Pills are not easy mode

A couple of times in articles the last few days I’ve seen someone talk about how pills are somehow an easy answer as if a doctor  comes to a patient, gives them a pill, and goes away again.  This is not my experience, and I object to its presentation.

My understanding thus far is that this is mostly meant to be an indictment of society and the medical establishment. I’m spitballing on the theory here: maybe doctors are pressed for time, perhaps even greedy, curtailing appointments to achieve higher throughput? So pills are their easy out; they can provide a prescription and tell the person to come back in a month or even longer, once the medication’s effects have become clearer.

I can’t imagine where the patient fits into this idea; they would seem, to me at least, to be reduced to a victim, devoid of agency, shunted off into the void by a medical system that is massively underprovisioned for their care.  And there’s a grain of truth there – as a society which believes the game of market economics is the best way to provide a high standard of living for a maximum number of people, we are damned to a fate where our public services never have enough money to cover all the bases adequately, and so we stretch those resources to the breaking point.

The people speaking from this perspective seem to be in the midst of treatment, so they are drawing on their own lived experience. It’s hard to fault anyone in that position for saying what they believe.

But I think there’s a difference between telling your experience and condemning the system for that experience. There are, no doubt, major gaps in the system as it exists today. Very few psychiatrists will discuss Cognitive Behaviour Therapy with you; even fewer would get into something like Rational Emotive Behaviour Therapy. I’m lucky in this respect – my significant other is training for and is passionate about the field of counselling.

I’m also lucky enough to have coverage for an Employee Assistance Program, which gives me access to specialists who can provide these services. My experience with counsellors is the mirror of the experiences I’ve discussed above: counsellors, as a rule, focus on non-medical therapeutic approaches and won’t mention pills.

Neither one of these is a “complete” solution. If you need help, you probably need some of each – counselling to give you a safe place to discuss the worst bits of yourself and to try to find new approaches to thinking through your problems, and psychiatry to examine the possibility that you have an issue that can be fixed medically.

People like to use cancer as an analog for mental illness, probably because cancer is a severe, life-threatening illness that is widely treated and often, but not always, treatable and, to a lesser extent, mitigable. It works as a counterpoint to mental illness in this respect – we have a lot of it, it can be very bad for sufferers, but the treatment side of it isn’t, for a variety of reasons, comparable to more recognizably physical ailments.

The analogy works on another level as well, however: You have some cells in you, almost certainly, that are a kind of cancer-in-waiting.  The disease that is cancer is a definition: At some point, those cells gain enough of a foothold to survive your body’s self-repair mechanisms. At that point you have cancer.

For mental illness, we don’t have the primitives to discuss that level of detail, but we have the DSM. The furor around the release of the 5th edition, and particularly around the politics that are involved in including diagnoses, may have made it somewhat more well-known than many medical textbooks, but I think it may also have eclipsed the purpose of the text.  Its entire focus is on classifying the thresholds at which a symptom (more correctly, a cluster of symptoms) may be correctly diagnosed as a particular mental disorder. The word “disorder” is key here – you can be inattentive without having Attention Deficit and Hyperactivity Disorder, just as you can have individually malfunctioning cells in your body and not have cancer.

Having a diagnosis opens a path to certain types of treatment, including medication. It’s important to understand that a patient may receive more than one diagnosis over their lifetime, and hence be subject to more than one treatment.  This is exacerbated by the fact that many medical treatments for mental illness have a lead-in time before they begin to work correctly.  Antidepressants, for example, can take up to 6 weeks before their effects become fully apparent. So a patient is required to be patient, and it may feel unhealthy, unfair, ineffectual, or even overtly counterproductive to wait through one failure after another, especially if the doctor is actually unwilling to try other options quickly.

That’s not unique to mental illness, though.  When I tore my Achilles tendon off the heel bone in 2005, I had a surgical repair done.  At the end of the healing period, my doctor and I discovered a post-operative infection had set in. We tried a few drugs, each of which had its successes, but for several months I was given Ciprofloxacin in larger and larger doses. The medication obviously wasn’t working, and I eventually discovered that it is counterindicated for tendon injuries because it can cause inflammation and re-injury. But it is also a very powerful wide-spectrum antibiotic. In the absence of a solid diagnosis, it was a reasonable option. I later tried an even more powerful antibiotic, and it seemed to be working much better; then one day the back of my ankle fell off and the black, dissolved flesh and blood that had accumulated inside poured out on the carpet, and I decided to quit my job at a theatre company.  I had a surgical debridement the next month, and thankfully it actually worked.  My ankle is working now, although it will never be what it was when I was young.

My point is this: for some folks, something will work, for others it will fail. As patients, we are responsible for the management of our own care; it seems unfair, but it’s important to recognize the fact all the same and to take the actions required to move care forward.

For those who find pills aren’t working, that’s moving on to a new drug or a therapeutic approach. I applaud the courage required to take that step.  But I would caution against telling people pills are “easy”. They’re not. They’re a tool like any other.  Stating that they are an easy way out for doctor or patient tells those who might legitimately be helped with medication that theirs is somehow a disease or a treatment that is not worthy.

It may sound crazy. I may be a little crazy. But I’m glad beyond words that I at least have a pill for it.