Are we there yet?
Reprinted from the "Medications" issue of Visions Journal, 2007, 4 (2), pp. 4-5
In 1996, two Harvard researchers with the World Health Organization (WHO) published a landmark book, The Global Burden of Disease.1 For the first time, the cost of illness was estimated using disability-adjusted life years (DALYs), which is the sum of years living with a disability and years lost due to premature death. One DALY is equal to the loss of one year of full health for one person.
This book identified five of the 10 leading causes of disability in the world as psychiatric disorders. Major depression was identified as the costliest illness in the world. The other four mental illnesses included alcohol use, self-inflicted injuries (i.e., suicide), manic-depressive illness and schizophrenia.1
These findings were a surprise because, historically, emphasis in medicine was placed on the effect and management of acute rather than chronic physical illness. In addition, many people are confused about the nature of mental illness. Some believe these disorders are diseases of the soul and spirit. Others understand that psychiatric symptoms are the result of disordered processes in the brain.
Modern psychiatry, however, views mental illness as a combination of genetic, biological, cultural and social effects, resulting in psychological symptoms. These factors result in an individual who is both the producer and the product of complex chemical events in their brain.
Development of specific medications for mental illness has paralleled the increase in our understanding of chemical events that occur during abnormal brain function.
Since the early 1950s, management of psychiatric disorders has included medication. For over 60 years, mental health and addictions researchers have been searching for ‘ideal’ medications.
Medications identified during the first 30 years were far from ideal. They did offer significant relief to individuals suffering from mental illness and worked quickly to calm individuals. However, they were not effective on all symptoms and were associated with a number of side effects.
The best medication is the one that works. For some people, it’s the older meds; for others, the newer. Side effects in newer medications are different, but not always better.
What makes an ‘ideal’ medication?
Regardless of the disorder, the characteristics of an ideal medication include:
effective on all symptoms
no side effects
no drug interactions
doesn’t wear off
Medications aid in deinstitutionalization
In 1913, British Columbia officially opened the Hospital for the Mind, later renamed Riverview Hospital. Riverview Hospital held more than 5,000 patients at its peak, but by 2007, patient numbers were less than 500.2
What happened? Medications that helped with psychiatric symptoms were identified—though researchers did not discover the cause or cure for mental illness.
Improving symptoms enabled individuals to participate in supportive programs. As a result, some individuals with mental illness could be completely managed within their community, while others only required hospitalization for stabilization of their symptoms. Many avoided the prolonged periods of institutionalization that had occurred in the past.
Today’s clinicians are increasingly aware of the issues and challenges in using medication. There are now more medications to try and more combinations of medications are used.
A patient’s age, sex and the presence of other medications and medical conditions affect treatment options and management. Medication use—in the young, the elderly and pregnant females, particularly—should be approached with caution, evaluating risks versus benefits. In some situations, the risks of not using medication are greater than exposure to medication.
These young, elderly and pregnant patient populations are rarely included in controlled clinical trials, because they pose additional risks to research studies. The elderly have numerous illnesses and medications; the young may not respond the same as an adult; and in pregnant women there is the risk of harm to the developing fetus. Therefore, evidence supporting medication use in these patients is frequently limited.
Are we there yet?
No. But we have come a long way. We are at a unique time in the management of mental illness. New evidence (see articles by Ric Procyshyn and Sylvia Zerjav) and a better understanding of psychiatric illness permit us to optimize treatment and to provide the best fit of medications to a patient, within an individual treatment plan. Future treatment management may include an individual’s ideal medication, along with the always necessary support to attain the goal of a healthy, active lifestyle.
Within this journal, you will discover articles on the past, the present and the future of medication use in mental illness. This issue of Visions offers a wide spectrum of practical information and professional and consumer perspectives on the challenges of medication use in mental illness. It also offers some hope for the future, as the discoveries of scientific and medical research accelerate.
About the authorDebbie is the Clinical Pharmacy Consultant in Psychiatry for Fraser Health, Mental Health and Addictions. She provides support and service to clients, families and staff from Burnaby to Boston Bar. Debbie is also a classroom and clinical instructor for the University of British Columbia Faculty of Pharmacy undergraduate program.
Murray, J.L. & Lopez, A.D. (Eds.). (1996). Global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: Harvard University Press.
Riverview Hospital: www.bcmhas.ca/AboutUs/History.htm.
Andreasen, N.C. & Black, D.W. (2001). Introductory textbook of Psychiatry (3rd ed.). Washington, DC: American Psychiatric Publishing Inc.