important triangle between the physician, the patient & their psychiatric medications

8/2/2019 Important Triangle Between the Physician, The Patient & Their Psychiatric Medications

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Important Triangle Between the Physician, the Patient & their Psychiatric Medications

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Spec ia l In te rv iew w i th Dr .Hashem on the Impor tan t

Tr iang le Be tw een the Phys ic ian , the Pa t ient & the i rPsych ia t r i c Med ica t ions

( published in Summer 2011 Issue of Empowerment magazine http://www.empowermentmagazine.org/

Pages/DoctorHazemHashem.aspx)

INTERVIEWER:

Medica t ions he lp peop le fee lbe t t e r , but do peop led i sempower themse lves

w hen they g ive a l l the cred i t

to med ica t ions dur ing thehea l ing process?

DR. HASHEM: Absolutely. Thats a very good

point, actually. I dont feel medication by any

means is the only reason people get better orworse in certain cases. As we just mentioned,

the perception people have about theircondition is also paramount. Placebo is aperfect example. I read an article that said

drug companies are having big problems with

INTERVIEWER: So the heal ing t ime can

also vary f rom person to person?

DR. HASHEM: Yes. Two of the main factors areperson to person and from condition to condition. In

my clinical observation, we generally tell the patients

it takes about four to six weeks in order to see anynoticeable effects. In the cases of some new

medication such as serotonergics, which include

SSRIs for depression, we observed some who sawimprovement in three days, some people improved

in a week, some people took two weeks, and some

people took four weeks. But in general, the cardinalrule is not to give up on the medicine for at least four

to six weeks. Now, another factor is the prescribeddosage of a medication. For example, many peopleare familiar with taking Tylenol. Commonly, most

people take two Tylenol tablets for the normal

INTERVIEWER: Why do

psych ia t r i st s somet imes o rde r l ab

t e s t s?

DR. HASHEM: Lab tests are useful for certain

conditions. Some depression, for example,

can be caused by low thyroid function. Thethyroid is a very important hormone producing

gland located in the lower part of the neck. In

this case, anti-depressants may be completelyineffective and lead to much frustration during

treatment. Sometimes there are no other

symptoms that can be observed to determineif a patients depression is caused by thyroid

dysfunction. After discovering this, it hasbecome standard to perform a test called TSHto check for this condition so we can begin

effective treatment. For other medications,

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the impact of placebo because the placebohas such a strong impact in the healing

process that placebo success rates often

surpassed the success rates of the actualmedication. The pharmaceutical company,

Merck, tried to create an antidepressant they

thought would be highly successful. Ironically,when confronted with the fact that they would

be trying a brand new highly successful

antidepressant, when they gave the controlgroup the placebo they felt better strictly by

the perception and the new medication couldnot be approved. We still dont fullyunderstand the effect of placebo or the ability

of the mind to heal itself, so I would say

perception by the patient is just as importantas the choice of medication.

In a large study early on it was found that thegroup of depressed patients received only

cognitive therapy with no medication improved

as much as the patients on medication alone.I recall when Prozac came out it was found to

be very helpful to a lot of people the issue of

how long to stay on medication came up. Inmy experience I found that when depressionis improved on medication the person actually

change their interaction with their environment

and people around them. This positiveinteraction feeds back into them positively. If

you can copy that positive interaction and

cognitive thinking and behavior and continueto do it without the medication you would be

able to get off the medication.

So somehow you need to learn that you are

feeding into the environment that is causing

some of the problems you are experiencing.

Your role in the environment is very important.In my experience, this method applies with

disorders like depression and anxiety. Bipolarand schizophrenia on the other hand, are

purely biological conditions. In these

situations in particular, the mind over matterapproach would not be the preferred method

and would probably have little effectiveness.

There is no doubt about it; I always encouragepeople to take steps in the way of cognitive

function which will eventually take place of the

antidepressant or anti-anxiety.

INTERVIEWER: Oft en p eopleg ive up on the i r med ica t ionsbecause they lose pat ience

headache. If you were to take just one tablet, yourheadache might not go away and you would believe

the medicine doesnt work. Its the same thing with

psychiatric medication. You can take one Prozac,and you may not get better. Your proper dose may

be two Prozacs, or three, or four. The dosage

normally goes up to 80 mg. So a rule of thumb, thatis generally not used when medications are given up

on, is that you should try a medication up to its

maximum dosage for up to six to eight weeks beforeabandoning it. If after this you continue to not see

results, then a medication can be deemedineffective. I believe giving up before this, is a littlepremature. What will help people strengthen their

faith in a medicine would be to think of their affliction

as a cut on a finger. One day of covering it with aband-aid will not complete the healing process.

Visualizing it like this helps when a condition is not

visual like a cut or scrape. Unfortunately, nerve cellsin the brain and the body are the slowest tissues to

heal.

Dr. Hazem Hashem

INTERVIEWER: How do psyc hiat r is ts

he lp empower peop le to acc omp l i sh

the i r t rea tmen t goa ls?

DR. HASHEM: In the last few years, Psychiatrists

have actually been cornered into just beingmedication prescribers. But we also my use the

short time we have to give cognitive therapeutic

such as lithium or Depakote, it has beenfound that the effectiveness of the drug is

based on how much is actually being

absorbed into your system. You need acertain level of the medicine in your blood in

order for the medication to be effective. Above

that level, it may give cause side effectswithout additional benefit and below that

range is ineffective. In the case of l ithium,

monitoring the level in the blood is veryimportant. Lithium is excreted in the kidney.

If you have a fast kidney, you will need morelithium than someone who has a slow kidneyin order to reach the ideal level in the blood.

This is why therapeutic treatment sometimes

must also be complimented with lab tests tocomplete the treatment process.

INTERVIEWER: So as oppo sed t o aspeci f ic doesage, one must look

a t how the med ica t i on i si n te rac t i ng w i t h the i nd i v idua ls

body?

DR. HASHEM: Exactly. There is also anotherrealm of lab work we use in order to tell is a

medication is doing harm to a patients body

or is creating an adverse reaction when mixedwith another medication. For example,

Depakote, Tegretol or other seizure

medications tend to sometimes harm the liverat a very slow pace. We periodically check

liver function and keep track of a patients

blood count to make sure these harmfuleffects are not occurring. Commonly, with new

second-generation antipsychotics like

Zyprexa, Seroquel and Abilify, , it was foundthere was a high percentage of patients who

developed diabetes and high cholesterol while

on these medications. In those cases we willclosely monitor weight, BMI, blood sugar and

cholesterol.

INTERVIEWER: So reinforcementof o ther s t ra t eg ies - cogni t ive

behaviora l , phys ica l , sp i r i tua l , e tc .

i s ve ry impor tan t i n thet rea tmen t p rocess?

DR. HASHEM: Definitely. But in medicine we

learnt not to say always or never. So in manyof the cases of depression or anxiety, the

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wh i le w a i t i ng fo r resu l ts ,

s i nce mos t peop le won t fee l

be t te r r igh t away . How longdoes it t ake fo r mos t

psych iat r i c m ed ica t i ons toge t i n to the sys tem and s ta r t

no t iceab ly he lp ing?

DR. HASHEM: This is a very important aspect

of treatment. Interestingly, a national studywas done by the National Institute of Mental

Health, called the CATIE. This study dispelled

a common belief among mental health staffthat patients stop taking their medications

primarily due to side effects. Actually, the

study showed the number one reason patientsstopped taking their medication is because

they believe the medication is not working.

The time in which a medication begins tobecome effective varies from condition to

condition and from person to person. In

conditions such as depression orschizophrenia, one theory is that receptors in

the brain seem to change in patients afflicted

with these conditions. The problem can varyfrom these receptors malfunctioning, to the

presence of too many receptors or too few. In

order to heal these receptors, the body takestime to repair them effectively. The medication

itself may affect the neurotransmitters

immediately, but that healing process in thebody does take time to complete. This is

where some individuals may become impatient

hints. The most empowered patient is a patient whois knowledgeable about their condition. This is the

foundation of empowerment. This is why I always

encourage people to research on internet, look uptheir symptoms and read about the conditions, read

about the medications, and read about the different

side effects and things like that. In some cases, thedoctor may miss to ask the right questions. This can

lead to a physician missing important clues to a

patients condition, inevitably resulting inmisdiagnosis. When a patient says I read about a

particular condition and I feel it fit me perfectly.

I amhappy to discuss and match their symptoms with theright treatment. Doctors should not feel insulted by

that. Much to the contrary, it is very helpful for the

person to know exactly what symptoms theyredealing with. So I also ask people to put every

symptom they have on a scale of one to ten before

we start treatment and a number after treatment.Each time we readjust the dose or change a

medicine. This way, youre actually giving the doctor

a good picture of whether the medicine has workedor not. If a patient is not aware of or doesnt keep

track of their symptoms, the medicine may have

worked perfectly, but they deem it ineffectivebecause they themselves were not aware of the

changes taking place. So it is very important for both

the doctor and the patient to recognize what hasbeen achieved and what has yet to be achieved.

Knowing a patients preference is also helpful in the

treatment. In some cases a patient might say,oh, Iheard horrible things about Zyprexa, or Prozac or

any drug for that matter. If the doctor continues to

insist on giving that medication anyway, the patientmay be reluctant to take it. Additionally, the patient

will most likely give a negative report on the

medications effectiveness since they already have a

bad impression of the medication anyway. So it isvery important for the patient to know what they are

taking and to be educated on exactly how they arebeing treated

cognitive and behavioral and the spiritualaspects of treatment are as powerful as or

more powerful than the medication itself. This

also has no side effects, obviously, becausemedication has side effects that you dont

want. Sometimes in the absence of this

cognitive approach, no antidepressant canseem to work.

INTERVIEWER: What c an peopl e

do to t ake more pe rsona lresponsib i l i ty for the i r heal th?

DR. HASHEM: Complete awareness of your

condition and treatment, in addition, a basicknowledge of what constitutes a healthy

person. I actually like the spiritual aspect of

thinking. The spiritual aspect of life gives uskind of reassurance, some degree of faith that

takes away the sense of the depression.

When you always feel that there is a higher

power, you always feel that there is a hopeand there is a reason. I think, spirituality also,

in all religion and all philosophies, encouragesyou to be healthy. All the exercises in all thereligions are meant to keep you healthy. A

healthy body has a healthy mind and so forth.

So to take more responsibility for your healthis by being educated about health and being

aware of what produces negative results in

your body and your mind.



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INTERVIEWER: And, last bu t no t least , i s psych ia t ry a sc ience or an ar t o r bo th?

DR. HASHEM: Well, I think psychiatry is primarily a science, and I would say its art that uses science. There are a lot

of things that take this form, like computer graphics for example. Its art thats using the science. The reason is we are

not going to use any medication without a scientific experiment or testing that proves beyond doubt that this medicine isreally effective in this group of people. Unfortunately, to do that, they have to pick patients who have only mostly pure,

single conditions and change the environment so it will be very specific to this condition and use this medication in

that context and prove that his medicine works for this condition. On the other hand, humans are not created based ona textbook. God did not open the DSM to put the specific criteria in different people. All patients are a mix of different

things. Nothing is exactly the same as the textbook. Nobody has one pure condition, or two or three, with all the other

factors that get involved in that. So I would say that the science is actually the proof that each single medicine clearly hasa function. The art is mixing all this together; matching medication together with people and conditions. This perfect

balance cannot be taught and must be acquired through experience, observations, involvement, notions and feelings. That

I believe is the definition of art.

Dr. Hazem Hashem is the medical director of Visions Unlimited and Wellness and Recovery Center North.

He is also Chief Psychiat rist/ Chief of mental health at Solano State Prison, and Board Certified ingeneral psychiatry and Forensic Psychiatrist.

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important triangle between the physician, the patient & their psychiatric medications

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