Prescriptions for Health: Believing in medicine

11 mins read
Dr. Art Dingley
Dr. Art Dingley

The weekly Prescriptions for Health column is part of an ongoing community health education effort by Franklin Memorial Hospital to provide information on an important health topic by its medical staff, with support from intern Sam Bennett, a junior at the University of Maine at Farmington majoring in biology and creative writing.

By Art Dingley, DO, JD

How do psychiatric medicines really work? First, medicine must be absorbed into the body. Medicines which are injected tend to act more rapidly because absorption is quicker, but some injected medicine is very long lasting. Some pills are made in timed-release forms, to slow down the absorption process. These may often be identified by a suffix, such as CR, ER, XL, or XR.

Once medicines are absorbed into the bloodstream, they pass, sooner or later, through the liver. The liver breaks down big molecules into smaller ones. This explains one way in which drugs can interact with one another. One medicine may cause the liver to speed up. This will make other medicines less effective because the liver breaks them down faster. Or, one medicine may monopolize the liver’s ability to break down certain kinds of molecules. This may cause blood levels of other medicines to rise.

Although the brain has a good blood supply, many medicines cannot get from the blood into the brain. We have a natural barrier, which is partly physical and partly chemical, to protect our brains against many foreign molecules.

Now, assuming we have a medicine which can be absorbed, withstand the liver, and cross into the brain, how does that medicine change brain chemistry? There are proteins called receptors on the surface of brain cells. Receptors normally interact with natural brain chemicals. If the drug is similar enough to the natural brain chemical, it can bind to the receptor. When this happens the receptor may be taken out of action for a while, or the receptor may respond by setting off a chemical chain reaction inside the brain cell. Medicines may also prevent the destruction of natural brain chemicals, causing levels of those chemicals to rise in the nervous system.

One frequent concern is “side effects.” Side effects occur because most medicines do more than one thing. For example, some medicines bind to more than one type of receptor. Some antidepressants bind to serotonin receptors and to receptors which ramp down nervous system activity. Depression gets better, but the patient feels tired. Sometimes drugs cause side effects because the receptors to which they bind are found in several different organs. Some blood pressure medicines block adrenaline receptors found both in the heart and the lungs. Blood pressure may improve, but asthma may get worse. Multiple drug effects are not necessarily bad. A medicine that makes you less depressed and more tired is perfect if you are depressed and also have trouble falling asleep. Watch for genetic testing to come into widespread use in the next few years as a means of predicting which medicines are right for which person.

Important as these biological facts may be, I have come to understand that beliefs and attitudes toward medicines are more apt to determine the outcome. For example, medicines are tested against inert compounds called “placebos.” When neither the patient nor the doctor know which group of people is getting the real drug, about a third of the placebo group gets better. The “placebo effect” is seen with every type of medicine for every ailment. There is no good explanation for it, except to say that, when people believe in the treatment, they get better. It likely results from the nervous system manufacturing more natural brain chemicals in response to belief.

Drug companies began capitalizing on patient beliefs years ago. The process of choosing a name for a new drug is surprising. Drug companies often hire a research firm to come up with a name people will like. The name of the new drug should convey something the company wants you to believe about the product. Market research shows that people believe a drug is more effective when its name includes Q, Z, and X. As a result, dozens of drugs have come to market with names which include those sounds or letters. You can probably think of several right now. Drug companies now spend more money advertising their wares to you than to me. TV ads for drugs use the same techniques proven to increase sales of all consumer products, particularly creating the belief that this item will improve your life. They also aim to reduce barriers to people asking their doctors about the “problem” and the treatment. Think Viagra.

Nationally, about one third of prescriptions written by doctors are never filled by the patient. There are many reasons for this. Some people are disorganized and lose the prescription. I have had patients lose a prescription between my office and the front desk. Some medicines are almost unbelievably expensive, even with insurance plans. Some people get “advice” from family and friends not to take a particular medicine because of something they “heard on TV” or “read on the internet” and so forth.

However, I think the biggest reason for unfilled prescriptions is that many people don’t believe they need to take medicine. They politely accept a prescription but were secretly hoping for something else. Some people are hoping that their doctor will just listen and understand them. They interpret the offer of medicine as rejection. Some people want a particular drug and have no intention of taking anything else. If the prescription is for something else, they toss it. Some people feel coerced by family members into “getting on meds”. They fear that, by taking medicine, they are admitting that they are the problem and that everyone else in the family is excused.

Once people begin taking medicine, the effect (and side effects) are powerfully influenced by belief. Few people with serious psychotic illnesses, such as schizophrenia, continue taking medicines to control their symptoms for more than a few months. This has much more to do with lack of insight than actual side effects. People who believe that they are taking a “powerful psychiatric medicine” (whatever that is) are apt to believe that they are going to be sedated or (my favorite) “turned into a zombie”. Someone who believes that a psychotic disorder is worse than a mood disorder will believe that medicine for psychotic disorders must be somehow “stronger” than medicine for depression and have the potential for worse side effects. Some people believe that their medicine is “causing weight gain.” In fact, weight gain is only caused by eating too much food. There are no calories in medicines, but, when someone believes that his medicine is making him fat, the medicine is more apt to go than the food.

Conversely, some people believe that their difficulties are all the result of a “chemical imbalance.” They want medicine and lots of it. If they don’t get better, and stay better, the problem is that their doctor has them on the wrong medicine or that the medicine “stopped working”. These people are apt to believe that they are powerless to improve their own lives or change their own behavior.

Medicine works, and fails to work, in many ways, for many reasons. We are fond of telling people to “listen to their doctor.” This is only part of the equation. The very best thing you can for yourself, as a patient, is to listen to your doctor and talk honestly and openly with him or her about what you think is wrong and what needs to be done about it.

Dr. Art Dingley was a construction worker, a social worker, and an attorney before attending medical school. His residency training was at Wake Forest University Medical Center and Maine Medical Center. He is board certified by the American Board of Psychiatry and Neurology. Dr. Dingley teaches in the Tufts University Medical School LIC program and at the University of Maine Farmington. He practices at Franklin Health Behavioral Services practice and provides psychodynamic psychotherapy, prescribing of medicine, consultation, integrated practice, and electroconvulsive therapy. He lives in Farmington with wife, Tami.

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