By Dr. Alex Dimitriu, 12/20/18

Even as the stigma associated with mental illness has – thankfully – dissipated over the last decade, millions of people still fail to get the help they need because the stigma around the medication that can alleviate their suffering endures. Fueled in part by celebrities talking about their struggles with depression, anxiety, and other conditions, openness about mental illness has become more acceptable. But even as people find understanding and support for their illness, they are also subject to a host of unhelpful and stigmatizing attitudes about medication, ranging from the implication that they’re just not trying hard enough to overcome their condition, to the recommendation that all they need is a certain diet, or exercise, or meditation, to the assumption that the cure for what ails them is as simple as taking a pill. Unfortunately, these attitudes are often internalized by the very people who could benefit from psychiatric medication and prevent them from seeking treatment.

The use of psychiatric medications, also known as psychotropics, has grown significantly in recent years. Various studies have estimated that 10% of American adults had taken an anti-depressant, anti-anxiety, or anti-psychotic drug in the previous thirty days and that as many as 17% filled a prescription for a psychiatric medication in the previous year. The growing usage of these drugs has led to widely shared and incorrect attitudes. At the same time, that many people see the use of psychiatric medication as a weakness or a failing on the part of the patient, others downplay the struggle of overcoming mental illness because ‘there’s a pill for that. It’s important to dispel misconceptions about mental illness and the best way to treat it.

Many years of research and clinical experience have proven that the best outcomes for those suffering from mental illness result from a comprehensive approach that combines a medically crafted and supervised regimen of psychiatric medication with psychotherapy. Medication and psychotherapy work together. By relieving severe symptoms, medication gives patients the clarity and stability that enable them to benefit from psychotherapy that can address emotional and behavioral issues and bring about the changes needed. Medication treats the physical aspects of mental illness, managing the levels of certain chemicals in the brain just as a statin manages levels of cholesterol in the blood. Taking medication for mental health is no different than taking it for physical health. With chemical imbalances in the brain under control, the patient is free to work on improving behavioral and emotional imbalances.

Common misconceptions that stigmatize psychiatric medication:

“Isn’t medication a crutch for people who are too weak to manage their problems?” A psychotropic medication relieves the symptoms of a medical disorder. It is no more an indication of weakness than taking medication for high blood pressure. Stigmatizing the taking of medication as a weakness implies that if the patient would just get it together and work harder, medication wouldn’t be necessary. This is akin to advising someone with high blood pressure to just relax. In fact, it takes strength to recognize that you have an illness that can be helped with medication and that you need to use every tool available to take care of yourself.

“Won’t a psychiatric medication change my personality, dull my senses, turn me into a zombie?” There is nothing more destructive to a person’s sense of self, to the unique characteristics that define a personality than a mental illness. Motivation, concentration, even the ability to get out of bed, are often gone. Medication can alleviate the symptoms of illness that sap energy and impair functioning and restore a sense of self. That said, some medications do have troublesome side effects, and the same drug can affect people differently. The medication that works for one person might not be tolerated well by another. That’s why we sometimes have to try several medications until we find the one that works.

“Is medication masking my problem rather than fixing it? Is it just a temporary solution, a quick fix?” Psychiatric medication is not a miracle cure. It doesn’t produce an instant change in mood. It takes a while for the drugs to build up in the system and causes a gradual change that alleviates symptoms enough to improve functioning and enable getting the therapy that will help over the longer term.

Psychiatric medication has helped countless people reclaim their lives. It is an important support for the journey to well-being, not an easy way out. And taking every step necessary to get well is nothing to be ashamed of. Bringing medication out of the shadows will overcome the stigma associated with it and encourage millions of people to get the help they need.

Alex Dimitriu, MD, is founder of Menlo Park Psychiatry & Sleep Medicine in Menlo Park, CA. He is dual board-certified in psychiatry and sleep medicine.

In people with both depression and insomnia, determining which disorder surfaced first may be key to improving clinical care.

Studying the timing of emergence of symptoms in people with both depression and insomnia may help identify differences in patients’ clinical presentation and aid treatment decisions, according to experts at the joint meeting of the American Academy of Sleep Medicine and the Sleep Research Society in Baltimore in June.

Insomnia is both a risk factor for depression and a symptom of depression, noted Rachel Manber, Ph.D., a professor of psychiatry and behavioral sciences at Stanford University School of Medicine.

Manber reported preliminary findings from the multisite Treatment of Insomnia and Depression (TRIAD) clinical trial, for which she is the principal investigator.

TRIAD, funded by the National Institute of Mental Health, seeks to determine whether combined treatment of major depressive disorder and insomnia improves depression outcome.

Started in 2008, TRIAD has enrolled about 150 participants, Manber told Psychiatric News. Recruitment recently concluded. Treatment will continue through the end of this year at Stanford, Duke University, and the University of Pittsburgh.

Participants receive 16 weeks of treatment with the antidepressants citalopram, sertraline, or desvenlafaxine. Choice of medication is based on the individual’s previous medication use, response, and tolerance. Participants also receive either cognitive-behavioral therapy for insomnia (CBTI) or desensitization psychotherapy for insomnia.

A pilot study, published by Manber and colleagues in the journal Sleep in April 2008, found that augmenting an antidepressant medication with brief, symptom-focused CBTI helped alleviate both depression and insomnia in individuals with both disorders.

About half the TRIAD participants reported at baseline that their insomnia started before their current depressive episode, Manber said. The remainder said their insomnia started at the same time as their depression or afterward. Members of both groups reported comparable severity of insomnia and depression.

In the first group, Manber said, insomnia may be independent of depression and require separate treatment.

If insomnia has emerged as a symptom of depression, she added, one might expect that treating the depression adequately will prompt the insomnia to resolve. While that often occurs, insomnia persists in some patients even after the depression remits. People who toss and turn often come to view the bed as a cue for poor sleep, she noted, and develop an insomnia disorder that needs additional sleep-focused treatment.

TRIAD participants who reported having insomnia before they experienced depression had higher scores on the Childhood Trauma Questionnaire, indicating childhood adversity such as sexual or other physical abuse. This surprising finding, Manber said, raises the possibility that events that disrupt sleep in childhood may foster both insomnia and depression later on.

In another report on TRIAD findings at the sleep meetings, Andrew Krystal, M.D., a professor of psychiatry and behavioral sciences at Duke University School of Medicine, analyzed participants’ responses to the Ford Insomnia in Response to Stress Test (FIRST).

The FIRST asks respondents about their likelihood of sleeping poorly after a bad day at work or an argument, before leaving on vacation, and in other situations. It assesses trait-like vulnerability to developing insomnia under stress.

“We were attempting to test a bias in the field that is not empirically based,” Krystal said, “that insomnia occurring in people with depression is driven by the depression and that there is a diminished etiologic role of factors that precipitate and/or perpetuate insomnia where depression or other conditions are not present.

“Our analysis appears to speak against that bias,” he said. It suggests that the same factors that seem to precipitate and/or perpetuate primary insomnia—which include dysfunctional beliefs and attitudes about sleep, worrying about sleep, stress, and anxiety—play a comparable role in insomnia that develops in people with depression.

The findings, he said, provide the first evidence that there is a trait vulnerability to developing insomnia under stress among at least some patients with major depression, similar to that in people with primary insomnia.