Electronic Spring 2023 | Issue 54

The ‘M’ Word – Balancing Choice and Necessity

By: Gary Wu, MD

Some time ago, I came across an article in the New York Times titled ‘Doctors Gave Her Antipsychotics. She Decides to Live With Her Voices’ authored by Daniel Bergner. The article briefly touches upon the history of antipsychotics and highlights a woman’s journey through navigating the voices in her head, trying to understand the voices, and walking the reader through her personal choice to co-exist with her voices rather than to medicate herself. Ultimately, she set out to lead Hearing Voices Network (HVN) groups to bring awareness to the fact that the M-word (medication) is not the single panacea for mental illness. As the article references, this movement shifts mainstream thinking away from medications toward acceptance and co-existence with our current understanding of psychiatry and mental health.

In the last century, the paradigm of psychiatric care has shifted from a psychotherapeutic approach to a pharmacotherapeutic approach with the advent of psychotropic medications. Although advancements in the field of psychiatry have made significant contributions to how we now look at and treat psychosis and other disorders, we should not fall prey to heuristics and practice psychiatry without taking into account the patient perspective. To understand why this current movement away from psychotropics came about, we have to understand flaws in our current practices. I can postulate that stigma, healthcare barriers, lack of knowledge, cultural/community barriers, and personal preferences all play a role in dictating individual care. The article also cites metabolic side effects from antipsychotics, changes in personal appearance and self-esteem, as major reasons for discontinuing medications. Combined with frustration with institutional infrastructure and a psychiatric focus on risk management instead of individualized care, patients are turning towards self/group-help as motivators for recovery.

As a psychiatrist, there are numerous times when I have had patients who are evaluated with a predetermined list of cons about why they don’t want medications. Where I go from here is to do my best to assess the patient’s current level of functioning, knowledge about their illness, and perform a quick risk analysis. For example, I had a patient who I was consulted on for their auditory hallucinations since childhood. Upon further questioning, hallucinations were non-command, and described as a mix of good and bad voices. This patient stated that more often than not, the comments were self-depreciative but when he heard something affirmative, it served as a source of motivation for him. My patient was puzzled when I explained that treatment does not only equate to medications and other forms of treatment like psychotherapy and groups are not mutually exclusive. Like the success story in the article, my patient ultimately decided against psychotropics and opted for individual psychotherapy to co-exist and manage the ‘negative’ voices while still retaining the benefits of the ‘positive’ voices.

Medications are great tools in our field to help with "unstable" patients, chronic management of psychiatric conditions, emergent situations, etc. but may not be the best treatment method for every patient. By de-stigmatizing mental illness, educating patients about medications, incorporating patient principles and preferences, the physician and patient can come to an informed decision-making process that leads to individualized treatment plans suitable for one’s needs – with or without medications.