Finding Help

It can be hard to find help that suits you well.

Individuals seeking help sometimes ask me directly if I will see them. At this point, I am not able to see very many new patients; those new patients I do see have often been waiting a very long time, and because I work as part of the staff in a university clinic, I need to restrict new assessments or psychiatric follow-up to the university student population.

Here is some general advice about finding psychiatric care in the Vancouver area (maybe some of these suggestions could apply to other parts of the world too):

1) Find a primary care physician you are comfortable with. Many gp's (general practice physicians) are at least as capable as a great many psychiatrists, in terms of providing good, thorough, compassionate psychiatric care. A good gp should be a good listener, have a good knowledge of psychiatric conditions, be comfortable dealing with psychiatric problems, and be comfortable with some psychotherapy principles as well as with medications.

It can be hard to find a gp you are comfortable with. But it is probably a much easier task in most cases than finding a psychiatrist or other therapist.

2) Be familiar with other mental health resources in the community. In Vancouver this would include the community mental health teams and specialty clinics such as the Mood Disorders Clinic. Some of these resources may not offer follow-up but could at least offer some advice to help you and your gp move on with some new therapeutic ideas.
Links:
http://www.vch.ca/mood/
http://www.vch.ca/psychiatry/adc.htm
http://www.vch.ca/community/mental_health.htm
http://www.vch.ca/psychiatry/opp.htm

3) Be well-informed yourself, so that you can communicate your problems clearly to any new physician or therapist. If there is a past medical record, it can be helpful to have copies of this information yourself, which can speed up the process of a new person understanding your history.

4) Be open to alternative resources: other types of therapy or counseling outside of the medical or psychiatric system can sometimes be very helpful.

5) Be open to therapeutic ideas that might not necessarily be your first choice. For example, you might be referred to some kind of group therapy program, instead of to a 1-on-1 therapist (sometimes groups are more readily and immediately available). This kind of experience can sometimes be very helpful, and also help you become more connected with other resources. Many people are so insistent on wanting 1-on-1 therapy that they will not consider a group.

6) Be reminded that the hospital emergency rooms are always open, and help is available at any time. In most hospitals a psychiatrist would be available to see you for an urgent or life-threatening problem. Also, most hospitals would have other resources, such as social work, which could be useful to help with other circumstantial difficulties accompanying your symptoms. The emergency room experience can be chaotic and frustrating, though.

More links to some different Vancouver-area resources:

http://www.anxietybc.com/
http://www.heretohelp.bc.ca/
http://www.bcss.org/category/resources/
http://www.mdabc.net./

Antipsychotic Medications

Antipsychotic medications are frequently prescribed by psychiatrists. They help directly to reduce symptoms such as hallucinations, extremely disorganized thinking, suspiciousness, agitation, or delusions.

The first conventional antipsychotic medication was chlorpromazine, which began to be studied in the treatment of schizophrenia in the early 1950's. Many other antipsychotics were developed afterwards.

There is not much evidence that any one of the conventional, or "typical" antipsychotics works better than another. But there are differences in side-effects: some of these drugs--such as chlorpromazine-- are more sedating; others are less sedating but more prone to cause muscle stiffness--such as haloperidol.

All of the older antipsychotics cause an increased risk of developing a movement disorder called tardive dyskinesia, in which there is abnormal, involuntary muscle activity, often involving the mouth or tongue. Sometimes tardive dyskinesia can be irreversible. The risk is approximately 20-30% for individuals taking older antipsychotics long-term; the risk is probably higher in women, in the elderly, and in those with mood disorders.

I have not prescribed an old "typical" antipsychotic in years. But some people may have taken them for years, and may prefer to continue with them, especially if they are benefiting from the medication without having side-effect problems. They are still used quite frequently in hospitals, since they come in an injectable form which can more rapidly help to calm some extremely agitated patients who are unable to take oral medication.

In recent years, a new class of antipsychotics has appeared on the market; these are usually called "atypical antipsychotics". These include risperidone, quetiapine, olanzapine, ziprasidone, and clozapine (there are a few other newer ones, less commonly used in Canada).

Initial enthusiasm for these new antipsychotics led to various claims about their superiority over the older drugs for treating symptoms of schizophrenia. There is a lot of marketing money being spent on the atypicals. But there is more evidence right now that they actually don't work very much better than the old drugs, if at all. However, the evidence is quite clear that the atypicals have a smaller likelihood of causing movement disorders, especially tardive dyskinesia. For this reason, I consider them to be the drugs of choice to use when prescribing antipsychotics.

Because they are safer than the older drugs, the atypicals have been used quite liberally to treat other psychiatric symptoms aside from those of schizophrenia. They are probably useful mood-stabilizers to treat or prevent manic episodes in bipolar disorder, and there is also evidence that they can be useful adjuncts to treat symptoms of depression. Many of my patients, who may have mixed symptoms of anxiety, depression, primary insomnia, and emotional lability under stress, benefit from small doses of atypical antipsychotics, at least for short periods of time.

There is not much evidence showing that any one atypical antipsychotic is superior to another, with a few exceptions:
1) olanzapine may be slightly superior to other antipsychotics except for clozapine. However it has worse side-effects, including weight gain, which can sometimes be severe.
2) clozapine is without a doubt the most effective antipsychotic. For the majority, it works about as well as any of the others. But for a significant minority (maybe 30% of people) it is markedly superior, and leads to a vast, sometimes miraculous, improvement in symptoms and quality of life. However, clozapine has serious side-effect problems, including a small life-threatening risk that white blood cell levels can drop dangerously (agranulocytosis). Also there is a small but significant risk of seizures. So, at this point, the standard practice is to reserve clozapine for those who have attempted several other antipsychotic medications without adequate benefit.

Antipsychotic medications are imperfect. For the majority of people, they are helpful in reducing psychotic symptoms, and are tolerated reasonably well. For some, they almost instantly and completely relieve symptoms. For many others, they do not reduce symptoms very well, and may merely cause a type of unwelcome sedation. The sedation can feel like sleepiness, but often the most bothersome type of sedation from antipsychotics is a feeling of indifference, or emotional restrictedness. A common phenomenon among people struggling with schizophrenia or bipolar disorder is of stopping medications against medical advice -- often people stop the medications because they don't like the side-effects, and they don't feel feel that the medication is helping with respect to quality of life.

In any case, it is certainly true that it can take time for antipsychotics to work best. There is some evidence that a full therapeutic effect may accumulate over a period of at least 6 months. So I encourage people who are giving these drugs a try to be patient with them, to give them a chance. Also, there are a variety of options to choose from, and sometimes one drug can suit a person better than another. Dosing is another matter; sometimes larger doses deserve a thorough try; other times it can be worth trying a much smaller dose, which may work as well, with fewer side-effects, provided it can be stuck to consistently for a long trial (e.g. at least 6 months).


REFERENCES:

http://www.ncbi.nlm.nih.gov/pubmed/17443500
--a study summarizing the expected effects of a standard antipsychotic (in this case, chlorpromazine) in schizophrenia; in general, the evidence supports that relapse rates are reduced by at least 50%, with a modest improvement in quality of life and symptom control--

http://www.ncbi.nlm.nih.gov/pubmed/12804396


http://www.ncbi.nlm.nih.gov/pubmed/17015810
--an important study showing no advantage to quality of life among those using atypical antipsychotics, compared to those using older, typical antipsychotics, in fact the data from this study show a slight advantage for the older drugs--

http://www.ncbi.nlm.nih.gov/pubmed/17924259
--a summary of an important study showing a slight advantage of olanzapine over several other atypicals, and with the older typical antipsychotic perphanazine working as well as these other atypicals--

http://www.ncbi.nlm.nih.gov/pubmed/16625629
--a study showing no significant difference in effectiveness between risperidone and olanzapine--

http://www.ncbi.nlm.nih.gov/pubmed/19015230
--another large recent meta-analysis showing a slight advantage for olanzapine and clozapine--

http://www.ncbi.nlm.nih.gov/pubmed/18505352
--another major European study showing a slight advantage for olanzapine and clozapine over other antipsychotics--

http://www.ncbi.nlm.nih.gov/pubmed/18232726
--a study showing that extremely high doses of olanzapine (over 30 mg/day) may work as well as clozapine for treatment-resistant patients with schizophrenia; but the olanzapine caused more weight gain--

http://www.ncbi.nlm.nih.gov/pubmed/17651705
--a very recent study showing that clozapine is markedly superior to high-dose olanzapine for treatment-resistant adolescents--

http://www.ncbi.nlm.nih.gov/pubmed/18332662
--a study showing a reduced rate of tardive dyskinesia in patients taking atypical antipsychotics, compared to those taking typical antipsychotics. Of note, this study showed a risk of tardive dyskinesia in patients not taking any antipsychotic at all, and this rate was actually slightly higher than the rate in patients taking atypicals. This is consistent with some evidence that atypicals such as olanzapine and clozapine may actually be used to treat tardive dyskinesia--

http://www.ncbi.nlm.nih.gov/pubmed/18329720
--a nice long-term study showing that antipsychotic+mood stabilizer (in this case, fairly low-dose quetiapine plus either lithium or valproate) was much superior to antipsychotic alone or mood stabilizer alone in preventing relapses in bipolar disorder--

http://www.ncbi.nlm.nih.gov/pubmed/18681749
--a study showing that an atypical antipsychotic (in this case, risperidone) can reduce suicidal ideation and other symptoms when added to an antidepressant in treating depression--


It should be noted that the results of these studies, as with those from most studies, give us ideas about how groups of people with specific diagnoses respond to certain treatments. The studies rarely tell us how a particular individual would respond to a given therapy; I find that in clinical practice, sometimes one particular medication or therapy suits an individual much better than another, regardless of what the studies show. In this case I think the studies show that a whole variety of different medications--including the older ones--have a decent chance of working, and so I think this could instill some hope that it can be worthwhile for an individual to keep searching for the one that works best.

Love

The ancient Greeks described three different forms of love:

1) Eros -- sensual desire; attraction and appreciation of beauty; passion
--In describing eros we need not assume that it only refers to sexual passion; I think there is a component of the "erotic"-- in a broad metaphorical sense--in all moments of life, all motivations, all experiences of beauty in all its forms--

2) Philia -- virtuous, loyal, attachment between friends or family members; dispassionate but balanced, stable, reciprocal, equal.

3) Agape -- this term was adopted by early Christian theologians, referring to unconditional, giving, selfless love for all. In this type of theological view, agape was felt to be the feeling of the divine towards humankind. Psychiatrically I might say that agape was a projection of a feeling onto the projected character of "God" that fit with an idealized philosophy of life which was prescribed by religious leaders to the rest of the community.

I have to wonder if the "agape" idea was a bit of a defensive construct, since people with conservative religious beliefs or values might not want to be using a "love" term associated with eroticism or sexuality in their description of the divine, or in a prescription for ideal behaviour to espouse.

--since I am neither a scholar in Greek, nor well-versed in theological debate, I recognize that my above introduction may contain inaccuracies--

I do think love is one of the great joys of life, a requirement for happiness, a requirement for life itself to continue. A life without love can be intolerable.

But many of the experiences of love can lead to exquisite suffering. Love can be unrequited. Love can lead to obsession and despair. Love can fade and disappear. Love sometimes can throw off our judgment.

I do think that love is an ingredient of the psychotherapy experience. The struggle with "love problems" is one of the most frequent themes bringing people to psychotherapy.

If love occurs between patient & therapist, this love exists within the boundary of the therapeutic frame. Actions associated with this love--according to the rules of psychotherapy--take place through dialog. Actions outside of dialog (such as gift-giving, etc.) may or may not be allowed within the therapeutic frame, but if they do occur certainly would require careful attention or discussion through dialog. In many cases I feel that to reject a gift would be akin to rejecting a handshake--at times it could be humiliating--and that it may sometimes be part of the development of a healthy relationship to permit gifts in psychotherapy. I realize that many of my colleagues would disagree with me (all kinds of talk about boundaries would arise, I'm sure). I do realize that accepting gifts could give rise to a variety of problems in some cases (e.g. anger at generosity not perceived to be reciprocated, or gift-giving "getting out of hand" with more and more financial expense involved, etc.); in some cases I will gently let people know that their presence is a gift, and that other types of gifts can't be something I can accept. Gift-giving can be a much subtler theme, as many times patients may "try harder" in their therapy as a gift to the therapist, etc. Such gifts should not be rejected, yet of course it is important therapeutically to understand this motive, and to find ways to expand the range of motivations for "trying harder".

I affirm strongly that I have--and aspire to maintain-- a feeling of agape towards my work as a psychiatrist, and towards all of my patients.

I feel it is important to convey this positive feeling directly at times, and that it is often a fear of impropriety, or of boundary-crossing, etc. that prevents many therapists from openly pronouncing positive regard for their patients. As a community of therapists, I think this fear stems in part from recognition of many disturbing examples of boundary-crossing behaviour(e.g. therapists having affairs with patients, often with components of exploitativeness, and often causing complex harmful consequences for the patients). Or some therapists may have been taught to believe that the therapist should not "meet a patient's dependency need" but should rather interpret such a need, or help problem-solve around it, to help the patient meet that need outside of the therapy. Well, in many cases I feel that depriving a patient -- in this case, let's use totally frank language: depriving a patient of love -- is merely a tactic that keeps the therapy less personal, more frustrating, and less helpful. Also it fosters greater detachment in therapists, which I think fuels a broader phenomenon of therapists not really enjoying their work, leading to increased cynicism, less appreciation for the beauty and potential of their patients.

I believe all three types of love exist in every human dynamic, in some mixture. This is normal and healthy, a fact of life. This includes patient-therapist interaction. Yet these other varieties of love dynamics may only colour the dialog or the narrative in a therapy setting, they cannot cause the therapeutic frame to change.

Having said this, I think that in many cases, the patient-therapist relationship is much more distant. It can be like the relationship between "homeowner & electrician" or "shopper and retail clerk". This kind of distance may work just fine, the therapy itself doesn't have to be a specific setting to work out "love problems". The therapy may simply be about obtaining advice to relieve a symptom.

There are some cases -- such as in patients who have a history of dangerous interpersonal behaviour, or in cases of psychosis which may involve the therapist in a delusional system -- where the therapeutic relationship has to be much more distant. It is still not without agape though. A truly loveless relationship cannot be of much help; in situations like this it is often necessary to refer the patient to a different therapist.

In some cases, the therapy itself becomes a setting to "work through" love problems, and the love dynamics present in non-therapeutic life may show up in the therapy itself. In the psychoanalytic community, this would tend to be called "transference". The idea of transference is extremely important, since feelings or dynamics in a person's personal or past life may very well appear in the therapy, towards the therapist, and this phenomenon may epitomize a recurrent relational problem in the patient's life. Yet the term "transference" may also be part of a defensive language on the part of the therapist, to negate "true" feelings which may exist between patient and therapist. So I feel that both "transferential" and "non-transferential" feelings can be present, may be something to acknowledge--and sometimes to affirm--in the therapy, provided the boundaries are clear and consistent.

The world needs to devote more of its energy and resources to solving its "love problems", and to celebrating its many examples of powerful, healing, healthy love.

The Tragedy of the Commons

In 1968 (just before I was born) Garrett Hardin published an article in the journal Science called "The Tragedy of the Commons" [Vol. 162, No. 3859 (December 13, 1968), pp. 1243-1248].

It is a metaphorical--and sometimes literal--illustration of how groups of humans behave, specifically when individuals are using a shared resource. It is a wonderful example of an academic area studied in the field of social psychology. But the ideas have been studied in other fields such as political science and economics.

In the metaphor, "the commons" could refer to a common pasture or field in a town of farmers. Each farmer would be entitled to use the pasture to feed his cows. With this system, each individual farmer will immediately profit most by allowing his cows to graze on the pasture for as long as possible. But, if each farmer does this, the pasture will quickly become overgrazed, and everyone loses. The question is, how long does it take between the time when individuals are "winning" and the time when everyone is "losing"?

Of course, the world has many examples of this situation. Pollution of all sorts is like this.

Proposed solutions to this problem have included the idea of privatizing everything (i.e. to eliminate any "commons"). The trouble is, part of the tragedy of the commons lies in an individual profiteer having a short-term motive. "Short-term" in an ecological sense could sometimes be considered to be 50-100 years. The profiteer may maximize his wealth by relentlessly exploiting a natural resource, whether he owns the resource privately or not. During his lifetime, there may not actually be overt negatives to this practice. But over several generations, this practice will destroy the environment.

So, privatization is not a rational solution (besides, carrying privatization to an extreme would yield such absurdities as individual private ownership of the atmosphere or the sky, etc.).

Shared resources must be managed. The management must be from a point of view of the community as a whole (hence it must be communal or governmental), and not only that -- the management must be from a point of view which encompasses the distant future as well as the present. So we must have a government, and a set of values, which makes substantial consideration for what happens even after every currently living person on the earth has died -- i.e. we must consider future generations of life.

I wonder if the common religious stories regarding the notion of an "afterlife" may touch metaphorically upon the importance of literally considering what comes after our own lives. In this practical case, though, we are considering our currently living role in caring for the lives of those who are yet to be born. We may exact such care by protecting "the commons." We may consider this a sacred act.

Such a perspective goes beyond what the mind has been evolutionarily programmed to do -- yet such a highly cultured perspective is what we are called to espouse, if we are to save ourselves, and to save "the commons." The most obvious example of such need is, once again, relating to pollution (of which the "global warming" issue is one of many facets).

The human mind has an innate difficulty with sharing, and it requires culture and a legal structure around the human individual's drives and yearnings, in order to prevent "the tragedy of the commons" from playing itself out.

In a modern society which allows a high degree of individual freedom, and highly advanced, unique forms of living out this freedom (e.g. the internet, telecommunications, rapid and convenient transportation almost anywhere in the world), we may be serving and developing those parts of our mind -- those parts we have evolved over millions of years -- which are most apt to "deplete the commons".

The parts we must strive to attend to are those which require us to use our intelligence, empathy, and imagination, in the process of learning how to share.

I think the modern conservation movements are just the tip of the iceberg, in terms of people making more deliberate, conscious, inspired efforts to protect the present and future environment. These efforts will not only literally protect the earth -- but they will protect our minds. The practice of empathy, and of sharing, of planning to protect something we will not even be around to see -- these are the crowning qualities of human culture, made possible by the human brain, but often thwarted by inherited aspects of the carniverous greed which our species required to survive for millions of years.

It is interesting that many dreams about fear, terror, and death feature wild creatures such as wolves. The wolf is an apt symptol for such frightening emotions--wolves and humans co-existed in a wild state prior to the development of a modern moral culture. In those prehistoric days, there might not have been much room for empathy and sharing in an average
human "household." Since that time, humans have befriended and domesticated wolves, (some of them at least) such that we have a type of wolf we keep in our homes, which we call a"dog." Perhaps to some degree me may remember in our dreams that dogs, or wolves, have been symbols of the terrors of the wild, of a simple but cruel kill-or-be-killed existence.

Our mind reverts to such "wild" states easily--after all, hundreds of thousands of generations of humans evolved under such wild conditions, and those traits in our minds have a strong genetic background. It is like a long war, which is finally over. We don't have to be wild anymore. It is no longer necessary--at least no longer in the peaceful parts of our world--to devour prey; to hunt; to kill our enemies before they kill us; to prepare for a panicked escape in the event of possible attack, etc.

In fact, as the tragedy of the commons metaphor illustrates, it is necessary to set aside aspects of our genetically programmed heritage, to over-ride this with a learned culture of love, sharing, and compassion, with the leadership offered in the culture (e.g. in the form of government or law) to ensure that moral excellence is favoured.

From a psychiatric point of view, I remind you that your mind is partially "wild", it strives for immediate safety, satiation, or relief. You may need to over-ride the wildness, using your intelligence, imagination, and culture (derived both from within yourself and from your community), in order to protect, or "conserve" your mind -- to protect your future mind from the wild emotional instability that may be seething in the present. Cognitive-behavioural therapy is a concrete example of this kind of idea. But more subtle -- and possibly more powerful -- examples include all imaginative, intelligent acts that are rooted in compassion, altruism, generosity, and protectiveness towards self & others.

Biases associated with Industry-funded research

There is evidence that research studies sponsored by pharmaceutical companies produce biased results. Here is a collection of papers supporting this claim:

http://ajp.psychiatryonline.org/cgi/content/full/162/10/1957
This paper from the American Journal of Psychiatry reports that industry-sponsored studies are 4.9 times more likely to show a benefit for their product.

http://www.ncbi.nlm.nih.gov/pubmed/15588746
In this paper, an association is shown between industry involvement in a study, and the study showing a larger benefit for the industry's product (in this case, with newer antipsychotics).

http://bjp.rcpsych.org/cgi/content/full/191/1/82
In this study, the findings suggest that the direct involvement of a drug company employee in the authorship of a study leads to a higher likelihood of the study reporting a favourable outcome for the drug company product.

http://jama.ama-assn.org/cgi/content/full/290/7/921
This is a very important JAMA article, showing that industry-funded studies are more likely to recommend the experimental treatment (i.e. favouring their product) than non-industry studies, even when the data are the same.

I do not publish this post to be "anti-drug company". I think the pharmaceutical industry is wonderful. The wealth of many of these companies may allow them to do very difficult, hi-tech research with the help of some of the world's best scientists. The industry has produced many drugs that have vastly improved people's lives, and that have saved many lives.

Even the profit-driven-ness of companies can be understandable and healthy...it may lead to economic pressure to produce treatments that are actually effective, and that are superior to the products of the competitors.

Sometimes the research trials necessary to show the benefit of newer treatments require such a large scale that they are very expensive...sometimes only a large drug company actually has enough money to sponsor trials of this type.

BUT...the profit-driven orientation of companies may cause them to take short-cuts to maximize profits...
-marketing efforts can distort the facts about effectiveness of a new treatment
-and involvement in comparative trials by eager, profit-driven industry, very likely biases results, and biases the clinical behaviour of doctors

A solution to some of these problems is a requirement for frank transparency always, when publishing research papers, in terms of industry involvement.

Another solution is to have more government funding for independent, unbiased large-scale clinical trials.

And another solution is for all of us to be better informed about this issue!