Expert: Ivan Goldberg, M.D. - 2/23/2010

Question
QUESTION: I've spent a lot of time studying psychopharmaceuticals and have found that the side effect profiles of most mood stabilizers are too high in comparison to their efficacy. While some doctors prescribe antidepressants in tangent with them, this cocktail ultimately helps more now in exchange for more treatment resistant symptoms later, which is not a trade I'm willing to make. I'm also not keen on something that's only 13% more effective than Skittles, especially if it can spark a full-on manic state. I've taken Depakote, which basically aged me 10 years and left me with nothing but crippling depression. I'm currently on 100mg Lamictal, which takes the edge off a bit in some ways, but the anxiety it causes keeps me from taking larger, ostensibly more effective doses.

As such, I've taken to augmenting my treatment with 5-HTP and marijuana (with the approval of a longtime therapist and no challenges from doctors that didn't lie to me about the existence of studies that I referenced), which help a bit. The marijuana has some less than ideal side effects, but the side effect profile is vastly more tolerable than psych meds. While I have more energy without it, I have vastly less control over the emotions that my head noise causes.

I plan to get a YMCA membership in the coming weeks to increase my physical activity in general, with plans to take Tai Chi and Yoga classes as I'm able. I try to stay involved with local activism as much as possible. I attend community college (barely) full time, taking classes that I love, and I'm able to largely get by due to the lax / variable schedule and various privileges by dint of my disabled status. I am unable to hold down gainful employment for longer than a few months without falling back into old habits of substance abuse (used to have issues with benzos, amphetamines, cocaine, alcohol, and general experimentation).

My old therapist and I were teetering between bipolar type I with psychotic features (characterized by mixed states and rapid cycling) or bipolar type schizoaffective disorder.

While everything I'm doing is helping, it's not enough, but the 6th edition of the Manual of Psychopharmacology and about 100 or more hours of other research has done little more than scare me off of what few medications have been shown to have a significant impact and make me question my assumptions about the knowledge that comes with a doctorate. What else can I do? What can help to further take the edge off, so to speak, so I can more effectively address my head noise behaviorally?

ANSWER: Hi, Max . . .

My reply will not make you happy. I think you are doing what the CBT people call "catastrophizing." You read about the potential side-effects of medications that have shown to often be effective and then use your fear of side-effects against your self by preventing you from taking the medications. I think this problem should become the focus of your psychotherapy.

You also might want to get a second opinion on your situations from a n expert. A list of such experts may be found at: http://www.psycom.net/depression.central.psychiatrists.html

Best regards . . .

Ivan
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---------- FOLLOW-UP ----------

QUESTION: That kind of deontological full-stop is fallacious. I've experienced the side effects. Depakote rendered me useless with depression, Lamictal at higher doses than I currently take crippled me with so much anxiety, which I had never experienced before and now struggle with (it caused a nervous breakdown; I thought I was losing my grasp on reality altogether). While lithium and other mood stabilizers help many people, a fact that I cannot deny, I have seen far too many people develop new problems which necessitated new medication which brought about a combined side effect profile worse than the sum of its parts. I understand what you're saying, and I don't deny that it occurs, but given the studies cited in the doctorate level classes or too recent for inclusion, I challenge the underlying assertion that challenging the overall efficacy of these medications on an individual level is automatically catastrophizing.

Think of it this way: if a person is labeled as some kind of mentally ill, innocuous behaviors will be perceived as symptomatic. Basic survival skills are suddenly "coping mechanisms." I imagine that you're aware of the sociologist that sent students to an institution to pretend to be crazy and then try to get out; everything that came out of their mouth in contradiction of paternalistic assumptions was dismissed as evidence for them. Of course, when the institution realized that they had been made a fool of, they ironically proceeded to turn away numerous legitimately ill people for fear of being made a fool of again. In the context of labeling theory, I don't understand how this sort of approach is anything but counterproductive to the betterment of those seeking treatment, advice, etc.

Again, I don't mean to be reductive about psychology, psychiatry, or psychopharmacology, but they are by no means at the pinnacle. Please at least consider the possibility that there may be more options than simply throwing pills, many of which with as-yet unknown methods of action and too little time to determine long term side effects. What about dietary changes, behavioral changes, different methods of therapy, etc.?

I don't mean to be disrespectful, and I do apologize if I unintentionally crossed any lines, but I don't accept anything I'm told unless it's backed up by reason and evidence in such a manner that shows that my assertions and concerns have actually been taken seriously, even if they are some kind of flawed (a prospect that I make a concerted effort to always remember). I do legitimately appreciate your time and consideration, no matter where we stand at the end of our discourse.

Answer
Hi Max . . .

I'm sorry that I nothing to offer you other than the viewpoint of a physician who has practiced for over 50 years using the biopsychosocial model of medicine. By cutting yourself off from the evidenced-based biological part of this approach, you seem to be limiting your capacity to recover. For your sake I hope I am wrong and you are right when it comes to what you need.

Best regards . . .

Ivan
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