Wednesday, October 31, 2012

The Inadequacy of Mental Health Treatments

I've written about treating addiction in its chronic or recurrent form much like we treat other chronic illnesses. Arguably the most painful part of doing so is accepting the limitations of our current treatments. It does not diminish the progress we have made to acknowledge that our current treatments are far from ideal. They fail too many people. (Yes, fellow treatment providers, treatment does fail people, we can't keep blaming our patients for not responding.) Addiction has a significant mortality rate. Cigarette smoking alone kills close to half a million Americans a year, and hundreds of millions globally. Alcohol addiction kills 85,000, and other addictions perhaps another 10,000. It is hard to live with this, to work so hard with people only to see them struggle in spite of everyone's efforts.

But as time goes on, and as I've done more clinical work again, I'm finding that mental illness is at least as hard if not harder to treat. Depression and anxiety are the most common mental illnesses, and they frequently co-exist with addiction. One thing I've learned is that the more chronic illnesses you have, the harder it is to manage any of them well. And our treatments for depression and anxiety are far from adequate. Between the two, anxiety is the most difficult, because for most people none of the treatments are very effective. Psychotherapy done well is probably the most effective, but it is hard to access good therapy and many patients are ill suited for it. (On the other hand, lousy psychotherapy can be had on every street corner it seems.) Antidepressants are the primary medications used to treat anxiety, but although some people respond very well, most do not. Benzodiazepines such as alprazolam (Xanax), clonazepam (Klonapin), lorazepam (Ativan) and diazepam (Valium) are extremely effective in the short run, but often become ineffective over time, leading to ever escalating doses. Unfortunately, one of the more common alternatives to the "benzos" is a second-generation antipsychotic, such as quetiapine (Seroquel) or aripiprozole (Abilify.) Sec-gen antipsychotics are effective for treating schizophrenia and bipolar disorder, and may be useful as adjuncts to antidepressants for depression, but they come with a lot of baggage and risk. They are terribly expensive, and they frequently lead to substantial weight gain, diabetes and heart disease. And they don't even work very well. Antihistamines such as hydroxyzine (Vistaril, Atarax) and diphenhydramine (Benadryl) don't really work at all in my experience. Anticonvulsants such as gabapentin (Neurontin) are usually not helpful. Most of the time, we struggle to find anything that works. And an uncontrolled panic or generalized anxiety disorder in an individual with an addictive disorder is a prescription for chronicity of both.

Depression is a little, but only a little, better. In the STAR*D trial, going through multiple iterations of medications yielded a remission or recovery rate (not at all depressed, or normal mood) in about 50% of participants. This rate is as good as it gets, because participants were screened out if they had addictive disorders or serious medical problems, or were homeless or did not have transportation, and they had sterling follow up and pharmacotherapy focused on adherence. In real life the figure is likely to be substantially lower. A majority, even in real life, do eventually show a response although in most people there are residual symptoms such as low energy, pessimism or irritability. However, finding a medication that works is trial and error, because the science is not yet available for us to predict who will respond to which drug. Thus, it may take weeks or months, trying multiple medications for several weeks each before finding something that works. So, many patients are left struggling with a serious depression that is not responding well to treatment, even while they are trying to establish recovery from a substance use disorder.

Bipolar disorder, schizophrenia and other psychotic disorders respond to acute treatment, but the long-term course does not appear to have changed significantly as a result of modern treatments. Compared to these diseases, addiction has a much higher rate of recovery. It is ironic indeed that the chemical dependency treatment industry has been highly successful in convincing people that treatment outcomes are poor because they defined success as complete and permanent recovery. Meanwhile, the pharmaceutical industry and, yes, psychiatrists, convinced the public that success rates for treating depression, anxiety, bipolar disorder and schizophrenia are much higher than they are in practice.


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