Medication Efficacy

There are some common misunderstandings about psychiatric medications. Some of these are even held by psychiatrists. One commonly echoed refrain in medicine, and specifically in psychiatry, is “some medicine is better than no medicine”. This is whimsically fantastic thinking as well as patently ignorant of pharmacology. 

All medications have a time that the medication requires to reach a steady state in a person’s body. A steady state is calculated as five times the half-life of a drug (or how long it takes for the body to metabolize one-half of the amount of medication in the body). This is dependent upon factors of the medication as well as the patient’s body.  A steady state can only reliably be reached with regular dosing. The vast majority of psychiatric medications require regular dosing and are ineffective when taken in consistently. That means a once a day medication needs to be taken every day for a set number of days to reach a steady state. Certainly taking a medication irregularly will result in a level of medication in the body, however, it will not be consistent and not qualify for a ‘steady state’. 

Why does this matter anyway? 

Well, studies of psychiatric medications are highly controlled and patients are typically administered medication to ensure the medication is being taken regularly. That means that the study is an “ideal” and not reflective of actual patient behavior. Even in these highly controlled studies, psychiatric medications have a pretty limited efficacy. Consider antidepressant medications as an example. Repeated studies have shown that 66% of patients taking an antidepressant have their depression respond. Response is defined as a 50% reduction in depression symptoms. The key here is that the patient is still having depression symptoms and meets criteria for Major Depressive Disorder but there symptoms score is 50% less than without medication. That is certainly an improvement, but they are indeed still significantly depressed. Of the patients who respond to an antidepressant, half of those will see remission of their depression. Remission means that a patient no longer meets the criteria of Major Depressive Disorder. This is the goal; they are no longer significantly depressed. Looking at the numbers, that means 50% of the original 66% responders, or 33% of all patients taking an antidepressant for Major Depressive Disorder will see their depression remit. That means that the overwhelming majority of patients, 66%, will see only partial improvement or NO improvement in their depression. This data comes from well-controlled studies where patients are ensured to take the medication regularly. 

Now let’s go back to that refrain, “some medicine is better than no medicine”. If the best studies only show one in three patients taking an antidepressant will no longer be depressed then how many will see their depression remit when they are not taking their medication regularly, or only taking “some medicine”? The answer is unknown as there are no studies to support this refrain.

So in the end, to see a real benefit of an antidepressant, in Major Depressive Disorder, a patient needs to take the medication daily as prescribed for the indicated duration (typically four to six weeks). Anything less than that that leads to unclear benefit. This leads one to ask the following question: If it is not beneficial, then is it harmful? Possibly, as increasing a dose of an irregularly taken medication (possibly from presumed lack of efficacy at the current dose), can lead to high variability in drug concentration in a patient’s body, which may result in mild to severe side effects. 

The take home point is:  most psychiatric medication needs to be taken regularly to see a possible benefit or it is not likely worth continuing at all. And, unfortunately, there is no evidence in psychiatry to support the optimistic refrain, “some medicine is better than no medicine.”

Health Ownership

Culturally, America has become a society that avoids responsibility of the individual. Think of the countless frivolous law suits in our recent past: 1. McDonald’s coffee was too hot resulting in the warning now on all cups — “Contents are hot”. 2. Doctors being sued for delay of diagnosis due to patients not completing ordered medical tests and subsequent negative outcomes like cancer or death. You can likely name some more. 

The osteopathic medical philosophy recognizes that the body has self-healing and self-regulating systems and that the patient is the owner of these systems as well as the health within. It is their body, it is their health to manage. 

Modern medicine has robbed the patient of their responsibility for their own health. It seems society wants to place responsibility on anyone but the person who actually has the responsibility. A problem arises when this happens. If the patient really owns their health, then pretending the physician owns it instead limits any real healing from occurring. The person who has the power to do something about the situation, is not the person who has the responsibility to do it. This illusion of responsibility creates a glass ceiling to optimized health and can lead to blaming the physician for not making the patient better. 

At Trinity Institute, we are committed to partnering with our patients to optimize their health. Our patients are responsible for owning their health and actively participating in the treatment plan We, as clinicians, are responsible for being competent in our knowledge, compassionate in our care and people of godly character. Both parties are responsible to hold the other accountable for their respective actions. A clinical relationship made up of a responsible patient and a responsible clinician is the only possible way optimized health can occur. This is the kind of optimized care we would like as a patient and it’s the kind of care we offer to our patients. 

Not All Counseling is the Same...

“What kind of counseling do you offer?”

The type of counseling we offer will vary depending on the kind of problem a person is struggling with.  We do not use a “one-size fits all” approach at Trinity Institute.  We use evidence-based medicine to guide us in selecting the best treatment for your diagnosed condition.  The idea is to work together with you to develop a plan that helps you optimize your health - body, mind, and soul.

“But my old therapist just let me talk for the whole hour…”

This refers to  something commonly known as “supportive counseling”.  Supportive Counseling is when the therapist allows the patient to talk for long periods of time and, in turn, offers supportive words and empathizes with the patient.  The therapist also works with the patient to recall effective coping skills they have used successfully in the past.  Although there is a time and place for this type of counseling (when a patient is in a crisis, for example), it has not shown to be effective in helping patients overcome problems such as worry, sadness, hopelessness, or fear.   Our treatment approaches are more active, dynamic, interactive and structured.  The goal is to give our patients a clear set of new skills that allows them to reclaim health and feel better. 

Competent Care

We strive to provide competent care for our patients. This begs the question of what we mean by competence. We rely on the standard definition of: an ability to do something successfully or efficiently. 

In our case we strive to be both successful AND efficient. In clinical care, competence is also understood to encompass a provider’s knowledge about their area of specialty and ability to provide that care appropriately. To ensure we are competent we have committed ourselves to being life long students and engage in continual educational opportunities. 

We are also committed to teaching clinicians in training. This requires us to be current in our clinical knowledge. In addition, teaching requires that we have a higher level of understanding of the material so that we not only apply it appropriately in clinical care but also can convey it to the student effectively. 

In the end, our commitment to competent care enables us to provide the best available care for a patient’s condition. It is the kind of care we would like as a patient and it is the kind of care we provide to our patients. 

Diagnosis Matters

Why is a diagnosis important?

We often have patients and their families ask us if having a specific diagnosis matters or “isn’t that just a label”.

Certainly, a diagnosis can be used just as a label, however, we strive to determine the most accurate diagnosis for a very different and important reason.

To explain, let’s begin with an illustration. If you speak a 2nd language then you may appreciate this comparison:

Words are powerful and have specific definitions. Many words have multiple meanings and as such can lead to some confusion or poor communication. The best chance for accurate communication occurs when a clear language is used.  This requires both engaged parties to utilize the same dictionary or definition for the words being used. 

This is also the case in psychiatric diagnoses. The Diagnostic and Statistical Manual (DSM), currently in the 5th edition, is maintained and updated with a primary goal of providing a common language for mental health clinicians in discussing the varied conditions that patients may experience. The DSM is the most comprehensive, widely studied and universally utilized language for psychiatric disorders in the USA and many other countries. 

Our goal is to provide the best evidence-based care for the patient’s diagnosis. Treatment studies use the DSM primarily to accurately identify and include patients who meet criteria for the mental disorder being studied. This ensures that a treatment is applicable to a specific diagnosis.

The most accurate diagnosis will enable us to utilize the best available treatments for that specific condition. The diagnosis is not ‘just a label’, but rather an orienting clinical concept that directs the provider in offering the patient the best path towards health. 

Updated Website and Content

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