To me, this makes it appear as though the psychiatric field denies potentially useful drugs to patients who need them.  This is, I strongly believe, incredibly unethical and downright cruel.

Not only are these drugs being denied to people like my friend who could well need them to survive, but to everyone else.  I've never known anyone who took any drug that has side effects that might be considered pleasurable with the exception of dextroamphetamines like Adderall and Ritalin.

The example I'm going to use here is opiates because they are commonly prescribed for other things of far less seriousness than suicidal depression.  They are very commonly prescribed for even moderate pain.  The last time I got one, it was because I was having trouble sleeping after I strained my back.  You're likely to get it for pretty much any invasive dental procedure.  The odds are that most people who will ever read this have been prescribed hydrocodone or a near relative.

My point being, opiates can be prescribed and they were commonly prescribed in situations where one's pain is far, far less than suffered by my friend (or, indeed, by myself during periods of suicidal depression during the first year or so I lived in Miami).

Here's where it starts getting, in my opinion, crazy.  Until the late 1950s, opiates were the most common treatment for depression, though.  When tricyclic antidepressants were introduced, though, opiates went out of use.

Go and look up tricyclic antidepressants.  They work but . . . hardly 100% of the time and they come with a lot of side effects.  Nowadays, tricyclics aren't used hardly at all having been replaced by the more effective selective serotonin reuptake inhibitors, which are also not perfectly reliable and come with their own side effects.

And it isn't that opiates don't work.  It's reasonably easy to find studies that demonstrate that opiates work . . . well, often very well.  In the mid-1990s, a study found that half of the patients treated wtih buprenorphine went from severely depressed to basically normal.  Most of the remainder had some improvement and only one person got worse.  This was published in the Journal of Clincal Psychopharmacology, vol 15 (1), 1995, pg. 49-57.

In 1999, The American Journal of Psychiatry published a paper, Treatment Augmentation With Opiates in Severe and Refractory Major Depression.  They also concluded that for at least some cases, opiate treatments are a good idea.  It's pretty easy to find such research.

Of course, this was all known.  For hundreds of years, opiates have been used to treat depression.  In America, right up to the late 1950s.  Heck, it's sort of a no-brainer.  Opiates make you feel very good.

I am certainly not saying that opiates should be the first course of treatment.  For most patients, normal antidepressants will work just fine.  However, to go back to my friend, he has severe and refractory major depression.  His depression is basically untreatable.  The suffering is so bad that he's seriously considering killing himself.  Since we know it works very well on at least half of the patients like him, why hasn't his doctor prescribed any opiates?

In those kinds of situations, what's the harm in trying?  After five years of treatment, I think it's safe to say that he's not just pretending to score some drugs.  Good lord, going to a doctor for opiates is probably the least effective way to do it.  You've got to get an appointment, get a prescription and then deal with the delays of the pharmacy.  Right now, with scant effort, I could get opium for about $40 a gram.  It wouldn't be too hard for me grow the stuff in my house, where no one could see it.  At a guess, it would take around $300 in hardware to get it rolling and poppy seeds are cheaply acquired (something like $10 for a hundred).  It isn't hard to make a small scale opium poppy field right in a one's closet.  No matter how you do it, opium just isn't expensive.  (The medical forms are, but opium is not, it's just flower sap, after all.)

I'm not actually advising that, though.  Because of all the drugs I listed as having useful psychiatric effects, opiates are easily the most dangerous.  They are physically addictive.  With them, you especially need a physician's supervision to avoid addiction.  (As to the rest?  Hell, experiment away.  I'd suggest some cannabis, first, as it's easy to get and reasonably inexpensive.  In many places, furthermore, it's legal to obtain for a variety of conditions.)

It is certainly my experience that psychiatrists are insensitive, even downright cruel, with their medications.  When I got to Miami, for about a year I was seriously, deeply depressed at regular intervals.  At no point was any kind of pain mitigation offered.  No drugs were offered that would effect my immediate pain.  The drugs I was given would routinely take weeks or even months to take effect, during which I just suffered.  And because the drugs were not the right drugs, all I did was suffer.

Indeed, I had been using Adderall successfully in California but the first doctor here in Miami took me off it because it was "too much dopamine".  This ignored the fact I was satisified with the drugs I was on at the time. 

I mean, I went in knowing that I was having a serious anxiety problem.  Anxiety is a bigger problem than depression for me, by far, and I was under all kinds of stressors.  I was freaking out because I was trying to buy a house in the vicious Miami market.  There was a cause.  I knew the cause.  I wanted to be treated for anxiety.  Instead, I got taken off one of the drugs that was really working for depression.  Eventually, it got to the point where my previous diagnosis for depression and anxiety was replaced with type 2 bipolar!  All I wanted was some relief from acute pain and somewhere along the line, my diagnosis changed.

More recently, I went to my psychiatrist and my primarily complain was that the drugs I was on were making mentally and physically exhausted.  I couldn't write.  It was driving me crazy and it was a huge stressor in my life.  Since we had been in the house for a while, outside anxiety stressors were gone, so I wasn't anxious, anymore, but the lousy drugs I was taking were exhausting me.  The problems with my exhaustion were not addressed.  My psychiatrist simply tried to refine the bipolar medication.

Mind you, NONE of the bipolar medication would make me less tired.  A common side effect of all the bipolar medication I was on - lithium bicarbonate, buspirone and clonezapam - is fatigue.

I was not depressed.  I was not anxious.  I was TIRED.  What happened was that my lithium bicarbonate and buspirone were increased . . . the very things I believed (correctly, as it turns out) that were making me tired.

There is, however, a fairly commonly prescribed drug for dealing with precisely this kind of condition.  It is a drug I had been on before, liked and wanted to be on, again.  Yeah, Adderall.  But rather than prescribe that, or anything else that might actually address my fatigue, I got more drugs that made me tired.

I don't think my psychiatrist is a bad doctor, mind you.  I believe he is trapped by the bigotry of his education.  You just don't prescribe drugs that make a patient feel good, or only as a last resort.  Just like with my suicidal friend.  It is better for us to SUFFER than to take drugs that make us feel good.  Even that is the whole reason we go in the first place - so we can feel good.  That's pretty sick if you ask me.

This puts me in a conundrum.  Should I go back to my psychiatrist?  I honestly do not know.  I am finding the profession unethical and, worse, ineffective.  Why should I waste money and time with a profession that cripples itself with prescribing drugs?  That is structured to hurt patients rather than commit to treatments that are effective but unpopular?  I don't like supporting those kinds of businesses when I don't have to . . . and I do not.  I figured it out.  If I stopped going to my psychiatrist and simply obtained drugs illegally, it wouldn't be that much more expensive.  Then I could research and decide for myself what a truly effective treatment would be.  On the other hand, I don't reject that medical psychiatry doesn't have a powerful pharmacology.  Most of the time, it works great.  I think if we addressed my real psychiatric problems (which I am increasingly believing to be primarily anxiety, which has proven intractable to treat in my case) that medical psychopharmacology could be just the thing.  But do I want to do business with such a manifestly unethical group of people? 

In the short term, I'm going to talk to my psychiatrist about it, but my guess is that he'll simply disgree with me due to the bigotry of his education and profession.  But I hope I'm wrong.

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