On pride and prejudice... (not the book)

I have previously discussed aspects of the discrimination against people with mental illness. Specifically, I have spoken about it in the context of romantic relationships, how remaining together “in sickness and in health” means in health and in most other illnesses expect psychiatric ones. And of course, intimate relationships are not the only context this occurs in. Even in the health industry there is a deep-seated contempt of those coming into hospital medical departments with wounds that are related to a psychiatric disturbance. But what I find even more bizarre is how people can discriminate against themselves, often denying themselves a better existence, because of a connotation to mental illness!

In my job I meet a lot of people, people who we as medical professional often create. Almost every health professional can tell you a story about “some junkie”, a person with a substance addiction that they met along the way. But there’s a particular sort of person that we at times encounter and we don’t immediately think of as “a junkie” but we know that they’re addicted to prescription medication. In my experience, it’s usually the benzodiazepines class of drugs, the Valium-type medications. There’s a few main reasons why benzos are particularly good to get yourself hooked on: 1) they work, 2) gives you immediate ‘results’, and 3) doctors have fewer qualms about prescribing it than other dependence-forming drugs.

A scenario I see very often, and which I admit frustrates me to my core every time, is the young man coming in to see me for his repeat valium (diazepam) prescription. I ask why he’s on it. He says anxiety. I ask how long he’s been on it. He says years. I ask why. He says for anxiety; it’s really “good” at “treating” it. I ask how much he takes. He takes it “only” 2-3 times a day. I do the sums – he is taking huge amounts of it! I ask why he never had his “anxiety” treated, why he didn’t get proper treatment, why he never had counselling, why he isn’t on more appropriate medication. He says it’s because he doesn’t get “anxiety” that often or that it is not very severe; he only uses the tablets every 5 or 6 of the 7 days in a week, 2-3 times a day.

Usually at this stage my heart sinks because the next part of the conversation is also very predictable. I ask does he know it is very addictive. Yes, he knows, but he only takes it when he needs it, those 2-3 times a day on those 5-6 days a week. Again I ask why he takes it (yes, I always pray the patient will have an epiphany – and no, they never do). He takes it for anxiety, of course. I tell him that it must be pretty devastating to be feeling anxious to the point of needing external relief 2-3 times a day almost everyday; surely that would be very uncomfortable. Yes, he tells me, it is pretty unfortunate – but luckily the drugs are so good at “treating” it that as soon as he takes one, within minutes he feels better. I offer a friendly suggestion: wouldn’t it be better to be able to function without having to feel so anxious almost all the time, wouldn’t it be great to be free of the anxiety? Yes, he concedes. Good, I am relieved he agrees! I say ‘ok, let’s get rid of the anxiety then’ (usually I’ll have figured out by this stage that this guy has no time or patience for psychotherapy, he prefers a pill, even a bandaid if that would do it). I suggest this tablet, you take it only once a day, it’s safe, not addictive, and it has a longer time of action so you need only take it once and you won’t have those flare ups of anxiety at random times during the day or week. He doesn’t believe that’s possible. I assure him, it is; in fact if he takes it everyday he won’t even need the valium for those random daily attacks of anxiety because he just won’t be having them anymore!

He has a question for me now: is the medication I am talking about also called an antidepressant? I say, well, it is an SSRI medication which are classed as such, but has a mode of action that will relieve him of his symptoms. At this point he says No!.. But, but, why? He tells me the story again about his anxiety not being that bad, he doesn’t get the symptoms that often (only 3 times a day, 6 days a week), he’s not depressed, he doesn’t need an antidepressant tablet, he’s not crazy, why change what is working, etc., etc. I explain in vain that what he is taking currently, the valium, isn’t working because if it was he wouldn’t need it everyday, multiple times a day. He assures me it does work, because he takes it and he feels better… and eventually I realize that no-one has ever made a person addicted to a substance rationalise about their dependency. It’s the very nature of addiction, there are no great epiphanies – at least not about why ‘feeling good’ is bad. And it breaks my heart that this person would rather take a tablet with much less stigma amongst prescription pills, almost with the status that alcohol has compared to illegal substances, than take the one he really needs. And he makes his choice because of the association this other medication has to “bad things”: a mental illness such as depression. Apparently it’s a matter of shame to have ANY association to mental illness.

Let me now tell you of another class of patient. He also doesn’t want to be thought of as mentally ill. Luckily for him, he isn’t! He has this condition, a complex pain syndrome, a condition that is very difficult to treat. I met a man once who had been diagnosed as having fibromyalgia. The poor guy, was such a shame to see him; he was in discomfort and pain all the time. He had seen a lot of GPs, a few specialists, spent hundreds on natural remedies and iridologists, spoke to anyone that might be interested and asked for help. Eventually one medical specialist got him started on a medication he hadn’t tried before. He didn’t get his hopes up because he had tried many many medications with no relief. But, amazingly, this one worked! He was free from pain; it’d been months, maybe years since he felt so ‘normal’. And then one day he picked up his tablets from the pharmacy and started to read the consumer information page in the pack. And then he read in there that this drug was a TCA – and that the A in that means antidepressant! He was furious, disgusted, so angry at the doctor that told him to take it. It didn’t matter that the tablet alleviated his symptoms; what was intolerable about it was its name, its association. He stopped taking it immediately and attended his doctor to express his disgust.

I spoke to him a few months afterwards, his face was all cringed and he seemed in a lot of pain. He told me the story of what had happened and about how disgusted he was that the doctor had offended him by giving him an antidepressant for his fibromyalgia. He imagined that the doctor thought he was “crazy”, that he was only pretending to be in pain, etc. I let him speak and then I asked it the medication had worked, though. Yes, he said it had – but that was not the point. My heart again sank a little and I explained to him (gently, not trying to tell him what to do), that the TCA type of drugs are commonly used for some types of pain, and that they are very effective. I said they are called tricyclic antidepressants because their original purpose was to be used as an antidepressant but this new use for them had been found and it was great for pain of that particular sort. Yep, good story, Vanessa; he believed me because he knew I have a medical degree, but pride isn’t always about having rational or accurate information. Poor guy, I still see him in so much pain.

Now I’m going to deflect a little to tell you about something I initially thought about when I was at university. There was a ‘gay rights’ rally and in response to someone’s judgement that homosexuality is a disease and a social evil etc., someone had made a banner saying “homophobia is a disease”. It was like the perfect comeback. Only I’m a nerd who probably overthinks things and I was at the time studying medical microbiology and infectious diseases, so I immediately thought: cancer is a disease too. The point is no-one chooses to suddenly grow a cancer because they want to endanger their life or a limb or organ, or because they like to suffer. Most of us can at least empathize on seeing a person sick with cancer, ravaged either by disease or chemotherapy. I have never met anyone who would discriminate negatively against someone with cancer, someone with a disease they did not ask for, a disease that is beyond their control. Mental illnesses are a disease also, something no-one asks for or can internally control. Why should we accept that it is OK to discriminate against those suffering an illness? It’s sad that almost any reference to mental illness, whether people, disease processes, and even the medications used to treat it, still attract such great discrimination. Maybe the time for a new human rights movement is arriving.