In the realm of mental health, medication plays a pivotal role in managing and treating a variety of psychiatric conditions. As a psychiatrist, I have witnessed the transformative impact these medications can have. Yet, I also recognise the complexities and concerns that accompany them. Often, apprehensions held by patients and their caregivers can lead to reluctance or refusal of this treatment modality, which can significantly affect recovery and stability. This write-up aims to demystify psychiatric medications, shedding light on their types, mechanisms, and the subtleties of their clinical use.

It’s crucial to acknowledge that medication is just one component of a comprehensive approach to mental health care. Effective treatment typically involves a combination of approaches, including psychotherapy, lifestyle adjustments to cope with real-life stressors, support from family and friends, and consideration of spiritual aspects, among others. Each of these elements plays a vital role in the holistic management of mental health conditions. However, the focus of this article will be on the medication aspect, aiming to provide clarity and understanding about this specific and often crucial element of psychiatric treatment.

A Primer on Psychiatric Medications

Psychiatric medications are diverse, each tailored to address specific aspects of mental health conditions. The primary groups of these medications include:

1. Antidepressants: Typically used for depression, these drugs modulate neurotransmitters such as serotonin to alleviate depressive symptoms.

• SSRIs (Selective Serotonin Reuptake Inhibitors) Example: Fluoxetine (Prozac), Escitalopram (Lexapro) and Sertraline (Zoloft)

• SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors) Examples: Venlafaxine (Effexor) and Duloxetine (Cymbalta)

• Other Antidepressants: Remeron (Mirtazapine) and Valdoxan (Agomelatine)

2. Antipsychotics: Crucial in treating psychotic disorders like schizophrenia, they influence dopamine pathways.

• Example: Risperidone (Risperdal) and Olanzapine (Zyprexa) are often used for schizophrenia and bipolar disorder.

3. Sedatives and Anxiolytics: Employed for anxiety and sleep disorders; this category includes benzodiazepines and Z-hypnotics, known for their calming and sleep-inducing effects.

• Benzodiazepine Examples: Lorazepam (Ativan) and Diazepam (Valium)

• Z-hypnotic Examples: Zolpidem (Stilnox) and Zopiclone (Imovane)

4. Mood Stabilizers: Vital in the management of bipolar disorder, helping to regulate mood fluctuations.

• Example: Lithium Carbonate and Sodium Valproate

5. Others, such as stimulants: Specifically designed for conditions like ADHD (Attention-Deficit/Hyperactivity Disorder), these medications help improve focus, attention, and self-control.

• Example: Methylphenidate (Ritalin, Concerta) and Lisdexamfetamine (Vyvanse) are commonly used to treat ADHD.

Occasionally, medications not traditionally categorized under these classes are also employed to alleviate symptoms associated with mental health conditions. An example is Propranolol, an “older” blood pressure medication. In psychiatric care, Propranolol is often utilized off-label for its ability to reduce physical symptoms of anxiety, such as palpitations and tremors

Mechanism and Efficacy

Psychiatric medications exert their effects by influencing various chemical pathways in the brain, akin to how other medications act on different parts of the body. These drugs target specific physiological processes to alleviate symptoms or modify disease progression.

• Neurotransmitter Regulation: Many psychiatric disorders are linked with imbalances in neurotransmitters. Antidepressants, for example, increase serotonin levels, often low in depression, while antipsychotics target dopamine pathways, which can be overactive in conditions like schizophrenia.

• Receptor Activity Modulation: Medications like benzodiazepines enhance the effect of GABA, reducing anxiety and aiding sleep by calming the nervous system.

• Promoting Neuroplasticity: Some psychiatric medications may enhance the brain’s ability to form new neural connections, improving cognitive functions and mood regulation.

• Variability in Individual Responses: The effectiveness of these medications varies greatly among individuals due to genetic, lifestyle, and health factors, necessitating a personalized approach.

• Trial and Adjustment: Finding the right medication often involves trial and error to balance therapeutic benefits against potential side effects.

Understanding and Managing Side Effects of Psychiatric Medications

All medications, including those used in psychiatry, come with the potential for side effects. Managing these side effects is vital and typically requires carefully balancing the medication’s therapeutic effects with the need to reduce any unwanted reactions.

As mentioned in the previous section, psychiatric medications are formulated to specifically act on certain pathways in the brain to treat mental health disorders. However, the very mechanisms that make these drugs effective can also lead to side effects, some of which may be unintended or undesirable.

1. Neurotransmitter Effects: For instance, increasing serotonin levels can alleviate depressive symptoms but may also result in nausea, headaches, or sexual dysfunction. Similarly, antipsychotics, which modulate dopamine pathways, can cause drowsiness or more severe movement disorders.

2. Receptor Activity: Enhancing GABA activity with benzodiazepines might relieve anxiety but can also lead to drowsiness, confusion, or dependency issues.

Common Side Effects by Medication Class

• Antidepressants (SSRIs, SNRIs): Typically include nausea, headaches, and sexual dysfunction, with risks like serotonin syndrome especially in the context of an overdose.

• Antipsychotics: Range from weight gain to more severe conditions like Neuroleptic Malignant Syndrome and tardive dyskinesia.

• Sedatives and Anxiolytics: Can cause drowsiness and dependency issues, with severe withdrawal symptoms upon abrupt discontinuation.

• Mood Stabilizers: Often lead to weight gain and tremors, with risks like lithium toxicity.

• Medications for ADHD: May result in loss of appetite and insomnia, with a potential for abuse in stimulant medications.

Managing Side Effects: Balancing Benefits and Risks with Professional Guidance

The management of side effects in psychiatric medication therapy involves a nuanced balancing act. This process is deeply personalized, as the occurrence and severity of side effects can vary widely among individuals due to factors such as age, overall health, genetic makeup, lifestyle, and the concurrent use of other medications. Adjustments in dosages, switching medications, or adding treatments are often necessary to counteract negative effects and to maintain the therapeutic efficacy of the drugs.

Given the variability in how individuals experience side effects, professional guidance and regular monitoring become essential components of effective medication management:

• Balancing Therapeutic Benefits and Side Effects: Striking the right balance is crucial for successful treatment. This sometimes involves the process of cross-titration, where one medication is gradually decreased while another is increased, to find the most effective and tolerable treatment combination.

• Understanding Medication Interactions: It’s also vital to understand the potential interactions between various medications, including over-the-counter (OTC) drugs, traditional medicine and supplements. These interactions can significantly impact the safety and efficacy of treatment.

• Informed Decision-Making: Making informed decisions about medication therapy requires a comprehensive understanding of potential side effects within the broader context of the patient’s overall health and treatment goals.

Patients are strongly encouraged to maintain open and honest communication with their psychiatrists about their experiences with prescribed medications. This includes discussing any side effects experienced, as well as the perceived effectiveness of the treatment. By sharing this information, patients play an active role in their treatment process.

• Reducing Polypharmacy: Open dialogue can help in minimizing the practice of polypharmacy – the use of multiple medications by a patient – especially if some drugs are found to be ineffective or cause adverse effects.

• Adjusting Dosages: Feedback from patients is crucial in determining the optimal dosage of medications, aiming to achieve the maximum therapeutic effect with the minimum necessary dose.

• Minimizing Side Effects: Understanding each patient’s unique reaction to a medication allows for adjustments that can reduce side effects, improving overall treatment adherence and quality of life.

• Teamwork in Treatment: The psychiatrist and patient, along with other healthcare professionals if needed, work as a team. This collaborative approach ensures that treatment decisions are made considering the patient’s comprehensive health profile and personal preferences.

Navigating Financial Constraints in Psychiatric Care

Financial considerations are a crucial and often challenging aspect of psychiatric treatment. The cost of medications can significantly impact treatment choices, especially for patients with limited insurance coverage or financial resources. Open discussions about the cost of medications can lead to the exploration of cost-effective alternatives that do not compromise the quality of care.

• Understanding Medication Pricing: The cost of medications can vary widely, influenced by factors such as brand versus generic formulations, the cost of research and development for new drugs, marketing, and patent issues. Newer, branded medications are often more expensive than older generics, but this does not necessarily correlate with increased efficacy or safety.

• Generic vs. Branded Medications: Generic medications, which are typically less expensive, can be equally effective as their branded counterparts. They contain the same active ingredients and undergo rigorous testing to ensure their safety and efficacy.

• Therapeutic Equivalence: When cost is a concern, psychiatrists can explore therapeutically equivalent medications that provide similar clinical benefits but at a lower cost.

• Insurance Coverage and Assistance Programs: Understanding a patient’s insurance coverage and exploring available assistance programs can help in mitigating the financial burden of medications.

• Balancing Cost and Clinical Needs: The goal is to balance financial considerations with clinical needs, ensuring that patients receive effective treatment without undue financial strain.

• Transparent Communication: Encouraging open and transparent communication about financial constraints allows psychiatrists to tailor treatment plans that are both clinically effective and financially feasible.

• Ongoing Cost Management: Managing the cost of psychiatric medications is an ongoing process. Regularly reviewing and adjusting medication regimens can help in finding the most cost-effective treatment solutions over time.

Empowering Patients through Understanding and Collaboration

In conclusion, understanding psychiatric medications is an integral part of managing mental health conditions. This article has aimed to provide clarity on the various types of psychiatric medications, their mechanisms, and the intricacies involved in their use. By demystifying these medications, we seek to empower patients and caregivers, enabling them to engage more actively and confidently in the treatment process.

As we navigate the complexities of psychiatric medications, let us remember that the journey towards mental wellness is a collaborative one, with each patient’s unique needs at its core. Psychiatrists, healthcare providers, patients, families and their support networks all play pivotal roles in this journey.

Together, through understanding, communication, and empathy, we can work towards effective, compassionate, and comprehensive mental health care.

Poor mental health is a growing concern in Singapore. The National Population Health Survey (NPHS) 2022 [1] revealed that poor mental health increased from 13.4 per cent in 2020 to 17 per cent in 2022 (with young adults contributing to the highest proportion of poor mental health at 25.3 per cent). Whilst this increase may not be dramatic per se, it is an indicator that the state of mental health in the country is significantly declining. The survey also revealed that young adults are most vulnerable to declining mental health. 

In our lives, it is common to have an inkling about a loved one’s deteriorating well-being. Whether you’re a parent, sibling, friend, partner, or colleague, you may have felt the urge to intervene in the lives of someone you care about in hopes that they would seek professional psychiatric help. However, this display of love can be tricky. 

The stigma around the topic of mental health is, unfortunately, still evident in our communities. A 2017 [2] study in Singapore revealed that almost half (approximately 44.5%) of respondents, made up of adolescents, associated mental illnesses with negative, derogatory terms like “stupid”, “dangerous”, “crazy”, and “weird”, while 46.2% of them said they would be “very embarrassed” if they were diagnosed with a mental illness.

Given the negative connotation around the subject, how can you masterfully suggest seeking help for the ones you love? In this article, we have provided a comprehensive guide on techniques to convince a loved one to seek psychiatric help. 

1. Don’t push the trigger button 

Culturally, Asians seem brasher in casual conversations, though it is not necessarily intended with malice. For instance, a mother may observe her son’s binge eating tendencies and voice it as “You are going to become fat if you keep this up!”. Whilst this sentence, when dissected, is harsh, there is often genuine concern about her son’s well-being and the impact that binge eating will have on his health.

However, the method employed by the mother will not halt her son’s binge eating tendencies. If anything, it may cause further upset and fuel the root cause masked by this specific behaviour. So, how can you approach your loved ones tactfully? 

The first step is to understand their list of triggers. For example, for individuals dealing with anorexia, pointing out their weight loss, whether positively or negatively, could further encourage starvation behaviour. The trigger, in this case, is weight loss. If you’re dealing with a loved one who’s depressed, blatantly pointing out their behaviour change could result in self-consciousness.

Instead, frame your concern with more caution. For example, when initially approaching a loved one, your concern may be worded as:

•  “I am worried about your health and the future consequences. Do you have any intention of remedying them?” 
• “ I am deeply concerned and hope I am not overstepping, but it appears you are demotivated to nourish yourself. Would you like to talk about it?’”
• “I intuitively feel that you may be burdened by something. Is there an issue that is lying heavy on your heart? I hope you know I am always ready to listen.”

As shown in the examples above for various cases, when initiating a conversation about issues presented by your loved ones, you first take away the spotlight from them by highlighting how YOU are genuinely concerned for them with I-statements [3]. Once the concern you have presented is received positively, you can open the doors to seeking psychiatric help. 

2. Tone it down 

As important as it is to carefully curate your words when approaching a vulnerable individual, the tone of your voice is crucial. Have you ever gotten into an argument because the opposing party claims your tone was disrespectful, condescending or even patronising? Most people lack awareness of how their tone of voice [4] could add more fuel to the fire. As the famous saying goes, it is not what you say but how you say it. 

When speaking to a loved one in a troubled state of mind, it is important to present your intention as “concerned” versus “accusatory”. Your tone of voice will definitively play a significant role in how the message is relayed and received. When attempting to suggest to a loved one to seek psychiatric help, you should: 

• Speak in a lower tone: psychologically troubled people may be defensive and argumentative; however, that does not justify you raising your voice at any point. Stay firm with your intention and remind yourself they do not necessarily come from a malicious place. 
• Speak slowly: make sure to add pauses and provide conversation space. If you are talking over your loved one or rushing through your “speech”, it may be difficult for them to capture your intention. Remember, you are also creating space for them to open up about the issues they may be battling. 

“How do I know if my tone is right?’. For starters, try recording yourself and listen to how you sound. Often, this might suffice for you to correct your tone before approaching the one you love. You may also attempt a role-play with a trusted friend or family. Ask them to react negatively and observe if your tone changes when challenged. 

This is not to say that you should put up with disrespect or that an emotional reaction is unwarranted when boundaries are crossed. We are fully aware that the average person is not a trained professional, so if the conversation becomes heated at any point, diffuse the situation immediately and hold the conversation for another day. 

3. Set and setting 

As mentioned before, it is possible for a well-intended conversation to turn sour quickly. Therefore, taking some time to choose the right location to have this conversation is just as important. We advise opening a sensitive discussion, such as seeking psychiatric help in a private setting, perhaps in a familiar and safe place, like homes or favourite cafes. Padding the location with some of their favourite foods or drinks adds an element of comfort and encourages your loved one to open up. 

Essentially, you should try not to have sensitive conversations in a sterile environment, including their workplace or people they may react sensitively to. For instance, attempting to approach your sibling at home where your parents are possibly eavesdropping or would be quick to insert themselves in the conversation could cause further damage. Your intention may even be questioned as an attempt to humiliate or embarrass. 

If you attempt to help a coworker or subordinate, doing so over a dinner, which offers some privacy, may be better than a “meeting” in a conference room. Alternatively, a video call could be advantageous as they would be at home, allowing them to ruminate about the conversation within the safe walls of their home. 

4. Be prepared for the rebuttals 

In a society like Singapore, suggesting psychiatric help may cause a backlash. So be prepared for all the possible reasons your loved ones might oppose the idea, such as: 

• Are you suggesting I am crazy?: Just because I can’t visibly see the state of your mind doesn’t mean you should be deprived of help. I am in no way stating you are crazy, but I think it’s time you sought help in the name of self-kindness. 
• People will think I’m weird: weirdness is a subjective idea. I think you are an amazing person, and watching you deteriorate over poor mental health saddens me. It is my intention to preserve the beautiful person that you are, even if that means seeking psychiatric help. 
• I can’t afford an embarrassing diagnosis: a diagnosis is not a label nor a life sentence. It will help you accurately identify the issue at hand. You will then have all the tools to manage your life effectively and learn to navigate complex situations with a professional. I genuinely believe you deserve assistance to reach your peak potential in life. Please don’t allow a diagnosis to hinder you. 

As presented above, these rebuttals are not argumentative but come from a place of empathy. You are also wording your rebuttal in ways that present elements of support and care. 

5. Physical assistance

Assuming you are successful at the conversation phase of this process, it is now time to be physically involved. This includes guiding them to the appropriate healthcare provider, setting them an appointment (with their consent), following them to their first session, or even driving them to the clinic. When the person you love is vulnerable and potentially mentally distraught, these seemingly “simple” tasks could easily overwhelm them. Gifting them your time and effort will bring comfort and a sense of security to your loved ones. 

We recognise that intervening in the lives of a loved one and taking up some load could easily overwhelm an individual. Do not risk your mental health in the process of helping others, as this would not be beneficial to any party. Carefully gauge your comfort level and the extent you are willing to commit. Refrain from overpromising and under-delivering, too, as this could further disappoint the ones you love. 

Wrapping up 

If you’ve reached the end of this article but feel uncomfortable executing any of these steps, you can instead identify the next best person to help the ones you love. This should be someone you believe also has your loved one’s best interest and can execute this process more efficiently. 

If you believe the person you love is at risk of harming themselves or the people around them, you must consider contacting emergency lines in Singapore: 995 for an ambulance or 999 for a police emergency. You can also call the SOS Hotline (1767) or the IMH Helpline (63892222) If you believe the issues are urgent but do not warrant contacting the police/SCDF ambulances. If you have general inquiries, contact us to guide you per your specific situation. 

We applaud you for caring for the people you love and doing the due research. We hope that stigmas surrounding mental health are eliminated in the years to come. Until then, as long as one is surrounded by people who care for them like yourself, hope remains. 

References

1. Ministry of Health Singapore (2022) National Population Health Survey 2022 , NATIONAL POPULATION HEALTH SURVEY 2022. Available at: https://www.moh.gov.sg/docs/librariesprovider5/resources-statistics/reports/nphs-2022-survey-report-(final).pdf (Accessed: 08 December 2023).
2. Pang, S. et al. (2017) Stigma among Singaporean youth: A cross-sectional study on adolescent attitudes towards serious mental illness and social tolerance in a multiethnic population, BMJ open. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5652546/ (Accessed: 08 December 2023).
   
3. Rogers, S.L., Howieson, J. and Neame, C. (2018) I understand you feel that way, but I feel this way: The benefits of I-language and communicating perspective during conflict, PeerJ. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5961625/ (Accessed: 08 December 2023).
   
4. Raeburn, D.C. (2022) Improving and watching your tone of Voice, Raeburn Psychology . Available at: https://carolinaraeburn.com/improving-and-watching-your-tone-of-voice/#:~:text=Your%20tone%20of%20voice%20is,language%20through%20conversation%20with%20others. (Accessed: 08 December 2023).
   
5. Ho, R.C. et al. (2015) An overview of mental health legislation in Singapore, BJPsych international. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5618915/#:~:text=The%20Mental%20Health%20(Care%20and%20Treatment)%20Act%202008,-The%20Singapore%20Mental&text=Under%20the%20new%20Act%20(see,for%20up%20to%2072%20hours. (Accessed: 08 December 2023).
   
6. Institute of Mental Health Homepage (no date) Institute of Mental Health. Available at: https://www.imh.com.sg/Pages/default.aspx (Accessed: 11 December 2023).