This is about the pros of medication and when it is absolutely necessary. This is a follow-up to an episode I did about the pros and cons of receiving a diagnosis. In that episode I was discussing how meds are over-prescribed in the US and it has become in many ways a go-to for a lot of people instead of therapy. However, there are certain situations where meds are life-saving and the ONLY solution, so I wanted to discuss when that is and what those situations look like. For more about Dr. Moussai, check out DrMoussai.com
- First of all, Jacob, can you introduce yourself – your areas of expertise.
I’m a psychiatrist practicing in Los Angeles, California. I’ve been very involved with teaching our trainees, medical students and residents and until about a year ago I was an associate professor of psychiatry at UCLA. Now I’m currently an associate assistant professor at USC School of Medicine in the department of psychiatry. My area of specialty is adults, young adults with a variety of psychiatric disorders such as depression, anxiety, ADHD bipolar, schizophrenia, etc. I am glad we can have this conversation about medications and diagnosis because I know there are a lot of myths out there and it’s important to get the facts straight.
- You work with veterans too right?
Correct, for about 6-7 years I worked at the VA Medical center in west la VA, I was the medical director of the post-deployment clinic which provided psychiatric care to our returning combat veterans from Iraq and Afghanistan.
- So what would you say in your private practice, you see most people for – When do you prescribe meds most commonly?
I see a lot of adults, younger adults, struggling with a variety of psychiatric disorders such as anxiety, worrying obsessing ruminating, having panic attacks feeling depressed or low energy. Lack of motivation or appetite – as well as a lot of ADHD where they’re struggling with an attention, difficulty with focus and concentration.
- What do you prescribe meds for the most often? Someone comes in your office, I gotta put them on meds immediately – what is that type of thing?
The medication is a treatment modality in addition to other types of treatment modalities such as psychotherapy – but I do jump to medications when there’s an urgent issue, for instance they’re having severe psychiatric illness such as they can’t sleep, they’re seeing things and hearing things such as hallucinating or they’re feeling manic or out of control. We sometimes prescribe medications to calm the waters down until they can engage in different treatment modalities such as talk therapy.
- So basically when someone’s too far out of it to actually do talk therapy – that’s a situation you need meds?
You got it. Exactly.
- So what would you suggest to people –let’s say it’s not one of those severe cases. Let’s say I walk in your office and I say “I dunno, I’m just kind of bummed and my life kind of sucks.” What would be the first step for you before you suggest that people go on meds.
The first step is getting to know our patient – that requires us to do a full psychiatric interview. We really look at a number of different factors: is this psychiatric in nature? Sometimes we experience things that look like psychiatric in nature but they really are due to some medical abnormality – so sometimes we check labs. We make sure the don’t have any medical condition that may manifest or mimic psychiatric symptoms.
- What’s one medical lab that would pointing to something that made me feel crazy but I’m not crazy?
We see a lot of patients who come for depression and low energy. But if you check labs, at least once a month I get patients who have anemia – low red blood cells. Especially with my work at USC: students come in for a variety of problems, one of them is low energy – can’t’ focus or concentrate. Checking labs – that would be one. Another thing I see a lot of is patients who have anxiety or heart palpitations, or feel restless – and there are thyroid abnormalities then can mimic those symptoms. So checking routine labs can ensure there are no medical conditions that are manifesting as psychiatric problems.
- That makes a lot of sense. Let’s say I come in, I don’t have anemia, I don’t have celiac or anything that makes me depressed another way – what would you tell me is the first step for you – let’s try medication – or do you say, “let’s talk about it first.”
First thing before I talk about treatment modalities I make sure the patient is engaged in treatment, so I first ask the patient what his or her goals in coming to treatment are – are they here because there’s a problem or problems they need help with? What do they think is necessary to overcome those challenges? Some patients are opposed to medications and I certainly understand that – we may talk about talk therapy or other treatment modalities, some symptoms are so severe and the patient is requesting a medication – to calm the waters down before they can engage in therapy. I think it’s really important to empower our patients. SO not just give them a medication when they feel something, but teach them the tools or the skills to overcome those challenges. Sometimes in addition to medications quite often we recommend also talk therapy.
- So you kind of let the person guide their own treatment a little bit? Like if I come in – and I’m like, I’m really suffering – I don’t know what to do, and I’m anxious and depressed. And I don’t know what the solution is. Would you have suggestions or is it more based on what I’m comfortable with?
I think both factors are at play. I tell you your options: one option is medication, one option is talk therapy, other options can be exercise or increase social interaction. We talk about all the options and choose the ones that make sense for you. We don’t really try to force you to try to do something you’re uncomfortable with be cause you’re unlikely to follow up or be compliant with the treatment. Its’ really a convo between you and I. We’re on the same page: we want to get you feeling better. We’ve gotta find something that works for you.
- What happens if the person starts meds and then they immediately don’t like them. I know most meds have side-effects. So let’s say in the more average medication situation – a person goes on their meds and they don’t like them so they go off of them. What are the negative outcomes, what do you do in that situation?
As you mention, most medications if not all of them have side effects. The first thing we do is educate our patients. When we start we go over the risks: the pros, cons, benefits, and talk about the common side-effects. I tell them look if you’re experiencing any medication side-effects, don’t wait until your next appointment. Call me. And we can certainly talk about what you’re experiencing and if there’s an easy remedy for it or if we can alleviate it. If the problems persists and they’re too uncomfortable, we talk about other things – such as maybe trying a diff class of medication or a diff medication within the same class. Or even stopping meds altogether and trying something different.
- What would you say are the main bucket diagnosis – when you would say meds are the only option and they’re life-saving?
I’m afraid to say “the only option” because there’s always other options, but certainly if someone’s experiencing psychosis: psychotic symptoms, hearing things, seeing things, feeling people are after them or following them, we usually diagnosis those as schizophrenia. For those individuals medications can be life-saving, because if we don’t treat them they’re susceptible to acting on those thoughts and they may tell them to harm themselves or others. May put them at the risk of suicide or hurting family members. When situations life is at stake – the patient of people around them – especially if they’re manic or have bipolar disorder, certainly medications can be very helpful in preventing them from having an irreversible consequence from their actions or behaviors.
- So bipolar and schizophrenia, anything else? Are those the more severe?
I think so those are the main conditions when medications would be warranted.
- What happens if that person isn’t given meds? Let’s say with bipolar disorder.
Depends on the severity, depends on chronicity, depends no other factors – how much social support they have. If they’re manic or experiencing psychotic symptoms, often they need more observation or a higher level of care – that can be during a psychiatric hospitalization. We provide those safety measure, make sure they’re safe as well as those around them.
- How long do they have to stay on their meds? Like if I have bipolar disorder.
I wish I could give you a number. Varies. For people who have a chronic condition such as bipolar schizophrenia, they likely need medication on an ongoing basis.
Unknown but probably indefinitely. I wish I could tell you, we don’t know. Certainly some people do recover. Low likelihood but it can certainly happen. It is important that we have the patient under someone’s psychiatric care.
- How does it go away?
Overtime – with treatment, maybe they’re more cognizant of their symptoms – they can recognize them earlier on. They may be able to manage them on their own. This is in context of someone who has been in treatment for a while, understands their signs and symptoms, is aware of their condition. And gets help when they need feel like those symptoms are getting beyond their control.
- Would you say CBT would be a way you would treat someone who has bipolar disorder?
Cognitive Behavioral Therapy is one of our evidence-based behavioral therapies. They work particularly well for anxiety and depression or depressive spectrum disorders. Not so well for bipolar and schizophrenia – for those two we often end up using medications to manage the symptoms.
- But you said pairing it with talk therapy, right? What would be the therapy you’d par with bipolar disorder that could lead to their recovery because they’d be able to manage their own symptoms (in conjunction w medication)?
CBT is often used and it’s modified for different psychiatric conditions. In addition, we have supportive psychotherapy, such as assisting them with employment or housing opportunities – helping them adapt or adjust to their living situation can be very beneficial. So adaptive skills training is very important. Sometimes they need supportive psychotherapy if they’re going through something that’s quite stressful. Really depends on what life condition they’re struggling with at the time they seek treatment.
- Can people recover from schizophrenia? Or is more about maintenance.
It’s more about maintenance. Unfortunately we have no cure for psychiatric diagnosis – over time we can use a variety of medications or talk therapies or other treatment modalities – I mentioned employment assistant programs to help them manage life and recover.
- This is probably a long question… what do you think the origins are of things like bipolar disorder and schizophrenia?
That’s a billion-dollar question. I wish I knew the answer. We do know that it runs in families – there’s a genetic disposition for individuals who have bipolar and schizophrenia, but what causes it – we are not there yet unfortunately.
- As you know I’m in school – mostly from books from the UK. I’ve been reading a lot about systems theory – from the 60’s. They’re talking about in a family, that schizophrenia can be triggered or brought to the surface by a family where communications are contradictory. Do you subscribe to that belief or do you think that’s kind of crazy?
There are a variety of diff theories as to what is likely to cause or exacerbate psychiatric conditions such as schizophrenia. We don’t subscribe to systems theory; we think that might be outdated – we think there are some genetic abnormalities.
- You’re talking about psychiatrists – as we, right?
Yes, as in psychiatrists. And there’s been neuro-imaging studies, looking at your brain and the structure or the morphology of it – and we do know individuals who have schizophrenia have diff brain anatomy – if you took an MRI, you can see that individuals with schizophrenia do have different – their brain looks different. So we’re not sure it’s system-based, maybe it’s more biological or genetic.
- So like when, for example, someone’s stressed out – your brain does similar things. People with PTSD their brain does similar things. You’re saying with schizophrenics, their brains are not doing anything in common?
With schizophrenia their brain looks different than a normal average healthy adult.
- But do people with schizophrenia have consistent looking lit up areas of the brain? Like two people with schizophrenia have consistent looking lit-up-areas of the brain?
Absolutely. There are some studies that show patients with schizophrenia have in terms of variability in their ventricles, that’s when their central CSF fluids – the part of their brain that stores fluid looks different. That type of brain region. There are different parts of the brain that also has changes in size – such as the hippocampus where our memory’s kept – in the frontal lobes. SO there are diff parts of the brain depending on which study you look at that shows there’s a difference between a group of patients who have schizophrenia vs. a group of healthy controls.
- Is there nothing that schizophrenic patients have in common – in life experiences?
The diagnosis is highly variable – you can have a variety of diff symptoms and still meet the criteria, so two individuals who may be suffering may experience a quite different cluster of symptoms. They might have positive symptoms: hearing voices or seeing things or feeling paranoid, but they can also have a cluster of negative symptoms: don’t want to interact with others, don’t enjoy activities, they’re flat – don’t show expression of emotions. You can have a variety of symptoms and still meet the criteria. So they don’t necessarily look alike.
- But I mean – do they have any life experiences… for example, would you say there’s any research into the formative experiences of those with schizophrenia? Do they all have a certain type of family structure, or…
Great question – I’m not sure there’s been consistent literature showing that growing up, developmentally speaking, they’ve been exposed to similar factors or stressors or environmental conditions. So I don’t believe so but I’m not 100% certain.
- Okay. Do you have any hope or interest – I know a lot are yet to be tested – do you have any hope for any new treatments for things like schizophrenia and bipolar disorder – that are alternatives to meds? For example, EMDR I know is kind of newish and a lot of people are saying a lot of good things about it – or psychodrama. That’s one of those types of therapies that sounds pretty amazing.
So I do I am very optimistic about the future of the field of psychiatry. We’re just starting to understand brain structure and how it evolves over time and what factors influence the outcome in terms of psychiatric diagnosis – in terms of medications, we’d love to find out – genetically speaking – where the gene goes awry and goes abnormal. With genetic modification in the future, we can knock out that gene or replace that gene – where the patient never has clinical manifestations of that illness. They may have an abnormal gene that we find out is in schizophrenia, correct that gene and that patient never has schizophrenia. I am very hopeful we will end up there.
- What about treatments? That’s something before birth. Is your field looking into anything more than medication as a treatment?
There are other treatment modalities: one is TMS: trans-cranial magnetic stimulation. It’s FDA approved – a treatment that requires you for 4-6 weeks – basically they put this machine on your head an hour, hour and a half. It’s FDA approved for depression. I’m not an expert in TMS, but it uses wavelengths and it’s non-invasive. Not radioactive or anything like that. It’s not ECT (electro-convulsive therapy) but it is like a magnet and by putting it on different brain regions, such as the motor cortex etc, you can basically release different types of neurotransmitters – which is hypothesized to improve depression. It has bene shown in a number of studies to improve depressive symptoms.
- That’s awesome I’ve never heard about that. Besides that helmet thing, what else is there?
I brought up Electro-Convulsive Therapy, it’s a treatment that’s been around for decades – where the patient – under anesthesia – we induce seizures, and it releases a lot of neurotransmitters. That’s usually used for individuals who have refractory depression or OCD or other psychiatric conditions.
- Oh, that’s like One Flew Over the Cuckoo’s Nest right?
It has been used in the movies, correct.
- Okay, I thought that was the most inhumane thing but knowing it’s to release neurotransmitters makes way more sense.
And now we do it under anesthesia in a very controlled environment. It’s in a hospital, once they are found suitable for the treatment, they receive it on an ongoing basis and see significant benefit.
- So the results are really positive?
For those who need it – absolutely.
- Interesting. So what do you suggest to somebody – let’s say someone has a family member and they suspect that person has a mood disorder, or they’re just worried about them. They don’t know what’s wrong with them, they’re acting erratic, manic – what should they do?
Great question. At any time if a loved one or family member – you see them struggling, it’s important to get them the help they need because help is available. SO if you’re ever worried about someone’s ability to take care of themselves, if you’re worried they’re suicidal or homicidal – you can certainly call 911 or law enforcement – and they can do what’s called the welfare check. They arrive at the individual’s location–
- The what check?
It’s called the welfare check. Like a safety check.
- Oh, yeah! I’ve heard of that before.
All law enforcement in the united states are capable of doing the welfare check where they basically go and speak with that individual who you’re concerned about. And if they deem that person is incapable of taking care of their self, is homicidal or suicidal, they will take that individual to an emergency room to be further evaluated by a psychiatrist.
- So what if the person says they’re fine and that they act like nothing’s wrong?
The law enforcement do have their own guidelines and criteria of what they look for, so it’s not just what the individual says. Sometimes they receive collateral, they look at the individual’s behavior, they make look at the living conditions – they do look at the bigger picture and they determine based on the information available whether or not that individual should be taken to a hospital. Often they also call the psychiatrist in the hospital emergency room and have a consultation with a mental health professional or expert, with regards to the case that they’re evaluating. SO that is if you’re really concerned about someone’s safety or the safety of others or you feel like they can no longer take care of themselves, you can initiate help by calling law enforcement for that safety or welfare check.
- Got it – so that’s like in a ‘someone’s got a gun and going to kill themselves’ level of severity. What if the person’s still reachable but you can tell their behavior is a little bit odd and they don’t think they need help but you’re just concerned? What would be your advice to a person in that situation?
Great question. We never want to confront an individual who is suffering or struggling because we don’t know what’s going through their mind. What we want to do is come from an area of compassion. We would encourage them to seek an evaluation with whomever they’re comfortable with. Initially they may not feel comfortable seeing a psychotherapist or a psychiatrist. It may be with their general practitioner or their primary care provider – whoever they’re comfortable with, they can seek a qualified medical evaluation, and from there they would be given other referrals if necessary. If the individual still says, “I don’t want to go, there’s nothing wrong with me, why do you keep saying that.” We cannot force them to seek an evaluation unless those criteria are met: they’re suicidal, homicidal, or they no longer can take care of themselves with regard to food, clothing or shelter. But other than that-
- So those are the basic requirements: homicidal, suicidal, can’t clothe themselves or bathe themselves…
And those are called grave disabilities: those are the criteria used in the state of California that allows an individual to seek evaluation involuntarily. If they’re concerned about his or her safety, then the law enforcement can involuntarily take that person to be evaluated by a psychiatrist and they have 72 hours to perform that in an emergency setting.
- Got it. I know I’ve covered a lot of the life-saving reasons for medication and situations when medication is totally a positive thing… Are there any situations when you think meds are not the right answer ? What kind of patient can you imagine would you say is not a good candidate for meds?
In my private practice I see a lot of individuals who come seeking medications because they have not been able to accept the life-stressors that they’ve been dealt. A lot of times the solution is not a medication so they can power through their work or power through their challenges, but it may be to clean up their plate. They might be facing too many challenges. So one simple thing to do is teach them about multitasking or how to prioritize their life, or let go of the things that are not as important. So often an individual comes in and says, “Look doc, I need a medication for ADHD because I can no longer manage my life.” And before we talk about medications we really want to know why they’re coming in and asking for help. Maybe they’re more stressed, maybe they’re taking on too many responsibilities. Maybe they’re trying to achieve something they’re incapable of achieving. So we’ve got to look at all those factors. In addition, things like low self-esteem or low-confidence: I’m not sure medications can help with that. I think talk therapy can do a great job of that. Sometimes an individual has struggles in his or her relationship with their partner, their neighbor, family member and in those situations certainly talk therapy would be advisable over medications.
- Do you get people coming in and being like, “I’m having problems with my girlfriend, can I have some meds?”
And sometimes they say – “Can she have meds?”
- Oh, well, I guess that’s logical thinking, maybe? What’s the average thing you recommend to people besides talk-therapy?
When I see an individual I want to provide them with comprehensive treatment, so in addition to meds – and if advisable, talk therapy – we talk about practical techniques they can use when they’re feeling panicky or overwhelmed: what are things they can do at work or at school. We talk about the importance of exercise, healthy habits such as diet. Social interactions that are healthy and are not necessarily causing more stress. There are a lot of things we can do – talk about sleep hygiene, we can talk about having a structured routine during the day. So those are all important regardless of what the psychiatric condition is.
- So really practical stuff. So how do you feel about the prescription drug companies – or just prescription drugs – the way it’s regulated and the way it’s treated in the US. How do you feel about the ways it’s changed in the United States, even in the last years?
Depending on who you ask you’re going to get different answers. I think what’s been really interesting recently is the direct advertisement from the pharmaceutical companies to consumers via television or the media or radio. It has really changed how the consumers – the patients see an illness, and often they come in wanting whatever they saw on TV and not allow themselves to consider other treatment options or modalities. So direct advertising to consumers would be the one that I would call a big change.
- And that’s kind of messed up, isn’t it? To have somebody say, “I want the drug on the TV.” That seems like a backwards way to go about getting help, no?
The problem with the way that the advertisements work is the patient may not be necessarily educated about whether or not his or her conditions may meet those symptoms, and they may not be informed of all the potential long-term side-effects of drug interactions, medical conditions that may mimic their symptoms – that’s why it’s very important to seek a medical evaluation rather than saying, “I want drug A, B or C.”
- Has the way that drugs are advertised in the US – has it changed your industry or the way you see psychiatry heading, right now?
Absolutely it has changed, because consumers – the patients come in requesting a specific medication or drug because of what they saw on TV the night before. They’re not coming for an evaluation, they’re coming because they want the most shiny medication on the market – without considering the potential side effects, how long its been on the market, and other treatment conditions that may also be going on.
- Don’t you think that has the ability to steer treatment? I know that there are smart doctors like yourself who will not be swayed by somebody saying “I want that” but don’t you think there are a lot of doctors who will be like, “Okay, yeah, here’s the new thing.”?
Absolutely that can happen, especially if the doctor has samples and the patient is asking for that they’re more likely to be given the sample of that medication. Without really talking about the duration of the treatment, the chronicity of the treatment, other conditions that may exacerbate it – again, a drug or pill may not be the solution for everything.
- How do you think the DSM has changed in the last 10-20 years. Do you think it’s better now? Or do you think it’s maybe not better now?
About 3 years ago the DSM was modified, and now we’re on version 5 – so we have the 5th edition of the DSM. There are certainly pros and cons going from the 4th to the 5th edition: some diagnosis have changed in terms of the criteria used, and the language has been easier to understand for most clinicians. It’s broadened its use from just psychiatrists to everyone: psychotherapists, etc. The drawback of the DSM is that it continues to grow in size, so we have more psychiatric conditions labeled as problematic or pathological.
- Yeah! I mean I know there are a lot of great things about having a name for something, but I feel like everything – like “stubbed toe” is in the DSM. Like everything under the sun– that maybe doesn’t deserve a name. It seems like it is pathologizing everything just by adding more stuff.
That’s an important thing you bring up: just because an individual experiences a symptom or a cluster of symptoms, that doesn’t mean they should be diagnosed with a condition, per the DSM. The first few pages if you read through the book – it talks about, in order to be diagnosed with the condition, regardless of the symptoms that the patient experiences, they need to have what we call functional impairment. So if I’m feeling overwhelmed and stressed but it has not impacted my life in any way, I should not be diagnosed with depression. But if I’m feeling stressed to the point that I can’t leave my room and I lost my job and my family members are concerned and my loved ones no longer want to be around me, and I’m not eating – then that is a condition that needs to be treated. So we need to really clarify the difference between symptoms or a disease or illness.
- So what’s the line of functional impairment? If I’m bummed out for a while – let’s say a month or two, let’s say it’s depression. Am I functionally impaired?
If it hasn’t impacted your functioning in regards to school, work, social environment, relationship – no, you may have what we call mild or moderate depression. So you may not have clinical depression – what we call major depression. So for mild or moderate, we shouldn’t be prescribing you: this is what you were talking about early on. We shouldn’t be prescribing you an anti-depressant, we should be encouraging you to remove your stressor, have a healthy life, make sure you are exercising, and maybe consider talk therapy. If it is severe or debilitating clinical depression – we call major depression, you would have functional impairment.
- Is there any definitive line that tells you something is major or moderate? Or is it all different per each thing?
Unfortunately, it doesn’t say what we consider impairment, so from our usual day-to-day functioning, if there’s been a change or a decrease, we consider that a change in our ability to function. But it’s not as clear as we’d like it to be. Someone’s functioning may be very different than someone else’s.
- Right. So get a really, really good psychiatrist – because it’s kind of up to them – they’ll be the one who tells you whether you’re moderate or severe. What would you say to somebody who has been struggling for quite a while and they are trying now to start to get on the right track to turn their life around for the first time?
I applaud them because it’s so uncomfortable and stress-provoking to be seeking treatment. There are a number of barriers: finding a provider that’s available. Finding a provider that takes your insurance, if you do have insurance. Finding a provider that’s accessible from where you live. There are a number of barriers.
- And someone you like!
And that you like. And you might see a provider and it’s not a match. Or you might find the provider not to be capable of providing care to you on ongoing basis. So let’s say you’ve overcome all those barriers, do have access to the provider – and that can be anyone in the field of mental health: a psychologist, therapist, social worker, MFT – so a variety of different clinical providers can do those assessment or evaluations. Doesn’t’ have to be a psychiatrist. But regardless – if you do see a mental health provider, be open to what he or she is telling you What I always tell my patients is look at the first appointment as an informational session only: you’re going there to seek some knowledge, some information about what do you have and what he or she recommends. It doesn’t necessarily mean you’re obligated to seek treatment, it doesn’t mean you have to do what the provider’s recommending but it may give you some insight as to what you’re experiencing and what options you may have.
- Yeah, so it’s like you’re interviewing them – take it as a “what can I get out of this experience?” kind of thing. Any words of inspiration or hope – especially for somebody that’s unsure if meds or a psychiatrist are the right answer for them, or maybe for a family member?
Absolutely. I can tell you the large majority of patients who seek treatment – I find them to get much, much better over time. Now – it may not be with the first medication, it may not happen with the first session, but overtime if you continue with the idea of getting help – you will eventually get your needs met. I’m not saying that medications are side-effect free, or that treatment has no side effects – they certainly do, but it can help you in the long run. The idea is getting to be more functional, and happier in life. So look at treatment as an option when it’s necessary to get that help.
- In closing, I want to thank my guest: Dr. Jacob Moussai, and anybody who’s out there who wants to locate Dr. Moussai, you can check out his website at DrMoussai.com Anything else you want to throw out there?
No, thank you again for letting me be part of this podcast.
- Don’t forget to smile!