The honeymoon was over. One year after adoption, our rambunctious rescue terrier Pepper began to show signs of severe anxiety. In the coming weeks she shook uncontrollably, scratched the front door, left her mark wherever she pleased, and spent entire nights pacing. Despite a serious commitment to behavioral modification, and consultation with professionals and fellow pet-owners, her turmoil was relentless. I drew the line one night when I found her staring at herself in the mirror and panting, which was eerily similar to a horror film we had just watched. Sleep-deprived and desperate, we brought her to the veterinarian who, after a thorough evaluation, diagnosed Pepper with anxiety and recommended a medication called clomipramine (an antidepressant that also works for anxiety). Skeptical, I asked the doctor, "Are there any alternatives we can try? Vitamins? Supplements?" We left the office with a supply of clomipramine but opted to start with a pheromone collar/vitamin supplement combination.
As a psychiatrist, my decision confused me. I prescribe medications regularly, and in daily practice am surprised by how much time people are willing to suffer from symptoms of mental illness before reaching out for help. Once they make it to the office, it is often difficult to convince them to try a treatment that has the potential to be helpful. Here I was in a similar boat, full of worries about what it meant for Pepper to be on medication. Did this mean she was suffering and could not do well? Did this mean I was an ineffective dog mother? A psychiatrist's pet on an antidepressant, how original! I worried that something bad would happen, forgetting that something bad was already happening.
My hesitancy to start Pepper on clomipramine was clearly not based on lack of knowledge about psychiatric medication. Despite the obvious difference that Pepper is a dog (regardless of what she thinks), the medication is the same. When prescribed thoughtfully, psychiatric medications can lead to meaningful improvement in someone's life. Additionally, alternative treatment strategies such as herbal supplements are neither benign nor free from adverse effects. What I began to wonder was how much of my decision to delay the recommended treatment for Pepper was based on my own implicit biases about the meaning of mental illness and medication. As a mental health provider, was I not immune to this?
Stigma about mental health often prevents people from seeking help, and misperceptions about medications and psychotherapy often delay proper treatment. While conversations about stigma and mental health are happening, available mental health resources lag behind. The first interaction a person has with mental health care is often in the community, whether it be in a church, homeless shelter, primary care office, or other public setting.
Giving talks in the community to people with mental illness, as well as to organizations that provide first-line mental health care, my colleagues and I are learning more about different perceptions of mental illness. Some people have heard from the media that depression makes people violent. Some have heard only weak people get depressed. Some have heard that being on medication will ruin someone's life. All of these are false, of course, but these ideas run deep.
In exchange for information about each illness, my colleagues and I are learning valuable lessons. We are reminded of what it's like for someone, with their own ideas, biases, and fears, to have a first interaction with the mental health care system. To put it mildly, it's scary! It makes me realize that, as a mental health professional, I have to really take time with each patient to discuss and understand the meaning of mental illness for that person, to try to push stigma aside, and to encourage them to talk openly about their concerns. We can treat mental illness in a manner that takes into account each person's background, present reality, and future goals. Psychiatry is, in that respect, personalized medicine.
After acknowledging and understanding my concerns and recognizing that the treatment I initially chose for Pepper was ineffective, I felt empowered to make the decision to start the medication and I've never looked back. Drugs are not always the answer, but Pepper is no longer suffering and is back to being her sweet, sassy self. I am a mental health professional ready to educate, but most of all I am a person. I get it. My hope is that every person who walks through my door will feel as empowered to discuss the meaning of their illness openly with me, so we can work through the feelings together and create a common goal. Collaborative mental health care that acknowledges but surpasses stigma is the best treatment, and I wouldn't accept any alternative.