The Honorable Michael C. Burgess: Do you think the "Helping Families in Mental Health Crisis Act" takes the right approach in addressing the problems with the only "one drug" per therapeutic class policy?
Dr. Michael Welner: I do. As a clinician repeatedly board certified in clinical psychopharmacology, I have been treating folks with medication for over twenty years. As a point of reference, my practice specialized in those who did not respond to treatment and in treating those reluctant to participate in treatment.
With consideration to my earlier responses about those reluctant to participate in treatment, the best way to instill confidence in psychiatry, even in the person who denies illness, is for treatment to be effective. However, treatments for many are not magic bullets that cause full recovery. Even if, for example, seventy percent of patients would be expected to respond to a given antidepressant, partial response is exactly that. For those who have partially, if significantly, responded to a medication, combination medication treatment is the delicate exercise of getting a person all the way back with no psychotic symptoms, no depressive symptoms, no pathological compulsions, and no pathological impulses. The difference between symptoms being 70 percent better and 100 percent better is enormous, from a standpoint of quality of life.
Even if one practices, as I do, with emphasis on holistic adjuncts to treatment, promoting work, structure, healthy relationships, diet and fitness, a person with severe mental illness or in mental health crisis still has to recover to the degree that one can mobilize to employ these strategies. The psychiatric professional relies upon an array of medicines in each class that may be used in sequence or in combination, with choices that are unique to each patient’s history, medical concerns, drug sensitivities and side effects, lifestyle, and previous responses.
It is not correct to guide policy on psychopharmacology as if one is allowing for vitamins. Clinical practice does not distinguish antidepressants, for example, like Vitamin D. If you take something with the recommended amount of Vitamin D, the amount you need is the amount you need, regardless of who is the vitamin manufacturer. There are different subclasses of antidepressants, which target different symptoms and subtypes of depression. Even within subclasses of antidepressants, such as SSRIs, there are meaningful differences between the medications. I have patients in my practice, to that end, who have been on four different SSRI over the course of their treatment (for a variety of reasons) and numerous more antidepressants.
Medication treatment response, in my experience, is unique to the individual. That means that while clinical experience and excellent training and study guide one to make more prudent decisions, each patient that needs medication treatment is going to respond to one medication (or more), and may be the only patient of a group that belongs on that particular medicine. We try to be correct with that first decision, but sometimes we must change what is not working. It is no different from how physicians treat hypertension. Different medicines work for different folks, in different amounts and in different combinations.
HR 3717 does away with one drug restrictions. One drug per class therapeutics are untenable and do not bear any practical relationship to how psychopharmacology is taught and practiced in the real world. Moreover, worsening patient poverty when medicines essential to them are unaffordable, and at a time of their disability, is counterproductive to policy aiming to mobilize people back into a contributing role.
