August 10, 2012

Psychiatry: Start Listening to Your Patients and Their Families

By Dr. Peter Breggin

Medication compliance — the patient adhering to the doctor’s prescription instructions — is an important concern in medicine. Family members are asked to be involved to make sure patients comply with taking their medications as instructed.

On the face of it, medication compliance makes sense. Patients should take their medications as instructed and families should ensure that they do. But is it that simple? I am not alone in concluding that especially in psychiatry, getting patients to comply with medication runs counter to central principles of therapy. According to a paper printed in the journal Psychiatric Services:

Compliance is rooted in medical paternalism and is at odds with principles of person-centered care and evidence-based medicine … Shared decision making diverges radically from compliance because it assumes that two experts — the client and the practitioner — must share their respective information and determine collaboratively the optimal treatment. … Choice, self-determination, and empowerment are foundational values for people with disabilities, including people with psychiatric disabilities.

This month the British Journal of Psychiatry carries an editorial asking “Antipsychotics: Is it time to introduce patient choice?” The abstract states:

Evidence regarding overestimation of the efficacy of antipsychotics and underestimation of their toxicity, as well as emerging data regarding alternative treatment options, suggests it may be time to introduce patient choice and reconsider whether everyone who meets the criteria for a schizophrenia spectrum diagnosis requires antipsychotics in order to recover.

Despite the enlightened sentiments expressed in these articles, medication compliance remains a buzzword with enormous power to control psychiatric patients, their families, and even their non-medical health care providers, such as therapists. Students in psychology, social work, counseling, nursing and other health professions are taught that their job is to make sure that patients take their medications. Medication compliance becomes a tool for coercion.

When I teach or address students who are being trained as therapists, some usually express fear that they will “get in trouble” if they do not blindly encourage and even compel their patients to take the psychiatric drugs prescribed to them. Whether the drugs are being prescribed by a psychiatrist, pediatrician, ob-gyn or family doctor, most therapists feel obliged to avoid questioning the medication regiments of their patients, even if the patients appear grossly over-medicated. They are afraid that they will be accused of practicing medicine without a license. However, I’m in agreement with the Mental Health Desk Reference, which finds this to be an unrealistic fear, and sides with those who believe that therapists should learn about drugs and share information with their clients.

Family members tend to respond in a similar way as many therapists by blindly encouraging patients to take their medications, even when the drugs seem to be doing more harm than good. At the most, family members are likely to encourage the patient to “talk to your doctor” about the drugs. There are exceptions, and some more confident family members are sometimes more able to evaluate drug effects without their ideas being as clouded by the drug company propaganda that bombards prescribers.

In addition to the basic undermining of the patient’s personal freedom, autonomy, hope and confidence, there are a number of practical reasons why medication compliance is a particularly hazardous approach to psychiatric treatment:

  • When clinicians become overly focused on getting their patients to take psychiatric drugs, they can discourage patients from “complaining” about adverse effects. As a result, these clinicians may never get vital and even potentially lifesaving information from their patients and their families about harmful drug effects.
  • Psychiatrists, pediatricians, internists, family doctors and other prescribers tend to see patients for 10- to 15-minute “med checks,” during which time they can do little more than a superficial check based on the patient’s abbreviated remarks about how he or she is doing. To actually evaluate medication effects, the prescriber needs lengthier sessions, more focus on what the patient is feeling and saying, and greater feedback from the patient’s therapist and family. This collaborative team approach, which I describe in Psychiatric Drug Withdrawal, can be lifesaving.

  • Prescribers must keep track of the adverse effects of dozens of medications. In this information age with multiple Internet information sites, the patient, therapist, or family member, by contrast, can focus on the few medications involved in their specific case and spend time learning much more about a few drugs than the prescriber can possibly remember or integrate into the treatment. Even in regards to medications where I am very informed, patients sometimes tell me about new and important drug information that has thus far escaped my attention.

  • Because of medication spellbinding, patients often fail to perceive adverse drug effects. As I document in Medication Madness, when the patient declares “I’m doing better than ever,” it may potentially be a danger signal for impending mania that doctors can overlook. Therefore, family input is really needed to monitor patients during drug treatment, and especially during dose changes and drug withdrawal.

  • Since long-term exposure to psychiatric drugs can cause chronic brain impairment (CBI), patients exposed for months or years to psychiatric drugs may lack the cognitive ability to grasp increasing mental dysfunction.

Unfortunately, there is another yet larger problem. Drug company influence over prescription practices has made commonplace what previously was considered bad medical practice. These include:

  • Rushing patients onto brand new drugs before they have been field tested in the larger market over months or years
  • Giving patients multiple drugs at once even though they have never been tested in combination

  • Prescribing patients the maximum doses of several drugs when maximum doses are determined on the basis of a patient taking only one psychiatric drug at a time

  • Prescribing drugs off-label without any scientific basis

  • Telling patients to take drugs for the rest of their lives.


Trying to Impose Evidence


Ironically, the emphasis on pushing evidence-based medicine as the standard for prescribing has led to the abusive prescription of more expensive and more toxic medications, including the newer antipsychotic drugs, because doctors aligned with the drug companies lead the attempts to determine what particular practices are “evidence-based.” One of the largest attempts to standardize treatment in this manner, the Texas Medication Algorithm Project, was underwritten by 11 drug companies: Abbott, AstraZeneca, Bristol-Myers Squibb, Eli Lilly , Forest Laboratories, GlaxoSmithKline, Janssen, Novartis, Organon, Pfizer, and WyethAyerst.

Attempts to standardize prescription practices also have a potentially disastrous unforeseen outcome. There is such huge biological and psychological variation from human being to human being that many patients will respond in ways that do not fit the cookie cutter, including experiencing serious adverse reactions to relatively low doses. Rote prescription practices will tend to ignore or deny these untoward occurrences.

Psychiatric medications are being so over-prescribed for such excessive periods of time that in my professional opinion, it is no exaggeration to say that curtailing the use of these drugs would greatly alleviate a worldwide epidemic of adverse drug effects, including chronic disability and injury to the brain, which I have written about here and here and here. Furthermore, the health professions would do far more good if they put less emphasis on knee jerk prescribing and much more on learning how to help patients withdraw from psychiatric drugs. If prescribers spent more time undoing the widespread harm that’s already been done by helping patients reduce or stop the medications, these same patients and many new ones would feel empowered to seek out more effective psychotherapeutic and educational approaches. They would feel encouraged to explore the great variety of currently available psychotherapeutic approaches from which they could more readily benefit with unmedicated minds.


[1] Mental Health Desk Reference. Elizabeth Reynolds Welfel and R. Elliott Ingersoll, eds. New York: Wiley, 2004. pp. 90-91

Originally published on The Huffington Post