Blaming the Psychiatric Patient When It’s a Drug-Genetic Interaction

“One day, I made a remark that I might work with people with mental illness, and somebody in the press heard it, and it was in the paper. And the more I thought about it and found out about it, the more I thought it was just a terrible situation with no attention. And I’ve been working on it ever since.”

— Rosalynn Carter

Mental illness is a hidden scourge that attacks far too many people, especially those who have schizophrenia. It grinds down people’s dignity, throws their lives into disarray, and leaves them vulnerable to misunderstanding and derision even by mental health professionals.

Too often, I have heard patients belittled by staff, including psychiatrists, who threatened them with forceable IM medication or seclusion and restraint because “you aren’t taking your medication.” When the patient pleaded that they were medication compliant, they were viewed as liars. Coercion is not unusual in some settings.

“If you were taking your medication, you wouldn’t be having symptoms now,” was the retort. But they were taking their medication. The problem was that the professionals hadn’t caught up with genetic research in their field. Ok, it wasn’t as advanced then as it is now.

Then began a seemingly endless process of prescribing serial meds or, on the other hand, polypharmacy which returned to favor after years of disrepute. Washout of meds was ignored as a new med was added in place of the existing one.

My quandary was how spectacular someone would have to be at biochemistry to know the interactions of all those metabolites in the brain. Too many patients developed tardive dyskinesia (TD), which never resolved. The symptoms of TD were hidden by prescribing yet more medications.

A Change in Understanding

The dark days of psychiatry, I would hope, are behind us, but I can’t say that definitively. Some serve as psychiatrists who had their medical residencies and experience in pediatrics, cardiology, and other unrelated specialties. I say this because I’ve seen it first-hand. At least one man failed the psychiatry boards three times and then gave up on them.

The dawn of medical understanding regarding the role of genetics has come, and with it, a new appreciation for what works and what doesn’t. Are patients still blamed when a med doesn’t work? Possibly.

“Pharmacogenomics is the branch of pharmacology which deals with the influence of genetic variation on drug response in patients by correlating gene expression or single-nucleotide polymorphisms with a drug’s efficacy or toxicity.”

Psychiatry has gained sophistication in the knowledge of drug-patient interaction, but not everyone in the field has kept up. Such a failure can only mean more patient blaming.

Movement in the direction of consideration of genetic differences leading to medication inefficacy has begun.

Individual Differences Are the Key

“Pharmacotherapy is one of the primary treatments for psychiatric disorders. Given the variation in individual responses, a more personalized approach is needed. This paper will discuss methods for user-friendly referrals, recruitment criteria, data storage and dissemination, biological sample and clinical questionnaire collection, and advertising.”

The suggestion of biological sampling has begun at how many sites, practices or hospitals? Has anyone provided research to determine this and, if not, why is this gap in the literature permitted to exist? Is patient-blaming too easy?

Undoubtedly, the tests take time and funding, and the metabolic difficulties presented by cytochrome P450 which is always a consideration. But there is literature pointing toward the importance of this research.

“It has gradually been demonstrated that genetic differences in ion channels reflect differences in the distribution of polymorphic traits, such as disease susceptibility and drug efficacy…”

This approach to evaluating psychotropic medications’ efficacy has been further underscored in additional portions of the medical literature.

“For most psychiatric diseases, pathogenetic concepts as well as paradigms underlying neuropsychopharmacologic approaches currently revolve around neurotransmitters such as dopamine, serotonin, and norepinephrine…the effectiveness of these medications is limited, and relapse rates in psychiatric diseases are relatively high, indicating potential involvement of other pathogenetic pathways…”

Absolving the Patient From Blame

How can patients with psychiatric or any other illnesses be viewed as non-compliant with their medical regimes when there is a persistent failure to investigate how their race and genetics are affecting treatment? The answer is obvious, and the blaming must stop. How can we treat patients when this type of neglect persists in the face of overwhelming evidence that is being ignored?

One example that might be remediated if psychiatric treatment were fully compliant with recommended protocols would be homelessness. If patients’ illness can be brought under control, would they choose to live and die on the streets and remain resistant?