Dr. Rama's Feelings and Issues of Psychiatric and Medical Treatments Over the Years part 1--Anxiety Treatment In Psychiatry is Challenging and Limited--Dr. Rama

10/17/2013


This is a new series I would like to write about many nuances, issues, thoughts, opinions, feelings, suggestions and future vision of Health, Healing, Enlightenment, and Medicine.  I am starting with a series of treatments for various psychiatric medications and what I have learned and experienced over much time in practicing in this field.

Let it be first and foremost said that I advocate the middle path in treatment and I do not go to extremes in any case.

Conventional medicines of course I feel have their pluses and minuses--

In this blog post I am only rendering my opinions, thoughts, views, expressions, examples, insight and experiences over many years.

I am well aware it is always a blend of risks and benefits to patients with medications and various studies show mixed results, hopefully more positive with each med that is on the market.

However I would like to share what my feelings and thoughts are based on many years of treating patients in many settings and levels.

I am starting with anxiety treatment---


Anxiety in my opinion is one of the most challenging problem that faces physicians and health providers.  Psychiatry has had some breakthroughs but I find it the hardest to treat with conventional medicines

Benzodiazepines like valium, klonazepam and alprazolam, have their place and some people need short, medium and long term treatment.  Yet, I often find them difficult and problematic.  Often there is sedation, heaviness, sluggishness and fatigue (despite small doses) wear off and tolerance, cognitive confusion and memory changes.  Dependency on higher and higher doses do occur and when people try to stop or reduce benzodiazepines they have to go through slow tapers to avoid severe withdrawal side effects.  Also the problem is that there are ceilings of doses that most physicians do not step out of.  So then one is stuck with the situation where wear off has occurred and the person still has marked anxiety.

The other two knee-jerk, fairly vague and uncertain treatments in my opinion are to give hydroxyzine--an archaic antihistamine and Buspirone which is an anxiety medicine that acts on certain receptors in the brain to help with anxiety.

Hydroxyzine often does not work in my experience, is often a very temporary fix at best and causes dry mouth, dizziness fatigue sedation and confusion

Buspirone sometimes works for people but causes dizziness, foggy feelings, dry mouth and again some cogntive changes.

In medicine today it is quite cookbook and there are often a certain pattern in prescribing.  MD's go up the ladder to try various medications.

So sometimes the above medications are tried but sometimes antidepressants are initially used along with a benzodiazepine.

In my experience 50-70  percent give or take of patients do well on antidepressants to treat anxiety but more do better with combined benzos.  Sometimes all four medications are given--

The problem is is that it is easy to say that antidepressants like paroxetine, fluoxetine, sertraline, escitalpram, citalopram, and other related medications in the SSRI's family as well as venlafaxine, desvenlafaxine, and duloxetine SNRI medications work---..............

Yet in my experience many cannot tolerate these medications.  The main side effect?  Sexual of course!!--including a few other major side effects

We are in a society in a dilemma of sacrificing sex and sexuality or feeling better with these types of meds....

I often cross my fingers and hope that one or a combination of meds will help, but often I deal with highly variable with results.

Then when they do work, many people have the problem of battling with the decision to have long term maintenance therapy versus times when they taper off and see how they do.

Patients often tell me they often have to tolerate subtle background side effects because many tell me that they would rather feel better with meds than to give them entirely for the issue of experiencing on grade low dose toxicity or side effects.

Many people struggle with this issue of long term medication use;the usual answer given to patients is that people with diabetes, high blood pressure and so on have to take meds for the long term and it is the same with anxiety and depression---

And when people come down from antidepressants and anxiety medicines, whether they are controlled substances or not, many, many people have severe withdrawal effects.

In my opinion, the SSRI and SNRI side effects can be equally as difficult as the benzodiazepene withdrawal issues.

So there is often a merry go round circus of deciding if people's depression is due to relapse of  depression or whether it is the difficult symptoms of withdrawal when medications are lowered that people experience difficult symptoms---that is often a dilemna and often a question.  Sometimes it is one, neither or both......

I have found over many years that therapy interventions like psychotherapy, cognitive therapy, group support therapy are very hit and miss. 

Patients often say they "cannot afford therapy, the therapist is out of town, the patient is going on vacation or is too busy at home and work for therapy, there is no therapist available on their network, that they do not want to pay for Self therapy-or they say that they saw a therapist once or a few weeks or months ago but have not followed up--"---Self-help is also hard to gage---and patients and clinics including primary care tend to focus heavily on medications. Most of the time there is very LITTLE communication between therapist, MD and patient.  And also many psychiatrists find it hard to handle therapy issues when they are pressed to sometimes see anywhere from 15-40 people per day to keep up with their office costs and so on, as managed care is still volume driven with small amounts of time spent with patients.

This is changing somewhat---with a little more reimbursements for MD level extended med checks and therapy ---and with Obama care it remains to be seen if this can be improved or not.


Yet with all this, anxiety is one of the most common problem in the entire world.

I think there is a better model for all this ( I have a few ideas of course-----:) :) :) ) and I think that more and more natural treatments will continue to evolve and expand --- I think that natural interventions including natural plant and herbal extracts, the emphasis on gentle Yoga type practices, protocols from natural Western Medicine and ancient Eastern Medicine and other natural interventions need to be made more available and affordable.  Places where people can practice and reinforce these interventions is what is needed

Mastering anxiety is genetic but also under one's ability to improve, grow, change and transform.

I think what the main problem is is that conventional medicines go only so far and we are society that still depends on quick fixes.  It is up to the individual to take action and help as they feel ready and motivated. 

Centers now and in the near future I feel will provide atmospheres of growth and change and provide ongoing support for people to maintain changes in attitudes, behaviors, feelings, emotions, choices, thoughts along with both conventional and direct natural treatments

Dr. Rama