Advice to People Who Have Psychiatric Problems

October 8, 2019

Recently DSM-IV Chair Allen Frances, MD wrote 50 pieces of advice to clinicians on how best to help their patients. It seems fitting, then, to provide an equal portion of advice for patients who seek help from those clinicians.

COMMENTARY

I recently posted 50 pieces of advice to clinicians on how best to help their patients.1

It seems fitting here to provide an equal portion of advice intended this time for the patients the clinicians seek to help.

These 50 tips are derived from 50 years of learning from my own patients, who were always also my best teachers.

1. There are lots of different treatments-no one size fits all.

2. Many treatments have a strong base of supporting evidence, but some do not. Whenever possible, evidenced-based treatments are preferred.

3. Psychiatric treatments are about as effective (but also as ineffective. as treatments in the rest of medicine).

4. Outcomes are very variable and initially unpredictable. Most people experience at least some benefit from psychiatric treatment, some people have full recovery, a minority have no response, and a few are harmed.

5. The success of treatment depends on the person; the nature of the problem; the accuracy of diagnosis; the type of treatment; clinician skill and flexibility; patient effort; the strength of the therapeutic relationship; and the presence or absence of good luck.

6. The choice of optimal treatment depends on the person; the nature of the problem; its severity; patient preference; clinician training; availability; and the results of serial systematic trials to see what works best.

7. “No Treatment” may also be the treatment of choice-especially for people with normal, expectable problems of everyday living and also for those who have had no or bad responses to previous treatments.

8. For mild symptoms, watchful waiting, the healing powers of time, reduction of stress, and support from friends and family may be all that is needed.

9. In contrast, severe/persistent symptoms require immediate attention-the longer you wait, the harder they may be to treat and the slower and less complete the treatment response.

10. Good clinician/patient match is crucial to good outcome. If possible, interview several clinicians before picking the one you are most comfortable with. If choice permits, always avoid clinicians who don’t feel right for you.

11. Don’t be too ashamed to seek treatment-half the population has substantial symptoms at some point in their lives and any stigma of being in psychiatric treatment has mostly evaporated.

12. Be an informed and skeptical consumer-use the internet (though don’t believe everything on it); have probing questions prepared before visits; and expect good common sense answers. Second and third opinions also often help in good decision-making.

13. Put your heart, mind, and guts into the treatment; the more you put into it, the more you will get out of it.

14. Psychotherapy is usually the best treatment for mild to moderate problems and may also help people in managing more severe ones.

15. Psychiatric medication is essential for most severe problems; often necessary for moderate ones; and to be considered whenever symptoms persist and don’t respond to psychotherapy.

16. There are many effective specific psychotherapy techniques-cognitive; behavioral; interpersonal; psychodynamic; family systems; and group.

17. The best psychotherapists know most or all of the many techniques and apply them flexibly as needed by a particular patient at a particular moment.

18. A strong therapeutic alliance and good clinician/client personality match-up may be more important than the specific techniques used, so pick someone you like and want to work with.

19. Most psychotherapies are brief (5 to 12 sessions); goal oriented; and problem focused. Long-term treatment may be necessary for more persistent problems or more ambitious goals.

20. Most of the beneficial effect of psychotherapy comes from how well you use what happens within the sessions in your life outside the sessions. Expect homework from the therapist and figure out on your own how you can enhance your skills and stretch your boundaries based on what you are learning in therapy.

21. It is important to give psychotherapy a fair chance, but if it is not working, try something else or someone new.

22. Psychiatric medications are currently very overused-20% of the population is taking one; 12% are on antidepressants, including 25% of women over 40 and 4% of teens; 4% are taking a benzodiazepine, including 8% of the elderly (where they can cause falls, memory loss; confusion); 6% of kids are on stimulants. Antipsychotics are very overprescribed, especially in poor kids and seniors in nursing homes (where they shorten life expectancy).

23. Approximately 80% of psychiatric medications are prescribed by primary care doctors who have very little time to get to know their patients, receive very little training in psychiatry, and are often under undue pressure from patients wanting immediate relief as the outcome of a first visit.

24. It is easy to begin a psychiatric medication, but often hard to stop one. The decision whether to start should require careful thought and often an extended period of watchful waiting or psychotherapy before prescribing.

25. The placebo response rate combines the effects of time; expectation; and the fact that most symptoms are a response to a specific stress and remit spontaneously. Placebo response is very high (50% or more) for milder problems; very low (less than 10% for severe ones).

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26. If you begin a medication for a transient problem, your positive response to it is much more likely due to placebo effect than to any active ingredient in the drug. But you can’t tell the difference; many will likely give undue credit to the medication for relief; and many (for purely magical, and no real) reasons stay on it for the long term. This is an important reason for medications to be a last resort, not a first reflex, for mild to moderately severe problems.

27. Drug ads emphasize benefits and minimize risks.

28. Patience is important. It takes time for medications to work; don‘t jump from med to med before giving each a fair chance at proper dose and duration. Systematic trials are the only way to figure out what works and what doesn’t.

28. Medications should be used carefully and only for specific indications. All drugs have adverse effects, and some have rare but serious complications.

29. The sacred principle of beginning medication should be “start low/go slow.”

30. Many psychiatric drugs have withdrawal effects. The sacred principle of stopping a medication should be a very slow taper. Medications should never be reduced suddenly or without medical supervision-especially benzodiazepines.

31. Except for certain specific situations (eg, bipolar disorder), polypharmacy usually does more harm than good. The drugs may interact negatively with each other and cause combined adverse effects. When new medications are gradually added, old ones should usually be gradually withdrawn.

32. Medications are essential, sometimes life-saving, for the severe forms of most psychiatric disorders.

33. Three difficult-to-give treatments (lithium, clozapine, and ECT) are especially useful for some special indications, but they are under-utilized, precisely because they are difficult to give. ECT would be my choice for me if I had a severe depression.

34. The outcome of severe psychiatric disorders varies widely, from crippling to just annoying inconvenience. Some of this is luck and clinician skill but a large part is determined by how well you participate in the treatment and learn how best to manage your symptoms and life problems.

35. Access to, and funding for, mental health treatment is shamefully inadequate in the United States, particularly for those suffering with the most severe disorders and with the fewest family resources. It breaks my heart that 600,000 people with severe mental illness are relegated to jail or homelessness for callous want of available treatment and affordable housing.

36. Always get help when you have suicidal feelings-sharing them with others greatly reduces risk and will help you feel better. Don’t be ashamed and don’t feel you have to struggle on your own.

37. Prepare an action plan when you are not suicidal listing the coping strategies and supports you can access immediately whenever you do become suicidal.

38. Know that if you do succeed in dying by suicide, it will haunt your family for decades-not (as you probably incorrectly believe) relieve them of a burden.

39. Suicidal impulses peak during periods of stress or disappointment and usually lessen dramatically in just a few days or weeks. It is a great mistake to make an eternal “life vs death” decision based on how you feel on one of your worst days.

40. Suicide is almost always a mistake. Most people who survive a suicide attempt are very grateful to still be alive.

41. Alcohol and street drugs greatly amplify all the risks of having a psychiatric disorder and greatly increase the risks of suicide and violence.

42. Patients who have combined psychiatric and substance problems require simultaneous treatment for both.

43. Be sure not to own or have any access to guns.

44. Don’t have perfectionist expectations about life. It certainly has its bad bounces-but remember that life is also implausibly beautiful and precious.

45. Don’t have perfectionist expectations about treatment. It is only sometimes completely curative, but usually helps a lot, and can always provide comfort and support.

46. Be resilient. Sure, it’s unfair to be burdened with psychiatric suffering, but it is not the end of the world, and almost always is manageable, compatible with a good life, and likely to get better with time and treatment.

47. Don’t be demoralized if treatments seem not to work. It sometimes requires many trials of different treatment methods and/or different treaters to find the right fit.

48. Don’t give up hope. Sooner or later most people are either relieved of their symptoms or learn to cope with them well.

49. Become expert in what psychiatric, health, social, insurance, and housing services are available in your area and how best to access them. You will probably have to become an expert in wrangling bureaucracies to get the services you need. And sadly, many people will never get the help they need because public neglect has made it unavailable or because cynical insurance companies make treatment inaccessible.

50. Be a vocal advocate for better services for people with mental illness. Politicians respond only to squeaky wheel constituents. Patients with severe mental illness have been ignored in part because they have felt shamed and have accepted neglect. Similarly, NIMH has a research agenda that seems to ignore patients’ practical needs and instead privileges scientists’ pet projects. Speak up, be heard, join patient advocacy groups.

These are the 50 things that first occurred to me. Please respond with your suggestions regarding things that I left out that have been important to you by writing me on Twitter @AllenFrancesMD. Thanks, and I hope this is helpful.

The views expressed in this article are those of the author and do not necessarily reflect the opinions of Psychiatric Times.

Dr Frances is Professor Emeritus and former Chair, Department of Psychiatry, Duke University; Chair, DSM-IV Task Force. He is the author of Saving Normal and Essentials of Psychiatric Diagnosis.

 

Disclosures:

1. Frances A. Advice to Young Psychiatrists From a Very Old One. Psychiatric Times. October 4, 2019.