By “medicine,” I’m not referring exclusively to substances or agents that are directly introduced into the body; I’m referring instead to the type of medicine practiced primarily on physical health maladies vs. mental health-related issues.
Physical medicine has the advantages of laboratory testing, X-rays, and scans of all sorts that can quite accurately pinpoint specific problem areas, which in turn, help determine cause. In mental health medicine, we don’t have a single reliable scan, X-ray, or biopsy procedure to aid us in determining diagnosis. And even if we did, where specifically in the brain would we scan for evidence of depression? Where would we do a biopsy?
The Brain
The brain is cloaked in mystery, and this is the organ system that we focus on most in mental health treatment. The majority of medications utilized in the treatment of mental disorders cross what’s known as the blood brain barrier. Behavioral work can also be geared toward changes in brain function to help facilitate improved emotional states, healthier thinking and even better physical functioning. But it’s the mysteries that often leave us in a quandary. Because the brain is a complex web of nerve cells, neurotransmitters and receptors, we most often have no idea how psychotropic medications will work until the client takes the first pill. It’s equally clear that no one behavioral intervention can be applied uniformly with success across client populations.
Medication
What do we want medication to do and for how long? These many seem overly simple questions, but their importance often gets lost within the maze of drug options available nowadays for mental disorders. This is complicated by the fact that medications in some psychotropic drug classes generally produce paltry results – antidepressants certainly come to mind – and drugs such as benzodiazepines, although effective for most people, carry the attendant risks of abuse and dependence. And also there’s the issue of overprescribing whereby some prescribers chase every new symptom with a pill when often it’s the diagnosis that’s wrong. It is the rare instance where “more is more” in psychotropic medication management.
Randomized Controlled Trials (RCTs)
Randomized controlled trials have long been considered the gold standard of clinical research. There’s no doubt that well-designed trials are effective tools for testing a new drug or other intervention. Despite their strengths, RCTs have substantial limitations. They’re expensive, take years to complete, are subject to bias, and in some instances, don’t run long enough to assess the long-term effect of some interventions. Thus such trials are often proven wrong with the passing of time. For example, the “poop out” phenomenon associated with antidepressants took years to surface.
My Take
Physical medicine will always have a leg up on mental health medicine, because obviously, there are considerably more physical health maladies than mental health ones. Physical medicine, of course, can actually “see” medical problems, we only hear about them. What we can “see” presents via signs and symptoms – neither of which helps us determine cause, thus making safe and effective mental health treatment challenging for all of us, particularly diagnostically. Add to this increasingly complex medication regimens and behavioral intervention strategies packaged in seminars and workshops that can consume up to 3-4 days, and I find myself thinking it’s all becoming too entangled.
Regardless of professional discipline, when we’re working with clients with issues sans the aid of proven technology which physical medicine is able to employ – issues we can’t nail down diagnostically because of overlapping symptoms or can’t identify causes because we just don’t know enough, deconstructing and simplifying these complexities seems to me to be the most prudent course of action.
Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.