Category Archives: Psychiatric Medications

July 16, 2009 · 5:16 am

Rwanda Day 7


Started the day as usual with some quiet meditative reading on the porch overlooking the lake and the distant sound of many children getting water on the other side (yelling Muzungu (white person) to get my attention). Diane read us this quote from John Fawcett’s “Christ’s Precious” (published by W. Milner in 1839, p. 82)

I am but a stranger in this world, wherever I may be situated, or however I may happen to be distinguished. And such, it is my privilege that I am so. [However] when I look not upon myself as a stranger and a pilgrim, when I am captivated with anything in this place of my exile, I forget myself, and act far beneath my character, as a candidate for an immortal crown.

Fitting. It is easy in the US to forget our “exile” status. We focus, instead, on our own status. But here in Africa, there is little to do but remember how fragile life is and how we must depend on God for our daily existence.

Today we met with Justin Remera, a psychiatric nurse at Gahini hospital. The hospital was built in 1920s. He is the head of mental health. He sees some 30 patients per day and has a caseload of 500 with PTSD. He sees lots of “epilepsy” and has documented some 350 new cases in the past 2 years. But they have normal EEGs, thus it is trauma related not brain injury. Justin told us that there is an openness to therapy here because they see the benefits.

Problems noted by him? no medications other than Haldol. Infrastructure needs. His office is the size of a small closet and he has had violent patients and no escape (his desk and chair are away from the door). Also, next to his office are rooms where patients were screaming (while we were there). Seems they may have been doing some minor surgery without anesthetic. He also mentioned problems with demobilizing military and their own trauma as well as his own burnout.

Next we went to Kigali and met with the the permanent secretary of Defense. One of the persons there talked about having 520 peer counselors in the military to deal with the problem of HIV. Nothing dealing with PTSD. They have NO chaplains in their military.

Next, we visited the National Council of Protestant Churches of Rwanda. Specioise told us that 52% of the country are protestant. They have a program to deal with gender based violence, to educate the the church about laws designed to protect women. Their booklet combines Rwandan laws and biblical passages.

For our final meeting, we visited with Jean Baptiste at World Vision. He is new to WV in Rwanda but not new to WV (previously in Mali). He is a tall man with much presence. He spoke very openly and honestly about the issues of NGOs in the country and the problem of lukewarm Christians. He suggested they were much more problematic than rank atheists or Muslims. He gave us some advice as how to work with both churches and government officials. Josephine, a woman Diane had worked in Rwanda on previous trips, was there and spoke of the continued need to train and care for Rwandan caregivers.

Our day ended in Gahini with a farewell dinner. Members of the church and community (the local mayor) attended a dinner at the Seeds of Peace retreat houses. The dinner was outside under a canopy. During dinner we watched the local youth perform traditional dances with drums, singing and costumes. The young women danced with wooden milk bottles on their heads. We learned their trick. A heavy stone in the bottom of the bottle helps it stay on their head. Ouch! The night ended with gifts from our hosts to us and a few words of thanks from us.

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July 10, 2009 · 9:02 am

Rwanda Day Five


Today we visited Nsinda Prison (population 8000) to interview those convicted of genocide. As we pulled up to the prison we met a large group of prisoners returning to the prison from the fields. They had only 1 guard with a machine gun and another with a stick. Many prisoners carried produce. Again, it felt like we were transported back a century. It was a dusty ancient looking place with shirtless male prisoners carrying huge logs on their shoulders (for firewood for their cooking fires). We were ushered to a bare cinder block room with a log and metal roof. 4 stools were brought for us. One of us noticed several wasp hives attached to the roof. In walked 19 prisoners all accused and convicted of mass murder. Quite a few were women and two had babies. One baby nursed throughout the session. The one guard stood outside the room with the door open to the out of doors. We asked them about their experiences. These individuals denied much wrongdoing, felt their former government led them astray, confessed, asked for forgiveness but felt they were denied it. They espoused genocidal ideology in that Tutsis were accused of killing the president and succeeding in forcing out the Hutus in the country.

Oh, as we entered the prison, we were greeted with “Nothing but the Blood” in native tongue over a loudspeaker. Apparently, there was a church service going on. What a contrast between the song (which recognizes guilt and the need for cleansing and the perceived innocence of the genocidaires (“I only mutilated dead bodies.”)

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July 9, 2009 · 8:59 am

Rwanda Day Four


Spent the day traveling around Kigali. First stop was Ndera hospital, the only psychiatric hospital in the country. It sits atop a dusty hill just outside the city. Upon entering the gate and getting out of the cars, we were welcomed by patients asking for water and money. The hospital has a 19th century or impoverished cold war era feel about it. Sterile cement block buildings set in a square. Sparse is an overstatement. We learned many staff and patients were murdered during the genocide. This hospital has over 200 patients (but just 12 beds for children). Psychiatric nurses provide the bulk of the care. Their “intake” room had one chair, one table and very little light. Patients lie on the grass outside in various states of unhealth. They have many with PTSD and schizophrenia diagnoses. Their only medication is Haldol. No “atypicals” or newer medications. A woman started screaming just outside our door. Translated: “Why does everyone hate me?”

From this hospital we traveled to the National Memorial Center to tour the genocide museum and grounds where some 300,000 have been interred. I couldn’t handle the room filled with poster size pictures of young children in happier days. The small print told of their favorite foods and activities…and how they were hacked to death.

Another lunch with a Christian counselor, Ms. Paulette, who told of her counseling work and training of lay counselors. After lunch, we met with the executive secretary of the Commission to educate about and prevent genocide. This handsomely dressed man shows the signs of his own trauma. he desires our help to guide the country to remember in healthier ways. Right now they play videos of the actual genocide and so during their 100 day memorial (April to July) they see so much trauma responses. He wished us to start right away.

Here’s a thought in my head: Does Rwanda need us or do we need Rwanda. I am amazed at how community minded this country is. They have no choice. People sacrifice for the good of all. They make do with a little. They are action oriented and start doing things rather than waiting to get it right. Risk calculation is not part of their thinking. What amazing things we could do in this country if we would learn from these people on how to put neighbor ahead of self.

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May 22, 2009 · 8:49 am

Physiology Phriday: Side Effects of Meds


In a perfect world, our medicines would fix our problems and not create additional ones. Sadly, we don’t live in that world. Antidepressants may induce weight gain, foggy-headedness, flatness, impotence–things that wouldn’t necessarily make one feel better. Stimulants create problems with weight loss, rebound agitation, even tics in some individuals. Pain meds may create dependency.

Some encounter the side effects of psychotropic drugs and decide to tough it out. Others play around with dosages (on their own). Still others keep trying to find that right compound. All of it creates work. As a counselor, it is wise to monitor med compliance, dosage changes (doctor approved or otherwise) and side effects. Given that most clients see their medical doctor or psychiatrist only once every 6-8 weeks, do not assume they’ve talked to anyone or are still on their medications. Make sure to also ask how they feel about the meds as this may change. Even though the counselor isn’t in charge of medications, counseling issues related to the medication and the feelings about it surely are our domain. One clear benefit to our “med checks” is that we can help them get the most out of their 15 minutes with the psychiatrist by zeroing in on what they should talk to the doc about.

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May 1, 2009 · 5:42 am

Physiology Phriday: Dieting starves your brain?


I heard a psychiatrist recently tell her depressed client that she should not go on a diet to lose weight. The client was confused. She thought that losing weight would help her with her self-esteem. She had not been exercising and had put on 15 pounds over the past 3 years. So, she asked her doctor why not. This was the explanation (paraphrased):

Exercise does provide a natural antidepressant and so I heartily encourage you to start an exercise program. However, many diets consist of decreasing foods rich in carbohydrates. Getting more protein is good but your brain needs glucose to produce neurotransmitters (e.g., serotonin) and foods rich in carbs are more easily turned into glucose. When you starve your body of glucose, your brain is the first place that starves.

Maybe this explains a bit of yo-yo dieting. The person is feeling poorly about weight, reduces foods that provide simple sugars in order to lose weight, starves their brain of serotonin (thereby creating a greater feeling of depression), and then caves to a binge in order to feel better. 

Don’t know if this supposition is true, but it might be important for those on antidepressants to make sure that they are keeping a balanced diet and exercising frequently.

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April 17, 2009 · 5:28 am

Physiology Phriday: Will I be on meds for the rest of my life?


During the course of discussing a person’s anxiety or depression, the conversation turns to the possibility of using antidepressants. Inevitably, I am asked, will I have to take them forever? Clearly, the questioner does not want to and sees the possibility of taking medication for the rest of their life to be unacceptable. So much so that many resist starting or even going to see a psychiatrist in order to consider whether they might take a medication. Rarely do they ever ask if the medications will help.

Consider for a minute why a person might ask this question. Here’s some of the reasons I think I’m asked this question:

1. Everybody is on them and they never get off (from the viewpoint that too many people take them for every little hangnail and then allow themselves to stay on the crutch forever, never solving their problem)

2. Medicines are for weak people, I’m not weak. (Not sure if the person would have the same response if their medical doctor said their thyroid wasn’t working and so they would need synthroid for the rest of their life)

3. It is only a spiritual problem. Taking the medication will solve the problem but not the spiritual problem. I’ll be avoiding the real issues.

4. I hate medicines of all kind. I hate remembering to take them and I hate their side effects.

5. I don’t think they will really work.

Can you think of other reasons? Now, antidepressants do work from a research vantage point. They are not the silver bullet. They will not make a bitter, angry, depressed person, less bitter. They may help them sleep better, improve their mood, and thus more clearly come to terms with their bitterness. Medications never block the heart from spiritual matters. Only the person who does not want to deal with spiritual matters will use them to avoid looking more deeply inside. God can be found in both suffering and comfort. Whether we will look for him is a bigger question.

So, what if you need them for the rest of your life? What if they really do make it possible to function well? Is our distaste for medicines due to their side effects or due to the fact that we have to accept that we are weak and broken people?

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April 10, 2009 · 5:49 am

Psychiatric vs. Psychological evaluations: What is the difference?


In place of my usual physiology Phriday post, I give you this…

“I think I need a psychiatric evaluation? Can you test me?” These are some of the questions I get from time to time. And they reveal an ongoing confusion about testings, assessment, evaluations, the world of psychiatry, psychology, and neurology. Interestingly, if you type in “psychiatric evaluation” into wikipedia, you actually get redirected to an entry on psychological evaluations and testing. So, let me try to differentiate a bit here:

What is a psychiatric evaluation? It is done by a psychiatrist who is a physician with special psychiatry training (courses and residencies). This evaluation is comprehensive but medical in nature. Expect the person to ask for your physical, behavioral, and cognitive histories, order blood tests or other medical exams, evaluate (by observation and interview) your mood, your reality testing, and mental status etc. Ultimately, after an extensive (and usually expensive) interview, the doctor will arrive at a psychiatric diagnosis (if appropriate) and may also recommend medicines to help with the problem–which they can prescribe. A few also provide ongoing talk therapy but most do not. Rather, they recommend you find a therapist for that part. They will follow up with med checks as needed to titrate or refine your medicines. When a person has a very difficult, complex, or lengthy history of mental health, or, when the person is needing a diagnosis for legal reasons, a psychiatrist is a good choice. They are usually gifted at extracting subtle physical and behavioral matters that may help correctly pinpoint the problem. While a person might well get anti-depressants from their regular doctor, a good psychiatrist is better able to deal with complex matters and follow you more closely to get the right compound and dosage.

Neurological Evaluation. Stating the obvious, a physician with neurological specialties and qualifications does a neurological evaluation. Neurologists specialize in…wait for it…the nervous system (brain, spinal cord, and 12 cranial nerves). A neurological evaluation includes many of the things evaluated by psychiatrists but with special attention to your motor and sensory systems, your reflexes, and similar kinds of things. You might more likely see a neurologist when you obviously have a neurological issue. Neurologists are more likely to specialize in ADHD, brain injuries, and psychiatric problems that result from dementias or other known physical problems. They are often better able to give and interpret MRIs and other imaging that might be appropriate. They will also prescribe and follow medications.

Psychological Evaluation, AKA testing, psych assessment. These are offered, mostly, by doctoral level psychologists. These evaluations will cover much of the same history, mental status, and provide diagnoses when appropriate. Interviews, just like the previous two options, are essential. However, what sets psychological evaluation apart is its use of standardized tests. These may be paper and pencil or electronic. They may be filled out by the client or by family members. The results provide a snapshot of behavior, or cognitive functioning, or mood by contrasting the individual results against a peer group. For example, a child may complete a computerized test to assess attention span. The results are compared to thousands of children taking this test who either are “non ADHD” and or ADHD. A good psychologist collects data from multiple data points (test data, interviews by client and maybe family, observations, etc.) and uses that data to make interpretations and recommendations for ongoing care. Usually, the best psychological evaluations begin with a very objective, specific question. Just throwing a bunch of tests at a person to “see what comes up” isn’t all that helpful. Just because something pops up doesn’t mean it is meaningful.

It is true that masters level therapists (licensed or not) give and interpret some tests. But most of the best tests can only be given and interpreted by doctoral level, licensed psychologists.

There are other types of evaluations. Neuropsychologists are doctoral psychologists with specialized training and help pinpoint brain injury, unravel more complex learning disabilities, etc. Neuropsychiatric evaluations are done by another similar but slightly different professional. You can check out their interesting history on this wikipedia page.

So, how do you choose what is best for you? Answer a few questions.

1. What do I really want to know when it is all said and done? What might help me decide how to proceed? The more specific you are, the more likely you can get the answer you want.

2. Do I think I need to focus more on physical options or behavioral options?

3. Do I think I’m likely to need medications? The physician types are better. Psychologists cannot prescribe meds (unless you live in Hawaii or are in the military).

4. If I am given a diagnosis, what do I need it for? Both doctoral level psychologists and psychiatrists are capable of giving you diagnoses. However, some people or systems value one opinion over another. Figure out if it matters for your purposes.

5. Am I looking for specific behavioral/relational suggestions? Then psychological evaluations are more appropriate.

6. Am I looking to form an ongoing therapeutic talk based relationship? See the psychologist.

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March 13, 2009 · 3:38 am

Physiology Phriday: Anticipation and Anxiety


Anticipation and its relationship to anxiety.

This week we have been thinking about how we evaluate our world. Evaluations or judgements come from a variety of locations. Our expectations and desires prep us to look for certain kinds of “data.” Our histories and past perceptions prep us as well. Finally, what is actually happening is part of the data we use to evaluate ourselves and our world. Notice that we aren’t as logical and objective as we’d like to think. Instead, we ANTICIPATE life and then respond to data that fits into that anticipation.

The primary feature of chronic anxiety is that anticipation of negative, dangerous outcomes. The anxious person views ambiguous data (e.g., a boss who is grumpy, a funny feeling in the chest, etc.) and reads that data in the worst possible light (I’m going to get fired, I’m having a heart attack).

If the problem is bad habits in thought patterns, it would make sense that the treatment ought to be to challenge these logical fallacies with the truth. And while cognitive counseling does indeed work (clear data that one can challenge and reject anxious, ruminative thinking) most find that counseling stops anxiety from growing but doesn’t often stop it from starting in the first place. This struggle to fight anxiety leaves many Christians feeling quite guilty for not trusting God more. 

But what about the amygdala? There is significant research that anxious people have very activated flight/fight activity in the amygdala. In fact, brain scans of this area show greater activity in anxious people than non-anxious people even when they are responding to neutral events. Thus, the anxious person’s brain is in a chronic state of hypervigilance even when nothing is going on. Hypervigilance maintains higher levels of norepinephrine the body, which in turn keeps the adrenal system in high alert. Medications (of the SSRI and NSRI type) have the capacity to positively impact serotonin and Norepinephrine and thereby allow individuals to decrease the negative hormonal activity in the brain.

Which comes first?

So, does biological hyperactivity in the amygdala result from either bad experiences or bad thinking? Or does a predisposition towards overactivity of this part of the brain encourage negative and anxious thinking, forming a vicious cycle? 

Seems to me good treatment needn’t answer this question. Good treatment would include (a) medications that might make it easier to slow down the anxiety processes (biology and behavior), (b) recognition that vigilance can be directed via counseling work away from the feared object and to a better understanding of the brain, and finally (c) that one changes the goal from cessation from fear to a more godly and humble response to Jesus in their fear.

What I mean by (b) is that the anxious person see themselves as like unto a person with colorblindness or dyslexia. In each case, the brain functions in a way to send the wrong messages. The dyslexic person learns to recognize the problem and designs a means to compensate in order to truly see the right order of letters/words. The anxious person accepts that their brain sends certain messages but that their job is to stay remember that while something real is happening it is not necessarily the way their brain is putting the “facts” together. Thus, the work is not to remove the fear but to practice a better response to it.

Ironically, when the person reinterprets the stimulus differently, they do see a marked reduction in fear triggers.

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January 21, 2009 · 4:17 pm

Madness revisited


Yesterday I made mention of Marya Hornbacher’s On Madness: A Bipolar Life. Nearing the end today and I continue to be taken with her capacity to illustrate the experience of mania, of using it to successfully do great things and of being drop-kicked into depression, of repeated hospitalizations, of the experience of being snowed under by medications, of chaotic and fearful thought patterns, of the impact on relationships and more.

She writes of the experience of ECT treatments and the struggle to regain her ability to think, write, relate, remember. After many treatments and lengthy hospitalizations, she reflects on her more stable mind:

Much is lost to those two year of hospitalizations. I remember very little, because madness erases memory, and so does electroshock.

…Memory is not all that’s lost to madness. There are other kinds of damage, to the people in your life, to your sense of who you are and what you can do, to your future and the choices you’ll have. But there are some things gained. The years that have followed my decision to manage my mental illness have been challenging, sometimes painful, sometimes lovely. The life I life, even the person I am, is nearly unrecognizable compared to the life I had when madness was in control. There are things in common,obviously–my mental illness hasn’t gone anywhere, and it still, to some extent, shapes my every day. But the constant effort to learn to live with it, and live well, has changed the way I see it, the way I handle it, and it’s probably changed me. (pp. 216-7)

The interesting thing is these sentences are not the last words or the “happily ever after” of the book. In fact, she goes on to tell how she unravels again and finds herself back in the hospital. Later, she confirms that it is hard to accept sanity as normal when it FEELS like failure. She desires normal to be the manic days. And then she reveals why. When her therapist asks why everything has to be perfect, why it’s okay for others to be “good enough” but not for her she says,

“It’s that your pretty good is better than my perfect”.

I suspect many of us can relate to that sentiment even if not bi-polar.

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January 20, 2009 · 5:51 am

A window into the world of bipolar disorder


As a teacher I am on the constant prowl for books, movies, pictures, etc. that give a realistic and personal view of the experience of mental illness. I picked up a great book regarding the world of the Bipolar I person: Madness: A Bipolar Life, by Marya Hornbacher (Houghton-Mifflin, 2008).

Marya tells of her life in short chapters beginning with her memories of life as a 6 or 7 year old. It is less biography and more of a sampling of her thought and emotional life. She has severe highs that last for a couple years, severe lows, and many rapid cycling from high to low in a matter of minutes. You can help but get a sense of her inner world from times in the hospital (many times at that) to impact of her medications and the ineffective care by several psychiatrists.

She is also author of “Wasted”, a book about her anorexia and successful treatment. Ironically, while on her book tour for that book she was drunk most days (trying to control her mania), impulsive in every way, and completely out of control.  

If you check out her book on Amazon, you can search inside. See if you can read pages 11-13 (search for the word “goatman”) and get a rich and painful flavor of her inner world in 1978.

If anyone here as read “Wasted” feel free to let us know what you thought of it.

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