Off-Label
I started out curious about the way humans behave in my first psychology course. I guess I was in high school. I had to do a Powerpoint presentation (yes, Powerpoint, that ancient tool we used before ChatGPT) on a mental health disorder. I started reading all about anorexia and bulimia and became a bit fascinated with these disorders. I remember I included a picture of a young woman with her ribs all but bursting from her skin due to her prolonged food restriction. I didn’t know these things could make you lose your hair, make you stop having a period, or make the enamel on your teeth wear off from the acidity of your bile. But I was all in. I wanted to know everything about how things went so wrong with humans. Why did some people get dealt a lifetime of puking after every meal and counting calories and other people could eat every two hours and never have their weight fluctuate? Why did some people drink a liter of vodka every day and live well into their 60’s and other people overdosed on opioids and died at 23? Why did some people say that they’ll need therapy and medications forever? Why did some people see or hear things others didn’t? Why did some people believe in such pervasive delusions that it wrecked their entire world? Why did some people feel compelled to wash their hands 30 times a day?
Was it really a hand that they got dealt? According to every book I dove into, yes, of course! It’s your genes! Blame it on mom and dad. Blame it on their parents too. Did anyone in your family have an addiction problem? It’s in your blood. Good luck. Case closed.
Are you freaking kidding me?
I wasn’t buying it. I had the fortunate and unfortunate experience of being in my 20’s, getting my Bachelor’s and my Master’s in Psychology and Counseling, and having a front row seat to my older sister developing a lifetime of habits of binging, purging, drinking, and getting addicted to the numbness of Xanax and Prozac. Sometimes she even stole her dog’s Tramadol. That is, until I threw the pills in the toilet (and declined to tell her I did it) solely because I was convinced that she was on her way to killing herself. I say fortunate because there is no way I would care as much as I do, read as much as I do, obsess about medications and treatments and research the way that I do, and be as a big of a pain in the butt for everyone around me (at work at least) because I just won’t stop until I felt like I have advocated for a patient as much as I possibly can-I wouldn’t be that way if it weren’t for Sammi. She changed how I view addiction. She gave me the ability to really listen to a patient who has a BMI of 18 because she has been smoking meth for the past five years and can’t seem to stop. She’s the one that makes me stop and cover up that same girl with another blanket because I know she’s about to withdraw and want to die for the next day and a half. She’s the one that makes me act as if every addict is my sister. I want to treat every person in addiction as though they are as important as my sister. Because when you’re in addiction, you don’t think you’re deserving of anything good. Because you don’t love yourself. Because society shits all over them. Even now. Even in 2024. There’s so much “research” and “awareness” and despite that, every facility that I have worked at has shown me just how disgusted our society is with people who have substance abuse problems. And disgusted is the most appropriate word I can think of. Even therapists. Even doctors. Even nurses. Even mental health techs-that’ s a consistency in the States. We don’t like “addicts.” We view them as less than. We don’t get why they can’t “just stop.” We aren’t overwhelmed with the science behind addiction. We just know that we don’t like it.
Addiction counselors usually get paid far less than mental health counselors. Historically in the United States there was not enough funding for substance abuse treatment, however due to the ever increasing “opioid epidemic,” more funding is coming our way for treatments. But when it was crack that was flooding the streets, it wasn’t considered a health problem. It was considered a poor, intercity problem. It was a “just say no” problem. And let’s be honest the media did a good job of making it specifically a “black” problem. Talk about disgusting.
There is a discrepancy between what qualifies someone to work as a counselor in addiction versus the mental health field. In Florida, licensed mental health counselors need to have a bachelor’s and master’s degree, have two years of supervision in the field including 1,500 hours of face-to-face psychotherapy with patients, and pass the NMHCE test.
And after all of that school and hours-I still think that the theories and approaches and techniques are pretty much bull shit. For me, therapy is as simple as sitting with another person and giving them some tools to make their life look the way they want it to. I’ll never work harder than a patient does. I am 100% of the belief that if someone doesn’t want to change, nothing I say or do will change that. Lasting change comes from creating consistent daily habits. It always starts small.
But if you have ever met any of the weirdos in this field (I’m super weird just in a different way) they buy into this cookie cutter bullshit that we are supposed to practice therapy by using a certain theory and using certain techniques otherwise there’s no structure. And therapy “needs structure”. Insert eyeroll here. I just can’t even. The first thing I ask patients is “what’s not working in your life, what have you done that’s worked in the past, what are we eating, what does our exercise routine look like, how’s our sleep, and what medications are we taking?” And I use “we” and “our” so that they know that we’re going to work together on whatever they want to in the hopes that their lives will improve. That’s pretty much as simple as I make it to get an idea of future potential adjustments to start making their life look a little different. I use “adjustments” because that’s what we’re doing in therapy. We’re making small adjustments to our habits to reach an end goal. That’s it. It’s as simple and as complicated as that. If you have met other therapists, they’ll tell you their way is the correct way. They know best. The majority of the therapists I’ve encountered are incredibly rigid in their thinking and inflexible. In Missouri, Arizona, and Florida at least. I 100% believe that my approach is not the right approach for everyone. Some patients don’t respond well to my bluntness, sarcasm, or my adoration for the F word. Some people don’t want to actually do the work to make their lives different-some just want a pill and a sounding board. And that’s okay. But that’s just not my style. And that’s when I refer people to another therapist that will participate in that. Because I won’t. And I can’t be anything that I’m not. I’m not a good liar. So my laidback style isn’t for everyone, but I am certain that the rainbows and butterflies and working harder than your patients do approach and just medicate every symptom you’re experiencing is also not for everyone. Especially not in addiction. But it does work for some.
Addiction counselors in the state of Florida are not required to get a bachelor’s but are required to complete 6,000 hours of work-related experience, have 300 hours of supervised experience, and pass the Florida Certified Addiction Professional Exam. Even down to the job requirements for a counselor to work with addiction, there is less required experience-our society expects less to work in addiction. But for the mental health patients-well, those standards are a bit higher. That’s the message we send about addiction. And I 100% believe that this viewpoint affects patient care on a massive level-I’ve seen it in hospitals, outpatient programs, residential facilities, and intensive outpatient programs. It’s everywhere. And it’s crap. And I get so amped up about it because addiction makes way more sense to me than all of these mental health diagnosis that continue to expand to the point where now there are 297 disorders in the DSM-5. My personal favorite is Adjustment disorder defined as “the development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor.” That is a disorder? Having an emotional response to a stressor? It’s as though we have literally medicalized every aspect of being a human.
But back to this front row seat of mine. The front row seat to this lifetime of struggle and pain-for my sister and the rest of my family-didn’t make sense to me if addiction and mental health disorders are solely genetic. My parents weren’t addicts. (I use the term “addict” because the majority of my patients use that term to describe themselves.) Neither were their parents. My parents weren’t “crazy.” My mom’s side of their family has bipolar disorder and borderline traits, but that’s not what Sammi had. I also have three other siblings-why are none of us addicted? Why don’t any of us need benzos or antidepressants? What makes her different? I kept reading as much as I could. My second year of college, I became pretty fascinated with Social Psychology because it finally shed light on what I was not getting from my reading-it shined a light on how we behave in social situations. It’s not all genes-environment matters. Okay now that made more sense.
Sammi and I were homeschooled by our amazing mother from my 1st to 6th grade. She’s about 18 months older than me. My brother was homeschooled too, but most of my memories are of me and Sammi. There was no abuse in our home. We were super involved in church, (thankfully that faded by the time I got to high school-I had a complex relationship with the gods in my late teens until I was about 20 and then religion faded from my life) we spent holidays with both sides of my parent’s families, our parents told us and showed us that they loved us, we never went without, we never had to survive horrible disasters. My parents divorced when I was 15 and outside of that, nothing bad had really happened in our home. And that wasn’t even that bad-I was so busy being a teenager that I just tried to use the divorce to get away with whatever I could. We lived a privileged life. No one needed therapy. No one took medications. We routinely had family dinners. Alcohol was never a part of our family’s life.
Everything always came easy for Sammi. Or so I thought. I guess it seemed easy from the outside until she started shoving her fingers down her throat after every meal. Or vomiting in the shower so no one could hear her. Or until she started getting withdrawal seizures from alcohol.
Sammi got straight A’s, never studied, never got caught sneaking out, and was a fantastic liar. She was beautiful and never went through an ugly phase. She had one boyfriend in high school that cheated on her and then she ended up marrying her second boyfriend. She was charismatic and always the life of the party. I spent the first two decades of my life envying her life, being jealous of her confidence, and constantly comparing myself to her. She was my big sister-I thought she had it all. I didn’t realize the severity of what she was going through until I was in my late 20’s. Like I said, she was a fantastic liar. And I was dumb and in my 20’s and we were living in separate states often.
I, on the other hand, was a pretty standard middle child. I learned every freaking thing the hard way. I wanted to test all of the boundaries. I was a terrible liar and got in trouble frequently in high school. I pierced my tongue by myself twice. I did Adderall, pain pills, Xanax, MDMA, mushrooms, marijuana, lots of cocaine, and was smoking cigarettes and living off of energy drinks. I also loved diet pills-they gave me so much energy and made me want to eat less. Drove drunk and high all of the time. I did that for about two years in high school. Almost failed the majority of my classes my junior year because I just couldn’t be bothered to care about school. Then senior year came and I realized I want something out of life-I wanted to help people. Stopped doing drugs and tried to get good grades. Oh and maybe what helped this realization-my senior year I moved once again and went to a third new high school. Away from all of my friends that I was doing “fun” drugs with. Environment matters right?
Sammi went to the same high school all four years.
Google told me that to be a therapist I need to get my bachelor’s then my masters then be “supervised” for two years then I’ll get my official license as a therapist and make decent money. HA! For any of you in the field, there’s no freaking way that money factored into us getting into this grimey field. I say grimey because what I thought mental health and addiction were was something vastly different than what I signed up for. Sometimes I run into “colleagues” who share similar views as me, but it is far and few between. Everyone else just seems to drink the Kool-Aid (Google Jonestown if you’re too young to know what I mean.) When I started college, I didn’t want to stop learning on my own. I loved reading. I kept it up and still read constantly to this day. I got my BA and MA. But what kept coming up in all of my reading and college classes was this idea that brain chemistry somehow factored into depression. It not only came up in my readings and school, but my patients were pretty sold on this idea that their brain is “just different” than other people’s. Well when I want answers, I go to my friend Google, type in a topic followed by “scholarly articles.” Since everyone and their mom (and me I guess) can create their own blog and make it look pretty factual, I only use scholarly peer-reviewed articles when I want to look at research because allegedly they are the most reliable and perhaps least biased. But I always recommend you go to the very bottom of any research article and take a good look at the “Funding” and “Conflicts of Interest” section so you know who is benefitting from the study. Because someone or something or some agenda will always benefit from a study. Otherwise, what would be the point of the study in the first place? Studies serve a purpose, but we have to be responsible consumers and filter through who’s benefiting and what am I really reading. That’s the hard part. That’s what your doctor doesn’t tell you when he prescribes a medication. All medications have an FDA label in the United States. This label tells you risks, side effects, drug interactions, but most importantly-they give a brief synopsis of the clinical trials that were conducted to provide enough support that they work so that the FDA will approve them for a given medication. The label tells you what the drug was actually approved to treat. But in 2024 the term “off-label” prescribing is the norm and PCPs, psychiatrists, and other specialists are more than willing to take a medication used to treat one disorder and use it to treat something entirely different. I’ve seen this work well for some patients and turn out disastrous for others.
So if some brains are just “different,” is that what was going on with Sammi? Her brain was just different than mine and my other siblings? Trying to stay with this idea, I thought well if her brain is different and SSRIs (antidepressants that act on serotonin receptors) have been “proven” to correct this difference or imbalance, wouldn’t her Prozac just “fix” the problem? Well she was on it for years and still consistently ate pasta/soups/chilis because they were much easier to throw up later. So then I started wondering whether the Prozac didn’t work or her brain wasn’t different after all? After lots of digging, the answer I believe is both. There have been numerous studies discounting this theory of a serotonin shortage causing depression. NUMEROUS. It’s simply not true. Researchers have measured cerebrospinal fluid in people with depression and there is no shortage of serotonin to be seen! So why are my patients-in 2024-still repeating in their robot voices “my brain is just different?” Side note, 95% of serotonin is found in your gut. But I had yet to hear any doctor talk to patients, colleagues, or myself about the role of nutrition in mental disorders and addiction. In 2021 the National Library of Medicine published an article about a survey done across 52 countries. They surveyed psychologists, psychotherapists, and mental health practitioners in training about the diet of those with mental disorders. Every single participant agreed that those with mental disorders lacked a quality diet. And 74.2% of the psychiatrists and 66.3% of the psychologists “reported having no training in nutrition.” What might be even more interesting is that despite the large percentage of these professionals admitting that they have zero training in nutrition, 43.8% recommended diet changes to their patients. It’s not just medications being prescribed “off-label.” We’re being prescribed diets by professionals who have no training in nutrition. And yet, they are the ones prescribing the selective serotonin reuptake inhibitors despite lack of evidence supporting the idea that depression is caused by a shortage in serotonin. And most of our serotonin is in our gut. But they’re not trained about how the food we eat affects our gut health, mental health, as well as our physical health.
Could you see where I am confused?
Now more than ever, we are finally starting to see a vast amount of research being done on how foods affect our “gut health” and the implications of a healthy diet. Research has shown that eating plant-based diets can protect against autoimmune diseases. One study showed that a plant-based diet is effective in treating Type 2 Diabetes and can improve blood glucose concentrations and blood pressure. A Paleolithic diet has been shown to improve fat mass and insulin sensitivity.
The role of sugar and mood has been getting more attention recently, too. Added sugars can contribute to chronic inflammation. Inflammation occurs in bipolar disorder, schizophrenia, and anxiety. A study conducted in Korean adolescents showed that the combination of fast food with sugar-sweetened beverages was correlated with more stress, depression, and suicidal ideation. A diet high in sugar “enhances impulsive behavior, stress, anxiety and depression.” If you’re more prone to impulsive behaviors and have anxiety and/or depression, you are also more likely to use substances.
Earlier this year I had the privilege (when I say privilege I mean one of the hardest years of my freaking life trying to wrap my brain around this b/s mental health system in which we have a revolving door of people who never seem to “get better” despite their cocktails of prescriptions to manage depression, anxiety, sleep disturbances, and mood swings) of working in an inpatient setting at a hospital in Florida. That was the first inpatient experience I had and what an eye opener. I saw the same patients come in and out. Month after month. I watched women with Borderline Personality Disorder dictate their entire treatment including what medications they “know” works best for them and what milligrams. I was called as a witness in so many mental health court cases. (For those of you that don’t know-mental health court is when a professional initiates an involuntary hold on you, that hold then expires after 72 hours, your doctor wants you to stay in the hospital longer for more treatment, and so he/she petitions a judge to decide whether or not you’ll be forced to stay or not. It is a pretty miserable experience-for the patients, for their families, and for me. It’s grimey. Read my 72 Hours…The Baker Act Process for more info) I watched a pregnant woman with a Schizophrenia diagnosis stay in the hospital for 37 days against her will, give birth to her child, have her child taken away by the Department of Children and Family Services, and be discharged to a homeless shelter. Her delusions never stopped despite all of the medications. That’s what 37 days produced for her-her child taken away and a discharge Lyft to the nearest homeless shelter. That was another point in my career when I really started considering if this work was really for me. I’ve had several. Like a lot. Felt like I was the only person in the hospital who wasn’t buying what everyone there was selling.
I watched as people came in, got put on medications with serious side effects, and watched their doctors tinker with their medications until they were discharged-er, I mean “stabilized.” That’s what we called it. HA okay. I also listened as the medical director told someone with a bipolar diagnosis “your brain is just different.” He told that same patient “you’re going to need these medications for the rest of your life.” Ah. There it is. That’s where these ideas are coming from. Whose place is it to tell another person what they are going to need to put in their bodies for the rest of their lives? Especially when the long-term effects of antidepressant use are: weight gain, sexual dysfunction, lethargy, and emotional numbing. Mood stabilizers have their own variation of side effects: weight gain, metabolic dysregulation, akathisia, and sedation. Benzodiazepines: cognitive impairment and ataxia (when you cannot control your muscles to walk/balance/speak.) And lastly antipsychotics: tardive dyskinesia, akathisia, sexual dysfunction, constipation, weight gain, myocarditis, and dry mouth. Ew.
But not all of those ideas are coming from all doctors. I had the pleasure of working with one of the most brilliant psychiatrists I have yet to meet. He is the reason I am still in this field. He’s the reason I didn’t lose my passion to help people. I was transferred to his service after I provided an unwelcomed testimony in mental health court in which my opinion on whether or not a patient met criteria to be transferred to the state’s mental health hospital differed greatly from our medical director’s professional opinion. The medical director kindly told my supervisor the following day, “she doesn’t believe in mental health-I’ve tried talking to her so many times, but she just doesn’t get it.” Mind you, a state hospital is the highest level of care and houses the most challenging patients. I say challenging because “sick” in my opinion is a disservice to them. These are patients who cannot manage to live outside of an institution for a variety of reasons and whose lives have become unmanageable. So after this incident where I advocated for a patient and consequently got transferred to another psychiatrist’s services, my life changed a bit. And I got to work with the most brilliant doctor I’ve ever met. And that first week, I listened as he told the first-year residents, “it’s basically torture that we don’t have a space for patients to go outside while they’re here-even inmates get to go outside.” A doctor was acknowledging the need for people to have fresh air and sunlight? This was just unheard of for me. I only heard doctors talk about diagnosis and pills. Oh yeah and clinical trials to provide evidence to support their prescribing of pills. That's about it.
The week after that a resident asked him about a diagnosis to which he replied, “I think the DSM is just garbage.” Whaaaaaaaaaaaaaat? I had done some reading recently because I wanted to know how the DSM even came about-essentially, a group of doctors came together, compared symptoms, and that transformed into meetings/conversations/debates that led to the first Diagnostic and Statistical Manual of Mental Disorders. Mind you homosexuality was considered a mental disorder in the DSM until 1973. That’s only 51 years ago. My belief in the DSM is about as solid as my belief in Santa Clause. It sounds like a nice idea, but I think what it started out as-a way to identify treatments for a cluster of symptoms-has translated into every single person on this planet could have a qualifying diagnosis at any point in their lives. Everything is a diagnosis. We have literally turned into a society that has made a diagnosis out of every single human emotion and experience. But why? Did the development of all of these psychotropic medications, the creation of all of these diagnosis, technological advances, options for telemedicine in a post-COVID world, and all of these new types of therapies result in a healthier America? Are we “better” than we were back when we were putting people in insane asylums and treating them with ice baths, insulin comas, blood-letting, and non-sedated ECT treatments? Are we doing better now?
Survey says: not even a little bit better.
According to the CDC, heart disease, diabetes, chronic liver disease and cirrhosis, and stroke are among the leading causes of death in America. In 2021, suicide was the 11th leading cause of death in the U.S.
We’re killing ourselves through chronic preventable diseases and via suicide. No, we’re not doing “better.”
So if we’re still incredibly unhealthy physically and mentally, what has the development of all of these psychotropic medications done for us? I think they’ve taught Americans that we need a pill/magic fix/quick solution to everything. That’s the American way. Instant gratification. I think we’ve been taught that we can simply medicate all of our distress/problems/emotions and there are no consequences for doing so. There are consequences for everything and the pills that you’re putting in your body every day are no exception. But the pills are “fixing” our brains right? Doubt it.
Right now in the DSM you can find diagnosis such as Antidepressant Discontinuation Syndrome, Medication-Induced Acute Akathisia, Medication-Induced Acute Dystonia, Medication-Induced Postural Tremor, Substance/Medication-Induced Bipolar and Related Disorder, and Substance/Medication-Induced Psychotic Disorder. The medications being prescribed to treat mental disorders are also causing mental disorders? I don’t understand this. And, odds are, neither do you. Because our Western treatment of mental disorders doesn’t start with a conversation about the true long-term consequences of taking these medications and other alternatives for treatment. It starts with a patient identifying a problem and a psychiatrist taking 30-45 minutes to medicate it. Then they’ll see you once a month or every 3 months for 15 minutes to ensure that the medication is working. Have more than one problem? Are you depressed and anxious and have problems with focus and sleep problems and have mood swings? Well then you certainly need an antidepressant, anti-anxiety, stimulant, soporific, and a mood stabilizer to make sure all of these are addressed promptly. Polypharmacy is the norm now. If you think about it, having everyone depressed, anxious, and medicated for life is a pretty lucrative business.
Ask me how many of the hundreds of patients I’ve seen (in the 7 years of being in this field) were fully aware of all of the side effects and risks and withdrawal symptoms of every medication that they have been prescribed? I don’t have a number but off the top of my head, my guess is about 5-10% had a full understanding of the long-term risks of the medications they were taking on a daily basis. And that’s being optimistic. Is that patient-centered informed care? Not really. Not at all. And yet, these patients were more than willing to sign up for increases and decreases and additions and subtractions to their medications as if they are a human experiment. Whatever “fixes” the problem.
Why?
I think there are a few different reasons for the why. People want to trust doctors. Doctors are the professionals. They went to med school. They have to be trained extensively so why wouldn’t I put my life literally in their hands? People also want to hope. They want to believe that they can get better, that things will change, and that this current way of experiencing the world is not for forever.
And the most important factor-people believe that these pills are effective. Because that’s what their doctor tells them. That’s what the nurse tells them. That’s what their therapist recommended. That’s what the commercials say. That’s what the TikTok videos are pushing for. Their friends and families are on these meds and they are doing fine.
It can also be confusing as to why primary care doctors commonly prescribe psychotropic medications when mental health disorders could be considered outside their scope of practice. One pilot study surveyed PCPs about their comfort level prescribing psychotropic medications. The surveys showed that they weren’t very comfortable with it. Yet they still prescribe them.
I have yet to come across a patient who, when I ask about what medications they are on, replies with “well I looked on JAMA’s website and it looks as though XYZ has had efficacy in several clinical trials that lasted 8-12 weeks with people of my age, gender, and with my diagnosis.” I’m still waiting for that day. The truth is that most people don’t go into rabbit holes researching medication efficacy online. The truth is that most adults have never read the FDA label for the medications they are prescribed. If they actually read the FDA label and truly processed that information, I have a hard time believing that the United States would be as medicated as we are today. There is no freaking way.
Let me give you some examples.
Prozac’s FDA label says: “there have been spontaneous reports of adverse reactions occurring upon discontinuation of these drugs, particularly when abrupt, including the following: dysphoric mood, irritability, agitation, dizziness, sensory disturbances (e.g., paresthesias such as electric shock sensations), anxiety, confusion, headache, lethargy, emotional lability, insomnia, and hypomania.”
Xanax’s FDA label says: “In a controlled clinical trial in which 63 patients were randomized to XANAX and where withdrawal symptoms were specifically sought, the following were identified as symptoms of withdrawal: heightened sensory perception, impaired concentration, dysosmia, clouded sensorium, paresthesias, muscle cramps, muscle twitch, diarrhea, blurred vision, appetite decrease, and weight loss.”
Wellbutrin’s FDA label says: “Depressed patients treated with WELLBUTRIN have been reported to show a variety of neuropsychiatric signs and symptoms including delusions, hallucinations, psychosis, concentration disturbance, paranoia, and confusion… Antidepressants can precipitate manic episodes in bipolar disorder patients during the depressed phase of their illness and may activate latent psychosis in other susceptible patients.”
Zoloft’s FDA label says: “In two additional placebo-controlled PTSD trials (Studies PSTD-3 and PSTD-4), the difference in response to treatment between patients receiving ZOLOFT and patients receiving placebo was not statistically significant.”
No, I don’t think medications are the solutions.
And while we are so disgusted as a society with addicts-it really does seem like we live in a society that sets people up for addiction. Our culture thrives on instant gratification, needing a pill for everything, medicating feelings, poor distress tolerance…which are pretty much characteristics of addiction…
We’re not doing or treating “better.” And addicts are, therefore, not getting “better” either. How could they?
References
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