Jordan, a new patient, comes to our psychiatry visit toting a bag full of medications. We start to discuss his psychiatric history. I ask about previous diagnoses and he replies, “everything,” noting the multiple diagnoses behind the stuffed bag. We dig further into his medication history and current prescriptions. Jordan’s not entirely sure which medications he’s supposed to be on, what they do, or when to take them. He recalls receiving one prescription in the emergency room, another from a primary care doctor, a third from a previous psychiatrist, and so on.
While Jordan’s case is extreme, variations of this scenario happen in mental health medication prescribing all too often. Current health care system constraints mean mental health care prescribing can be disjointed, hurried, and poorly coordinated, with inadequate follow-up. The result can be substandard prescribing practices, which may lead to poor outcomes and a frustrating experience for already-struggling patients. Numerous studies show that these systemic issues lead to lower patient satisfaction, worse outcomes, and a greater risk of patients not taking medications as prescribed. What follows are some of the key factors behind these poor outcomes.
A rushed system
Most mental health medication management today happens in primary care. Primary care physicians (PCPs) are strong partners in mental health prescribing since they understand the patient as a whole and are more available in the community. On the other hand, primary care visits are often short (15-20 minutes in some settings), so getting a patient’s full psychiatric history in that timeframe, on top of addressing the patient’s other medical concerns, is not easy. This strained system only contributes to the problems outlined below.
Getting the full history
A patient’s psychiatric history is complex. Not only are there symptoms to address, such as low mood, loss of interest in activities, and poor sleep, but there are also important contributing factors to consider before prescribing a medication. A patient’s full psychiatric history contains medical and social components as well—who are their support systems, where do they live or work, what substances are they using, what chronic medical illnesses do they have? In addition to getting that history, there is the overarching need for a level of comfort between patient and physician, given the sensitive nature of the information.
All of the components gathered from the patient’s history help form the assessment and treatment plan. At this stage, people can be misdiagnosed. For example, poor concentration can be a symptom of numerous conditions, including anxiety, attention deficit disorder (ADD), depression, and bipolar disorder. Let’s say the initial diagnosis is incorrect—that patient could then be stuck with the wrong diagnosis as they continue in care with other providers.
An ever-filled bag of medications
There are several different things that could explain how Jordan came to accumulate a bag full of medications in the first place. Some of those prescriptions may be for the wrong diagnosis. And others may have only been temporary. For example, certain short-term medications can help treat anxiety while a patient is waiting for the gold standard treatment (an SSRI) to take effect. Or, the patient may continue on the temporary medication indefinitely. Some of the medications may have been prescribed to treat temporary side effects. Meanwhile, others should have been stopped long ago once symptoms have been resolved, but were accidentally continued.
Even more concerning? Doctors sometimes prescribe medications without considering a patient’s characteristics. Then, when those medications are ineffective because they’re not the right fit or produce that person’s most despised side effect, a provider may prescribe yet another medication. Now the patient is on multiple medications to treat a single condition (otherwise known as “polypharmacy”), when a thoughtful review of their needs could have prevented this. Worse yet, the patient’s symptoms now take longer to improve. While there are rules to help guide mental health prescribing, they’re not always easy to implement in a time-strained system.
Insufficient follow-up
In the studies used to approve medications like antidepressants, participants are seen frequently (sometimes weekly), complete many assessments, and get lots of time with providers. In reality, follow-ups rarely happen that frequently, and a patient may stop taking their medication long before their follow-up appointment three months in the future. In other words, medications that work in studies may not work so well in our stressed health care systems, which could stem partly from having fewer touchpoints with care providers.
The need for shared decision-making
Probably the most important aspect of mental health prescribing is that the patient takes the medication they’re prescribed. Involving the patient in the decision-making process helps raise their chances of taking the medication. The patient should be central to this process–they may have particular side effects they are concerned about, or previous responses to a particular medication, and deserve to be part of an informed discussion. What’s more, a thorough consent process can prepare patients for a medication’s possible side effects and give them a sense of how long it will take to see benefits from the medication. This is especially important since side effects and not perceiving benefits are two major contributors to people discontinuing medication.
Let’s reconsider Jordan’s case. A longer appointment guided by structured questions and evidence-based material could help inform his assessment and treatment plan more effectively. In this case, Jordan may receive just one or two diagnoses rather than being diagnosed with “everything.” Shared decision-making and thorough, informed consent can help both Jordan and his physician decide together what medications make sense to start or not. And the proper follow-up and check-ins can help guide care along the way, so Jordan feels better faster.
Strange as it may sound, I love when patients bring in a bag full of medications—it can spark a crucial dialogue and occasionally, a mystery to be solved. Taking a thorough history, listening to the patient, involving them in medication decisions, and following them closely often leads to great outcomes. This is not only a win for the patient, but also incredibly satisfying to me as a physician seeking to improve the quality of mental health care.
DISCLAIMER
The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.
ABOUT THE AUTHOR
Smita Das, MD, PhD, MPH is Medical Director of Psychiatry at Lyra Health. She is an addiction psychiatrist and public health researcher, serving as a leader in local and national committees in psychiatry. She also practices at Stanford University School of Medicine, where she is a clinical assistant professor.
Prescription psychiatric medications are prevalent in the United States today, with about one in six U.S. adults taking medication to treat a mental health condition. While use of these medications is common and can be highly effective in treating conditions such as depression or anxiety, some stigma remains around taking them.
To help dispel some of the lingering misunderstandings about these medicines and shine light on key facts about their usage today, Lyra created a new infographic: Mental Health Medications in the U.S., by the Numbers.
This resource features statistics and trends about the current state of mental health prescribing in America, and aims to shed light on the following questions:
- What types of mental health medications are Americans taking?
- Who’s prescribing them?
- How easy is it to get an appointment with a psychiatrist?
- Who’s covering the cost of these medications?
Find answers to these and other questions about mental health medications in the U.S., in the new infographic.
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For employers who want to learn more about how Lyra’s enhanced EAP addresses network adequacy and quality issues, download our whitepaper on quality or get in touch.
And check in frequently here or follow us on Facebook, LinkedIn, and Twitter for more insights into supporting employees’ mental health.
DISCLAIMER: The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.
I first learned about mindfulness in graduate school. One of my professors led a course, and as a stressed-out student it sounded like the perfect escape. I remember feeling excited to finally find a bit of mental bliss and quiet.
Instead, I found myself impatiently waiting for everlasting peace, tranquility, and enlightenment. It almost never came, especially when I wanted it most. I would silently yell at myself, “C’mon, mind! Get to the part where I feel better!” I felt aggravated and defeated. Was I doing it wrong? Or worse, was there something wrong with me? As it turns out, I’m not the only one who’s had skewed expectations about mindfulness.
Mindfulness in pop culture
Over the past decade, mindfulness has exploded into the mainstream, and has been highly touted by everyone from Oprah and Katy Perry to Salesforce CEO Marc Benioff. And with good reason. Mounting research shows how beneficial mindfulness can be for a number of different issues.
In 2013, for example, a group of researchers pulled together more than 200 mindfulness-based studies, comprising over 12,000 participants. According to their research, these studies showed that mindfulness was especially helpful for people who struggle with anxiety and depression. Research like this can be encouraging. Taken out of context, however, mindfulness can easily be misconstrued as a panacea, or a shortcut to happily-ever-after.
Pop culture does a wonderful job of changing the context of mindfulness from being present to selling happiness. If you search for mindfulness on any browser, it won’t take long to find tips and tricks for using mindfulness to make you feel better. So it’s no wonder that many of us mistakenly use mindfulness with the hope of feeling better and/or finding relaxation.
What is mindfulness?
What do you think of when you read the word mindfulness? I used to get the image of someone sitting cross-legged on the floor, arms resting in their lap, eyes closed, trying to clear their mind. I’ve heard others mention positive imagery, breathing exercises, controlling emotions, inner peace, and staying present.
The confusion around mindfulness makes sense when you consider that even the research is uncertain about how to define it. However, there are a couple of themes that consistently pop up across the scientific literature. Jon Kabat-Zinn, one of the pioneers of westernized mindfulness practice, defines mindfulness as paying attention on purpose, in the present moment, and non-judgmentally. At first glance, this seems simple, but it’s worth unpacking.
Paying Attention: What we mean by paying attention is shifting the focus of our awareness. We frequently get caught up in the flow of our thoughts and never realize it. The moment you notice you are caught up in thought is the moment you have shifted your awareness from mindlessness to mindfulness.
On Purpose: This is all about intention – making the conscious decision to act on a given commitment. You do something because you choose to do it. When you combine it with paying attention, you get this: making the conscious decision to shift the focus of awareness.
In the Present: This is exactly what it sounds like – the here and now – except it’s not that easy. As soon as you notice this moment, it’s already gone. Rather than try to capture the now, mindfulness asks for us to notice the ongoing present as it is happening, in flight. When we put it together with the other two parts, you get this: making the conscious decision to shift the focus of awareness to the here and now.
Non-Judgmentally: This means being open and willing to have a full range of experiences, even the painful ones. Our minds are wonderful at making evaluations of others and ourselves. We typically qualify our life experiences as “good” or “bad” and react to these labels: do more of what’s good and less of what’s bad. In mindfulness, we work toward a willingness to sit with both pleasant and unpleasant experiences without attempting to avoid or change them. When we put all the pieces together, it reads like this: making the conscious decision to shift the focus of awareness to the here and now while being open to the range of our experiences.
Letting go of expectations
If you look back at Kabat-Zinn’s definition of mindfulness, the words peace, relaxation, and happiness aren’t included. Nor is there a reference to controlling painful and unwanted thoughts and feelings. In fact, mindfulness is just the opposite of searching for tranquility or avoiding unwanted experiences. The practice asks us to make room for, rather than suppress, even painful thoughts and feelings. This means holding expectations of outcome lightly, and noticing (i.e., paying attention to) whatever shows up.
One great way to practice non-judgmental mindfulness is to practice acceptance – and vice versa. There’s a Lyra blog about practicing acceptance, so I won’t reinvent that wheel. In the context of mindfulness, practicing acceptance can help you change your goal from seeking comfort and relief to allowing any and all thoughts, feelings, and sensations.
Research published this year shows just how important acceptance is when practicing mindfulness. This study randomly assigned 144 people who self-identified as stressed to three different types of mindfulness training programs: mindfulness with acceptance, mindfulness without acceptance, and mindfulness coping. It found that those who practiced mindfulness with acceptance were more likely than the other two groups to experience fewer physical markers of stress.
Earlier research showed that people who practiced mindfulness but were judgmental toward their experience struggled with their emotions as much as those who rarely practiced mindfulness. It’s no wonder, then, that people like me get frustrated when we spend our entire time during a mindfulness exercise focused on whether or not we feel more relaxed!
Letting go of bliss
It seems that chasing a positive outcome in mindfulness can be more harmful than helpful. So, what should you do instead? During your next session of mindfulness practice, intentionally attend to that part of your mind that searches for positivity, comfort, or relief. When that part of your mind shows up, simply let it be there without attempting to change or get rid of it. If a judgment shows up (e.g., “I shouldn’t be thinking this way”), observe it and let it pass in its own time.
Ironically, when you give up searching for inner bliss and stay open and willing to experience thoughts and feelings as they arise, it’s more likely you’ll find the very thing you gave up looking for. But don’t take my word for it. Try this out as a matter of experience.
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If you want additional support, Lyra can connect you to a behavioral health solution that is right for your needs. You can get started today if Lyra is offered by your employer.
And check in frequently here or follow us on Facebook, LinkedIn, and Twitter for more insights into optimal well-being.
DISCLAIMER
The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.
ABOUT THE AUTHOR
Zachary Isoma, Psy.D. is a clinical psychologist and co-owner of Harbor Psychology, serving the Greater Tampa Bay area. He specializes in practicing acceptance and commitment therapy (ACT) with men who struggle with anxiety and have difficulties expressing their thoughts and feelings. He is the founder of the Tampa Bay ACT peer consultation group and provides trainings, workshops, and seminars on ACT to students and professionals.