By / Jun 20

Midway through the last century, a prominent scientist named F.M. Burnet stated: “If one looks around the medical scene in North America or Australia, the most important current change he sees is the rapidly diminishing importance of infectious diseases. . . . With full use of the knowledge we already possess, the effective control of every important infectious disease . . . is possible.”

On the contrary, the wholesale control of infectious diseases—once presumed to be just around the corner—has yet to materialize. To be sure, remarkable progress has been made in our understanding, prevention and management of infections in the years since Dr. Burnet’s unrealized prediction. Advances in sanitation, hygiene, nutrition, diagnostic capabilities, antimicrobial therapies and immunization programs (to name but a few) have reshaped the world we live in and saved countless lives. But the assumption that civilization will one day marshal these medical resources to once-and-for-all regain an Edenic dominion over the whole realm of pathogenic microbes appears to be more hubris than anything else. Even as medical advancements are made and old foes are put in check, new challenges continue to arise.

Take for instance the concerning trend of antibiotic resistance[1]. The advent of affordable and effective antibiotics during the previous century was a major boon and understandably led to a high confidence in the medical community. But almost as soon as widespread use of these wonderdrugs began, reports of infections caused by resistant bacteria began to emerge. The incidence and clinical significance of antibiotic resistance have risen sharply ever since.

The Centers for Disease Control and Prevention currently estimates that two million people per year in the United States have serious illnesses due to drug-resistant bacteria, with nearly 23,000 deaths annually. Global surveillance has shown a steady trend of emerging antibiotic resistance, with new types of resistance to last-resort drugs appearing and spreading predictably. A recent report of a patient in Pennsylvania with a bacterial infection harboring a specific type of resistance not previously seen in the United States—the presence of the mcr-1 gene in E. coli, which causes it to be resistant to a last-resort antibiotic called colistin—has raised further concern. Many media outlets erroneously reported that the patient’s infection was resistant to all known antibiotics, but the difficult reality remains that the discovery of this new resistance mechanism (the last puzzle piece, so to speak) means that such pan-resistant infections are right around the corner.

It’s important to understand that these ever-encroaching public health threats have not come out of left field. This is the trajectory we have been on for quite some time. The emergence of resistance is a simple matter of natural adaptation for any bacteria exposed to the selective pressure of antibiotics. Even as an antibiotic is mowing down infectious pathogens (along with a host of innocent bystanders), small populations of bacteria seek to survive and adapt. If someone were trying to kill you, you’d try to squirm out of it too. In a sense, this is all that antibiotic resistance is—bacteria figuring out how to dodge or block the bullets being sent their way.

But just because it’s a natural process doesn’t mean we’re not partly responsible for the escalating problem. Inappropriate use of antibiotics fuels the engine that drives resistance and increases the number of difficult-to-treat infections. Common examples of inappropriate antibiotic use include taking antibiotics when they are not indicated (e.g., when you have a viral illness), treating bacterial infections with antibiotics that have an unnecessarily broad spectrum of activity (using a shotgun approach when you need the sharpshooter), and the overuse of antibiotics in food-producing animals.

Healthcare providers often talk about judicious use of antibiotics, though we are admittedly better at talking about it than practicing it. Even so, an encouraging emphasis has been placed on antibiotic stewardship, which is a commitment to use antibiotics appropriately and responsibly. In addition to getting healthcare providers committed to this, good stewardship also involves educating the community so that their expectations are well informed and they’re not tempted to pressure providers into bad prescribing practices.

The concept of stewardship brings us back to Eden. While we have no cause to think we can usher our world back to a paradisiacal state free from infectious diseases, neither should we adopt a slash-and-burn mentality. As God has intended from the beginning, we are called to be good stewards of the resources he provides. He put us here and told us to care for his creation, to toil and tend it, to thrive and flourish with it. If we do not live up to this calling, there are real consequences we must deal with. Most of us can see the sense in this when it comes to environmental resources, such as a rainforest, but it applies to his gifts of common grace as well. Inasmuch as it plays a role in helping human society thrive, medicine should be seen as a gift from God, a common grace which at times can offer a temporal restraint on sickness, suffering, and even death. Appropriate and responsible use of the medical resources God has put within our reach is a matter of good stewardship. If we abuse these gifts, we threaten our own well-being.

If we think of ourselves as conquerors of God’s creation rather than stewards of it, we will tend toward irresponsible and overreaching use of the good gifts he provides. Sometimes that means felling a rainforest, thinking we can just grow more. Sometimes it means using antibiotics injudiciously, thinking we’re in control of our infectious destiny. Hubris such as this has consequences. In this particular case, I’m finding the consequences increasingly difficult to treat with my dwindling repertoire of effective antibiotics.

Notes

  1. ^ In this article, I use the word ‘antibiotic’ to mean drugs intended to target bacterial pathogens (as opposed to other categories of anti-infective drugs such as antiviral, antifungal, and antiparasitic)
By / Sep 15

Let’s begin this discussion by placing the question in the correct category – whether an individual chooses to use psychotropic medication in their struggle with mental illness is a wisdom decision, not a moral decision. If someone is thinking, “Would it be bad for me to consider medication? Is it a sign of weak faith? Am I taking a short-cut in my walk with God?” then they are asking important questions (the potential use of medication) but they are placing them in the wrong category (morality instead of wisdom).[1]

Better questions would be:

  • How do I determine if medication would be a good fit for me and my struggle?
  • What types of relief should I expect medication to provide and what responsibilities would I still bear?
  • How would I determine if the relief I’m receiving warrants the side effects I may experience?
  • How do I determine the initial duration of time I should be on medication?

In order to answer these kinds of questions, I would recommend a six step process. This process will, in most cases, take six months or more to complete. But it often takes many months for doctors and patients to arrive at the most effective medication option, so this process does not elongate the normal duration of finding satisfactory medical treatment.

Having an intentional process is much more effective than making reactionary choices when the emotional pain (getting on medication) or unpleasant side effects (getting off medication) push you to “just want to do something different.” With a process in place, it is much more likely that what is done will provide the necessary information to make important decisions about the continuation or cessation of medication.

Preface: This six step process assumes that the individual considering medication is not a threat to themselves, a threat to others, and is capable of fulfilling basic life responsibilities related to their personal care, family, school, and work. If this is not the case, then a more prompt medical intervention or residential care would be warranted.

If you are unsure how well you or a friend is functioning, then begin with a medical consultation or counseling relationship. If you would like more time with your doctor than a diagnostic and prescription visit, then ask the receptionist if you can schedule an extended time with your physician for consultation on your symptoms and options.

STEP ONE – ASSESS LIFE AND STRUGGLE

Most struggles known as mental illness do not have a body-fluid test (i.e., blood, saliva, or urine) to verify their presence. We do not know a “normal range” for neurotransmitters like we do for cholesterol. The activity of the brain is too dynamic to make this kind of simple number test easy to obtain. Gaining neurological fluid samples would be highly intrusive and more traumatic than the information would be beneficial. Brain scans are not currently cost effective for this kind of medical screening and cannot yet give us the neurotransmitter differentiation we would need.

For these reasons, the diagnosis for whether a mental illness has a biological cause is currently a diagnosis-by-elimination in most cases. However, an important part of this initial assessment should be a visit to your primary care physician. In this visit you should:

  • Clearly describe the struggles / symptoms that you are experiencing.
  • Describe when each struggle / symptom began.
  • Describe the current severity of each struggle / symptom and how it developed.

As you prepare for this medical visit, it would be important to also consider:

  • What important life events, transitions, or stressors occurred around the time your struggle began?
  • What is the level of life-interference you are experiencing as a result of your struggle?
  • What lifestyle of relational changes would significantly impact the struggle that you’re facing?

STEP TWO – MAKE NEEDED NON-MEDICAL CHANGES

Medication will never make us healthier than our current choices allow. Our lifestyle is the “ceiling” for our mental health; we will never be sustainable happier than our beliefs and choices allow. Medication can correct some biological causes and diminish the impact of environmental causes to our struggles. But medication cannot raise our “mental health potential” above what our lifestyle allows.

Too often we want medication to make-over our unhealthy life choices in the same way we expect a multi-vitamin to transform our unhealthy diet. We assume that the first step towards feeling better is receiving a diagnosis and prescription. This may be the case, and there is no shame if it is, but it need not be our guiding assumption.

Look at the lifestyle, beliefs, and relational changes that your assessment in step one would require. If there are choices that you could make to reduce the intensity of your struggle, are you willing to make them? Undoubtedly these changes will be hard, or you would have already done so. But they are essential if you want to use medication wisely.

As you identify these changes, assess the areas of sleep, diet, and exercise. Sleep is vital to the replenishing of the brain. Diet is the beginning of brain chemistry – our body can only create neurotransmitters from the nutrition we provide it. Exercise, particularly cardiovascular, has many benefits for countering the biological stress response (a primary contributor to poor mental health). Your first “prescription” should be eight hours of sleep, a balanced diet high in antioxidants, and cardiovascular exercise for at least thirty minutes three days a week.[2]

A key indicator of whether we are using psychotropic medication wisely is whether we are (a) using medication as a tool to assist us in making needed lifestyle and relational changes, or (b) using medication as an alternative to having to make these changes. “Option A” is wise. “Option B” results in over-medication or feeling like “medication didn’t work either” as we continually try to compensate medically for our volitional neglect of our mental health.

STEP THREE – DETERMINE THE NON-MEDICATED BASE-LINE FOR YOUR MOOD AND LIFE FUNCTIONING

This is an important, and often neglected, step. Any medication is going to have side effects. The most frequent reason people stop taking psychotropic medications, other than cost, is because of their side effects.

If we are not careful, we will merely want to feel better than we do “now.” Initially “now” will be how we feel without medication. Later “now” will be how we feel with medication’s side effects. In order to avoid this unending cycle, we need to have a baseline of how we feel when we live optimally off of medication.

One of the reasons postulated for why placebos often have as beneficial an effect as psychotropic medication is the absence of side effects. Those who take a placebo get all the benefits of hope (doing something they expect to improve their life) without any unpleasant side effects. Getting the baseline measurement of how life goes when you simply practice “good mental hygiene” is an important way to account for this effect.

“As I practice medicine these days, my first question when a patient comes with a new problem is not what new disease he has. Now I wonder what side effects he is having and which drug is causing it (p. 191).” Charles Hodges, M.D. in Good Mood Bad Mood

There is another often over-looked benefit of step three. Frequently people get serious about living more healthily at the same time life has gotten hard enough to begin taking medication. This introduces two interventions (medication and new life practices), maybe three or four (often people also begin counseling or being more open with friends who offer care and support), at the same time. It becomes very difficult to discern which intervention accounts for their improvements.

Writing out your answers to these questions will help you discern if you need to move on to step four and make the needed assessment in step five.

  • What were the struggles that initially made me think I might benefit from medication?
  • How intense were these struggles and how did they manifest themselves?
  • What changes did I make in my lifestyle and relationships to alleviate these struggles?
  • How effective was I at being able to make the needed changes?
  • How much relief did the lifestyle and relational changes provide for my struggles?
  • How do I anticipate medication would assist me in being more effective at these changes?

STEP FOUR – BEGIN A MEDICATION TRIAL

If your struggles persist to a degree that is impairing your day-to-day functioning, then you should seek out a physician or psychiatrist for advisement about medical options. As you have this conversation, consider asking your physician the following questions:

  • What are the different medication options available for the struggle I’m facing?
  • What does each medication do that impacts this struggle?
  • What are the most common side effects for each medication?
  • How long does it take this medication before it is in full effect?
  • If I chose to come off this medication, what is the process for doing so?
  • What have been the most common affirmations and complaints of other patients on this medication?

These questions should help you work with your doctor to determine which medication would be best for you. Remember, you have a voice in this process and should seek to be an informed consumer with your medical treatment; in the same way you would for any other product or service you purchase.

In this consultation you also want to decide upon the initial period of time for which you will remain on the medication (unless you experience a significant side effect from the medication). In determining this length of time, you would want to consider:

  • Your physician or psychiatrist will make recommendations based upon additional factors not considered in this article
  • A minimum of at least twice the length of time it takes the medication to reach its full effect
  • Significant life stressors that would predictably arise during this trial period (e.g., planning a wedding)
  • How long it would take to make and solidify changes that were difficult to make without medication (see step three)

Once you determine this set period of time, your goal is to continue implementing the changes you began in step three while monitoring (a) the level of progress in your area of struggle and (b) any side effects from the medication.

STEP FIVE – ASSESS LEVEL OF PROGRESS AGAINST THE MEDICATION SIDE EFFECTS

Near the end of the trial period, you want to return to the life assessment questions you answered at the end of step three. Compare how you are able to enjoy and engage life at this point with your answers then. The questions you want to ask are:

  • What benefits have you seen while you were on medication?
  • What side effects have you experienced?
  • Is there reason to believe your continued improvement is contingent upon your continued use of medication?
  • Are the side effects of medication worth the benefit it provides?

The more specific you were in your answers at the end of step three, the easier it will be to evaluate your experience at the end of step five. At this point, try to be neither pro-medication nor anti-medication. Your goal is to live as full and enjoyable a life as possible. It is neither better nor worse if medication is or is not part of that optimal life.

STEP SIX – DETERMINE WHETHER TO REMAIN ON MEDICATION

At this point in the process there are several options available to you; this is more than a yes-no decision. But any option should be decided in consultation with your prescribing physician or psychiatrist. You can decide to:

  • Remain on medication because the effects are beneficial and the side effects are minimal or worth it.
  • Opt to stage off of your medication because the benefits were minimal or the side effects worse than the benefits.
  • Stage off medication to see if the progress you made can be maintained without medication; knowing you are free to resume the medication if not without any sense of failure.
  • Opt to try a different medication for another set period of time based on what you learned from the initial experience.

Regardless of what you choose, by following this process you can have the assurance that you are making an informed decision about what is the best choice for you.

[1] For more on understanding the choice about psychotropic medications as a wisdom issue, I would recommend the lecture “Understanding Psychiatric Treatments” by Michael Emlet, MD at the 2011 CCEF conference on “Psychiatric Disorders.”

[2] Additional guidance on this kind of “life hygiene” can be found at bradhambrick.com/burnout.

This article was orignally published here.