How psych meds are prescribed: The spaghetti method

How do you tell if your spaghetti is cooked? You throw it at the wall. If it sticks, it’s ready to eat. If it doesn’t, it’s not. Either way, you’ve gained new knowledge—via a pretty messy technique.

I’ve been hearing “throwing spaghetti at the wall” as a metaphor lately, and I think it’s a fantastic illustration of how psychiatric medications are prescribed—namely, a with a hit-or-miss, throw-it-and-see-what-sticks system. Though some biological tests are in the works (such as for schizophrenia, autism, and depression), none are currently part of the diagnostic criteria for any mental illness, or widely used at all (read: there is no lab test for mental health).

How prescribing psych meds works

So, instead of sending you to get your blood drawn, prescribers are supposed to interview you, use empirically-supported tests to diagnose you, and then? See the above spaghetti comment. They have you try something, you see if it works. That’s it. (My personal hypothesis is that, in 100 years, when future generations look back at today’s version of psychiatry, our current knowledge, medications, and diagnosing and prescribing methods will look about effective and accurate as the frontal lobotomy does to us today.)

Other issues with prescribing

I’ve worked with a fair number of prescribers (be it a doctor or physician assistant or nurse practitioner) over the years, and I guess this hit-and-miss system for medications isn’t my only complaint. While they don’t use laboratory tests, my experience has been that prescribers don’t fully utilize the tools they do have: written tests, official DSM diagnostic criteria, and the interview. Usually, on my first visit, the prescriber will ask me why I came in, and that’s that. Maybe once have I been asked a range of questions in order to discern if I have conditions other than the ones I bring up. I have been handed papers a couple of times with a written diagnostic test, but it’s not very common. It doesn’t seem like prescribers can always be bothered to make a precise diagnosis. Maybe they care more about identifying symptoms? Maybe they don’t have time? Maybe they feel like they’ve seen this a thousand times before and don’t need additional information? I’m not sure.

My other major complaint is that there has been almost no effort to ever track my symptoms in any systematic way—which means no data to figure out if or how well an intervention is working. One doctor I worked with did hand me a clipboard with a depression scale quiz at the start of every appointment—which then would go in a file with all the others. I don’t recall her even looking at them. I doubt she was ever pulling them out, adding up the scores, and looking for trends. Basically, the prescriber assessing whether a medication is working (or how well) is only ever based on how I respond to, “So, how are you feeling?”

Even if the prescribers don’t do it, I’ve tried to track my own symptoms with the help of an app. This helps, though it is hardly scientific. Still, it gives me an illustration—I can go back and see for example that yes, last month was pretty horrible. This does help me communicate better with healthcare providers–and that communication, I’ve learned, is key to getting help that works. You simply have to advocate for yourself.

Anyway, in order to help you better understand this “spaghetti method” and my other observations, let me sum up how working with a psychiatric prescriber seems to go down:

Visit 1:

Prescriber: What brings you in today?

Me: I think I have depression.

Prescriber: That sounds legit. I probably don’t need to give you a diagnostic test or anything if you already think that’s the case. Here, take this antidepressant medication and come back in six weeks.

Me (wondering about side effects and interactions, but concluding it will be just as easy to google it): Okay

Visit 2 (six weeks later):

Prescriber: So, do you feel better?

Me: Uh…I don’t think so? We weren’t like tracking symptoms or anything, so…

Prescriber: Let’s increase the dose. Come back in six weeks.

Me: Uh, alright…

Visit 3 (six weeks later):

Prescriber: So, do you feel better?

Me: Not really…

Prescriber: Here, try this nearly-identical antidepressant medication from the same class. Maybe it will magically work even though the chemically-similar one didn’t.

Me (wondering if I should be, like, tracking how I feel and looking for changes): Uh, alright

Prescriber: Come back in eight weeks.

Visit 4 (eight weeks later):

Prescriber: So do you feel better?

Me: Um, maybe a little? Not totally sure…it might just be that I have the day off today that’s making me feel better in this moment…

Prescriber: Here, add this medication to augment the antidepressant I prescribed, even though you already take an augmenting medication to help you sleep, and even though when you go home and google it, you won’t find any scientific evidence that taking more than one of these augmentation medications has a greater effect.

Me: Are there, like, lifestyle changes or something I should be thinking about?

Prescriber: I just do meds. Come back in six weeks.

Visit 5 (six weeks later):

(Some repeat of one of the previous visits, you can choose which.)

You get the idea.

What to do about it

So what do you do about this imperfect system? Here are my suggestions:

  1. Track your mood and symptoms. When a prescriber asks if you’re feeling “better,” it can be hard to answer. It can be influenced just by how you’re feeling in that moment, for example. Keeping track of your mood and most common and/or troubling symptoms can help you answer this question with more accuracy.

  2. Keep a record of what medication you’re prescribed, the dosage, why and when it was prescribed, and changes you notice while taking it (good or bad). This helps you discuss meds with your prescriber, and can be hugely helpful should you switch to a different prescriber.

  3. Educate yourself. Ask about side effects and interactions. Ask about other options for treatment. Look up the medication you’re taking. Talk to your pharmacist (they didn’t get that fancy degree just to become a glorified cashier). Learn about your condition and treatment options, and discuss them with your prescriber.

  4. Along with educating yourself, ADVOCATE FOR YOURSELF. You’re the expert on you. You know more about yourself than your prescriber does. If you want to try a different treatment, or you’re skeptical about a certain medication, or whatever, bring it up with them! For me, the first antidepressant I tried that actually helped was one I had learned about on my own and asked to try. Speak up.

Seeing a psychiatric prescriber and finding the right treatment can be a frustrating and inefficient system. Part of that is just a function of the knowledge and technology that’s currently available to us—but part of it is under your control! So try not to get too frustrated–and don’t be afraid to speak up.

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