Getting the treatment balance right

Drugs are most effective in treating some mental illnesses. With others, a careful balancing with therapy is needed

Drugs are most effective in treating some mental illnesses. With others, a careful balancing with therapy is needed. But often the required support network is not available. Sylvia Thompson reports

There is widespread belief among psychiatrists that there are certain mental illnesses for which drug therapy is an essential part of their treatment.

These illnesses include schizophrenia and severe depression, both of which are extremely disabling conditions in which patients have what are known as psychotic (symptoms include hallucinations, delusions, hearing voices, etc), manic (symptoms include over talkativeness, elation or profound irritability and anger, disorganised behaviour and poor judgment) or depressive episodes (symptoms include lack of sleep, loss of appetite, extreme lethargy, morbid thinking, etc.).

However, there is another spectrum of mental health problems including mild to moderate depression, obsessive-compulsive behaviour, anxiety or panic attacks or stress reactions where professional opinions vary about whether drug therapy is the most appropriate therapy.

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Sadly, the lack of other psychological interventions, which have been found to help these conditions, result in medication often being the first line of treatment for GPs and psychiatrists working in a hugely under-resourced mental health services.

Patricia Casey, professor of psychiatry at University College Dublin, consultant psychiatrist at Dublin's Mater Hospital, and author of the recently published From The Heart - your mental health questions answered (Blackhall Publishing, €14.99), believes there has been a trend to offer anti-depressants to patients who show symptoms of depression for more than two weeks regardless of the amount of stress they may be suffering from at the time.

"If you have suffered a bereavement or you have a family member in hospital with a serious life-threatening condition, you may cry a lot, lose weight and suffer from sleep problems.

"Some psychiatrists diagnose depression in these cases and give anti-depressant medication for this. I think this is absolutely wrong.

"It has also led to a belief that depression is everywhere and created a conflict between those who say there is no role for anti-depressants [ i.e. those who witness it given to patients suffering from such 'context-related' depression] and people like me who advocate anti-depressants for depressive illness which has its own momentum and symptoms which occur even after the stressors are removed. Really we are talking about two different types of depression."

Like many of her peers, Casey suggests the 'optimum' treatment for depressive disorders is anti-depressant medication and cognitive therapy.

"Cognitive therapy on its own can and does work for some patients but in cases of severe depression, cognitive therapy doesn't have much of a role because the patient can't engage in the therapy. They simply can't talk, comprehend and concentrate in the sessions."

Casey also contends that while as yet there are no biological or genetic markers for mental illnesses, these will emerge in time.

"I believe we will get diagnostic markers which, in the future, we will be able to use alongside patient symptoms which will help de-stigmatise mental illnesses and allow more precise drug treatments of such conditions."

Meanwhile, some studies have found that early intervention in the treatment of conditions such as schizophrenia can reduce or sometimes even eliminate the need for drug therapy.

"If patients present within months of the first symptoms of schizophrenia - which affects approximately 850 young people every year in Ireland - medication may be avoided entirely or used in low dosage alongside cognitive behaviour therapy and family therapy," says Dr Siobhan Barry, psychiatrist and clinical director of Cluain Mhuire Family Centre, Blackrock, Co Dublin.

"There is evidence that if schizophrenia is treated vigorously at the outset, the likelihood of full recovery is considerably enhanced. Otherwise, there is a much greater likelihood of relapsing illness and the revolving door situation in which patients are in and out of hospital throughout their lives."

Barry and her team are convinced of the value of early detection and intervention for psychotic illnesses in young people and they have put forward a multi-agency proposal for treatment of schizophrenia to the Department of Health earlier this year.

Barry agrees that anti-depressant medication is often given to patients without the presence of the six defining symptoms (low mood, sleep disturbance, appetite disturbance, loss of concentration, loss of interest and sense of pessimism about the future, loss of libido).

The face that patients in the Eastern Regional Health Authority can have free medication within the mental health services may be a factor in this, she adds.

The lack of psychological services and the temporary nature of many psychiatry posts within the public mental health services remains a huge block on the further development of multi-disciplinary services which would lessen the primacy of drug therapy in the treatment of mental illnesses.

At a primary care level, the dearth of public mental health services in equally problematic. "The real problem is that when patients go to their GPs, they have nothing to offer except medication."

And even if medication is reluctantly offered, it is driven by the extensive evidence that there is a huge amount of untreated depression and anxiety.

"To withhold treatment would seem cruel and GPs in Ireland have no access by and large to counselling or psychotherapy services," says Dr Justin Brophy, consultant psychiatrist in Newcastle Hospital, Greystones, Co Wicklow and member of the Irish Psychiatric Association.

There are two diverging trends regarding patients' willingness to take medication for mental health problems, Brophy says.

"Educated middle class people are far less inclined to want to take medication, yet those in the so-called Generation X [ under 35-year-olds who have already experienced the effects of cannabis, alcohol, ecstasy and other psychotropic drugs] often expect to be given medication to make them feel less angry or less sad.

"Then there are those in poverty, deprivation or constrained circumstances that you simply can't tell to go the gym more, take a holiday or work less [to help relieve depression or anxiety]."

Another difficulty faced by psychiatrists prescribing drugs for mental illnesses, is the reality that the majority of patients will come off their medication when they begin to feel better rather than following the advice of their GP or psychiatrist to continue on their medication for up to six months.

"Some patients will get away with going off their medication. Others will be back to see us in a month or so.

"It's very difficult to persuade people to stay on their medication if they begin to feel better. Yet if they stop their medication within six months, the chance of recurrence of their illness is far greater," says Brophy.

Coming off medication too early accounts for a large amount of recurring mental illness, he adds.

However, the prevailing view among almost all mental health professionals is that lack of psychological support services - from relationship and substance abuse counselling to anger management courses, vocational rehabilitation, social skills and self-esteem training - is just as big an obstacle to long-term recovery for many of those suffering from mental health problems.