Posted by alan2102 on October 11, 2007, at 10:21:18
Medical Hypotheses
Volume 65, Issue 5, 2005, Pages 823-828
doi:10.1016/j.mehy.2005.07.013
Copyright © 2005 Elsevier Ltd All rights reserved.
Editorial
Self-management of psychiatric symptoms using over-the-counter
(OTC) psychopharmacology: The S-DTM therapeutic model -
Self-diagnosis, self-treatment, self-monitoringBruce G. Charlton, Editor-in-Chief -- Medical Hypotheses
Reader in Evolutionary Psychiatry, Henry Wellcome Building,
University of Newcastle upon Tyne, NE1 7RU, UKAvailable online 19 August 2005.
Summary
Pharmacological self-management is becoming more widespread in
modernizing societies, as part of a general expansion of health
care. This may exert a vital corrective balance to the
professionalization of health by ensuring that the individual
perspective of patients is not neglected. There are many 'good
ideas' for new treatments being published which have a plausible
scientific rationale for effectiveness and a low likelihood of
harm, yet are essentially ignored by mainstream medical research.
The most likely avenue for progress is probably the spread of
self-management, together with increased sharing of experience via
the internet.There is considerable scope for self-management of psychiatric
symptoms with psychoactive medication purchased 'over-the-counter'
(OTC) and without prescription. A surprisingly wide range of
effective psychoactive agents are available with the potential to
self-treat many of the common psychiatric problems. These include
'medical' psychopharmacological agents such as analgesics and
antihistamines, a plant extract called St. John's Wort
(Hypericum), and physical treatments such as early morning bright
light therapy.But self-management currently lacks an explicit therapeutic model.
A three stage process of S-DTM -- self-diagnosis, self-treatment
and self-monitoring is proposed and described in relation to
psychiatric symptoms. Self-diagnosis describes the skill of
introspection to develop awareness of inner bodily states and
emotions. A specific sensation is identified and isolated as the
'focal symptom' for subsequent treatment and monitoring.
Self-treatment involves choosing a drug (or other therapy) which
is intended to alleviate the focal symptom. Self-monitoring
entails a continued awareness of the focal system and of general
well-being in order to evaluate effect of therapy. Self-monitoring
could involve repeated cycles of dose-adjustment, and on-off
('challenge--dechallenge--rechallenge') therapeutic trials.An example of S-DTM applied to psychiatry might include the
attempt to alleviate the fatigue and malaise symptoms underlying a
'depressed' mood by using OTC analgesics such as aspirin,
paracetamol/acetaminophen, ibuprofen or codeine. Anxiety symptoms
might be self-managed either using an 'unofficial SSRI' (selective
serotonin-reuptake inhibitor) such as the antihistamines
diphenhydramine or chlorpheniramine; or with St John's
Wort/hypericum.Article Outline
: OTC psychopharmacology
: S-DTM -- self-diagnosis, self-treatment and self-monitoring
: SD -- self-diagnosis
: ST -- self-treatment
: SM -- self-monitoring
: A further example of S-DTM -- anxiety
: Conclusion
: Acknowledgements
: ReferencesThere are many reasons why people might prefer self-management of
psychiatric symptoms to consulting a professional. These include
more rapid treatment, retaining control, maintaining
confidentiality, shunning the stigma of diagnosis, mistrust of
psychiatrists, avoidance of the cost and inconvenience of
attending consultations, fear of side-effects from prescribed
medications, and also the possibility that self-management might
actually give better results (especially given the time and
funding constraints, and conflicts of interest which affect the
health care establishment). Furthermore, self-management is
usually aimed at improving well-being, fulfilment and quality of
life; whereas psychiatrists usually aim at treating disease
syndromes, which may leave the patient feeling considerably worse
[1].Self-management of health is probably becoming more widespread in
modernizing societies, as part of the general expansion of health
care, with more drugs being made available without a prescription
following an era of several decades (triggered by the thalidomide
tragedy) during which most effective medications were
prescription-only [2]. This may exert a vital corrective to the
professionalization of health, and ensure that the subjective
perspective of patients is not neglected [3]. Self-management is
particularly relevant at present, when it seems that medical
research is failing to make therapeutic breakthroughs as it did in
the past, and is apparently insufficiently motivated by the need
to improve outcomes for patients [4].There are many 'good ideas' in therapeutics being published, for
example in Medical Hypotheses, which -- despite a plausible
scientific rationale for effectiveness and a low likelihood of
harm -- are essentially ignored. The most likely avenue for
short-term therapeutic progress in these areas is the spread of
self-management together with increased sharing of the experiences
via internet.OTC psychopharmacology
While psychiatric 'self-help' via psychological and
psychotherapeutic methods is very widespread, and always has been,
this is not yet the case for psychoactive drugs (with the
exceptions of alcohol, tobacco and caffeine [3] and [5]). The
principle of individuals managing their own well-being with
medication they have bought 'over-the-counter' from the pharmacist
or druggist (or via the internet) is very common for symptoms such
as pain, indigestion, nasal congestion and cough. But the scope
for applying this 'palliative' [1] self-management model to
psychiatric symptoms and OTC psychoactive drugs is so-far
unexplored.It is not generally realized that there are a wide range of
effective psychoactive agents available without prescription and
over-the-counter (OTC). Such agents are potentially usable by
individuals interested in managing their own psychiatric symptoms.
These include 'medical' pharmaceutical agents such as analgesics
and antihistamines, a plant extract called St. John's Wort
(Hypericum), and physical treatments such as early morning bright
light therapy.Even if judged by conventional psychiatric diagnosis-based
standards, rather than symptom-orientated subjective evaluations
of well-being, some of these therapies measure-up very favourably
against prescribed drugs. Early morning bright light therapy is
the first-line treatment for Seasonal Affective Disorder (SAD) [6]
which is essentially winter lethargy (including demotivation,
over-eating and over-sleeping) caused by short days. This
condition is now quite widely recognized and self-diagnosed in
countries with extreme latitudes (such as the UK), and typically
self-treated rapidly and effectively by early morning rising and
use of bright lighting (including proprietary 'light visors' and
'light boxes') And it seems possible that the plant product St.
John's Wort is actually superior to, as well as safer than, the
prescription-only selective serotonin reuptake inhibitors (SSRIs)
when used to treat mild to moderate depression and anxiety [7] and
[8].But drug knowledge alone is not enough. Psychiatric
self-management also needs a model. One possible way of
conceptualizing this is the three stage process of S-DTM --
self-diagnosis, self-treatment and self-monitoring.S-DTM -- self-diagnosis, self-treatment and self-monitoring
The S-DTM model of OTC psychopharmacology is here described in
relation to psychiatric symptoms. But the same therapeutic
principles are also applicable to medical complaints such as pain,
indigestion and nasal congestion.SD -- self-diagnosis
Self-diagnosis describes how an individual person starts with an
awareness of illness or some unpleasant feeling, and moves to
identifying the specific underlying symptom -- the 'focal symptom'
- which seems to be the cause of that illness. Self-diagnosis is
therefore a skill of introspection (or, more precisely,
'phenomenology' [9]) -- and introspection is a skill which can
usually be learned and developed, even when not spontaneously
present.For instance, an individual might be feeling 'depressed' and
miserable. They would first need to become aware of their inner
bodily sensations and emotions, and see whether the feeling of
depression seems to be associated with a specific emotion. For
example, it might be observed that the feeling of 'depression'
seems to be caused by a feeling of fatigue -- of malaise,
exhaustion, feeling 'washed-out', heaviness and aching limbs, a
dull headache over the eyes [10]. This symptom of fatigue (in its
various manifestations) is then isolated and becomes the focus for
attention and treatment [11].Of course, introspection is not reliable (although, to be fair,
neither is any other form of clinical diagnosis). The results of
introspection should therefore be regarded as a working
hypothesis, and open to revision on the basis of experience. On
the other hand, it is reasonable to assume that consciousness
evolved because it was adaptive [9], so the results of
introspection are worthy of consideration.It is not rational to treat the mood of 'depression' directly
using drugs, because moods are insufficiently precise to be
regarded as a focal symptom. Mood is an end-state, and there are
an infinite number of reasons why a person might be depressed:
hence moods do not respond directly to drugs but indirectly via
drug-induced or -initiated changes in emotions [9] and [10].
Emotions should usually be the focus of treatment [9]. If
'depression' can be put down to the emotion of fatigue -- as a
working hypothesis -- then fatigue becomes the 'focal symptom'.This illustrates the general principle that diagnosis is not
always spontaneously obvious, since many individuals will
spontaneously report an aversive mood change rather than the
underlying emotional cause. To make a clinically useful diagnosis
requires knowledge of the possible nature and range of focal
systems for which potential treatments are available.ST -- self-treatment
Self-treatment is the next step after self-diagnosis -- although,
of course, in self-management it is the individual who decides
whether or not they want to have treatment, and they may prefer to
avoid drugs.Pharmacological self-treatment involves choosing a drug (or other
therapy) which is intended to alleviate the focal symptom. The
choice of therapy is initially based on available scientific
knowledge regarding psychopharmacology. This provides an
indication of potentially useful agents; and also knowledge of
what should be avoided, as likely to be dangerous or make things
worse.So, if the focal symptom is fatigue, and if fatigue is experienced
as a kind of pain (albeit a dull, dragging kind of pain) -- then
one rational choice of treatment might be pain-killers [11]. The
choice of analgesic (or analgesic combination) will depend on
individual factors such as side-effects, interactions, and
individual idiosyncrasies in response.Having chosen a potentially useful drug, the first step is to read
the information label (and do some research on the internet) to
learn about effects, side-effects, contra-indications and
interactions -- just as for any other OTC situation. In
self-management the individual is responsible for the chemicals
they put into their own bodies (as, ultimately, ought to be the
case for almost all medical situations with competent adults as
patients [3]).There are five analgesics which are available OTC in the UK:
aspirin, ibuprofen, paracetamol (acetaminophen), and the opiates
codeine and dihydrocodeine (the opiates are only available OTC in
combination with one of the previous three drugs). These
analgesics may potentially be taken individually in various doses,
or in combination (avoiding combinations of aspirin and ibuprofen,
or the two opiates). A period of trail and error then follows --
and this is based on self-monitoring.SM -- self-monitoring
Self-monitoring entails an individual maintaining awareness of
their own body state, and the effect of drugs on their body state.
There are two aspects: awareness of the focal symptom and
awareness of 'general well-being'.The first skill which needs to be learned is focusing on the
specific symptom being treated, and monitoring the focal symptom's
response to treatment. This focal awareness perceives and
evaluates the specificity of the drug. The second skill is
monitoring the individual's own overall state of well-being in
response to the drug, to answer the question: is life better on
the drug or off it [1]? This general aspect of self-monitoring
evaluates whether the drug is subjectively beneficial or not.The most important aspect in self-monitoring is the first dose.
The first dose should be taken when there are a couple of hours to
spare during which the individual can concentrate on
self-monitoring of the focal symptom and of their general
well-being. Most drugs take about an hour to be absorbed, and at
that point the individual may become aware of changes -- changes
in the focal symptom, and other changes including side-effects or
other unforeseen effects. Overall they might begin to feel better,
or worse -- or be unaffected. (It might be useful to note these
observations at the time, for later reference.) If the drug does
not alleviate the focal symptom, or makes the individual feel
generally worse, then the individual will probably want to stop
taking-it, and trial some other agent instead.As a general guideline, an implication of evolutionary biology is
that the body has evolved so it feels bad when it is harmed and
feels good when it is healthy (more precisely, under ancestral
conditions and on average, things that are rewarding tend to
promote reproductive-success or 'fitness', while things that are
aversive tend to reduce fitness [12]). So, drugs that make someone
feel bad may be harming them. This provides a negative feedback
loop for self-management, one which has the potential to avoid
some of the most dangerous aspects of psychiatric treatment, which
have occurred when drugs made patients feel worse but patients
were persuaded (or coerced, in some instances) to continue taking
them because they were being prescribed to treat a 'disease',
rather than to make the patient feel better. Examples might
include the over-usage and inappropriate usage of neuroleptics
leading to tardive dyskinesia [13], the use of 'atypical
neuroleptics to suppress agitation in elderly people [14], and the
problem of suicidality induced by SSRIs [15]. Such problems might
have been substantially prevented if self-monitoring individuals
were able to do the 'natural' thing: i.e., stop taking drugs which
made them feel worse. In such instances, self-management offers
significant safety advantages over the standard medical model of
prescribing for diseases [1].By contrast, drugs that make someone feel healthy are probably
doing them good. An exception occurs when a drug is making the
individual feel euphoric and 'high' rather than healthy -- like
cocaine or intravenous heroin -- in which case the drug will
probably impair cognitive function, may be addictive, and possibly
harmful in the long term [3] and [9].Individual, subjective monitoring of drug effects is important
because drugs that alleviate a focal symptom may nonetheless make
the patient feel generally worse. Also, there is wide individual
variation, and the average effect of drugs in clinical trials does
not preclude minorities which have the opposite response:
'effective' drugs make some people worse, and 'harmful' drugs may
be useful in some individuals. Individual self-monitoring can help
determine whether this specific drug is useful for this unique
individual.If a drug works, then an individual may want to keep taking it for
a while. But the long-term is different from the short-term: new
side effects may emerge, drugs may lose their benefit (tolerance),
or the body will become dependent upon the drug (leading to
withdrawal symptoms) [16]. So, self-monitoring needs to continue
pretty much on a permanent basis. Self-monitoring involves
repeated cycles of dose-adjustment and on-off
('challenge--dechallenge--rechallenge') trials [1]. For example,
individuals could try reducing the drug dose while self-monitoring
(monitoring both the focal symptom and general well-being). Or
tapering-off the drug and slowly withdrawing, while
self-monitoring.For the above example of 'depression', the following scenario
might occur. A feeling of misery was self-diagnosed as probably
being caused by fatigue symptoms, perhaps following a severe bout
of influenza. The fatigue symptoms were treated with a range of
OTC analgesics and -- after trial and error -- ibuprofen was found
to be effective at alleviating the fatigue and was tolerable. The
focal symptom was improved by ibuprofen, and the individual also
had a greater feeling of well-being. When ibuprofen was stopped,
as an experiment, the fatigue returned within a day. So a 12 hour,
long-acting formulation of ibuprofen was taken twice a day, and
the individual was relieved of fatigue. Because of this relief
from an unpleasant symptom, they began to do more enjoyable things
(and enjoy doing them more), and over the next couple of months
the 'depression' lifted and they gradually felt happier and
functioned better. After a few weeks of feeling better the dose of
ibuprofen was reduced gradually to nothing. A few new aches and
pains become apparent after stopping the drug, but after another
week these disappeared, and the person was drug free. But if the
fatigue returned on stopping ibuprofen, they might decide to
continue taking the drug for many months, or even years.A further example of S-DTM -- anxiety
Anxiety -- feeling nervous, tense, wound-up, fearful, a gnawing
dread -- is probably the commonest psychiatric symptom [3].
Furthermore, it is a feeling which people usually recognise
without needing to go through an introspective process of
self-diagnosis.The commonest form of self-treatment for anxiety is alcohol --
which is a very effective short term anxiolytic [16]. Indeed, if
the hypothetical focal symptom of anxiety does not respond to
alcohol, then probably it is not anxiety. However, unfortunately,
for reasons which are too well known to rehearse, alcohol is an
exceptionally dangerous drug which damages health in many ways, as
well as causing harm to others [5]. Furthermore, because alcohol
produces cognitive impairment, it diminishes the capacity to
function at a high level (e.g., driving, operating machinery,
looking after children), and is therefore unsuitable as a daily
medication.The most obvious substitute for the anxiety-reducing effects of
alcohol is the benzodiazepines such as diazepam [5] and [16] --
however these are not available OTC. The most commonly prescribed
drugs for anxiety-type symptoms are the SSRIs such as
fluoxetine/'Prozac'. Fortunately, an 'unofficial SSRI' is actually
widely and cheaply available OTC, although this fact is not well
known [17].The clearest example of an unofficial SSRI is diphenhydramine,
which is an old antihistamine with a sedative action, usually sold
as a treatment for coughs and allergies (e.g., one well-known
formulation is called Benylin). Diphenhydramine was, indeed, the
root molecule from which fluoxetine/Prozac was originally
synthesized [2] and [18]. I am not aware of any formal clinical
trials of diphenhydramine for anxiety, but since it fulfils the
pharmacological definition of an SSRI it should, on
pharmacological grounds, be usable for the same indications.Chlorpheniramine (often sold under the name Piriton, for hayfever)
is a similar kind of antihistamine to diphenhydramine, and it
probably has similar anti-anxiety properties, having been the root
molecule for the original experimental SSRI, zimelidine [2] and
[18]. A small clinical trial of chlorpheniramine suggested that it
was (like the prescribed SSRIs) effective for the treatment of
panic disorder [19] -- so chlorpheniramine might well be useful in
treating other forms of anxiety.Promethazine (sometimes marketed as Phenergan) is a powerfully
sedative antihistamine and has been used to control agitation in
disturbed and psychotic patients [20] and [21]. Promethazine might
be a suitable self-management agent to induce 'emergency
self-tranquillization' for people who know they are prone to
escalate into 'manic' episodes of hyper-activity and sleep
deprivation, or other acutely excited states which have the
potential to become psychotic [9].Indeed, sedating antihistamines have been used to treat a range of
agitated psychiatric disorders before neuroleptics were invented,
or when neuroleptics were unavailable [2]. This is unsurprising
when it is considered that nearly all the major groups of
effective psychiatric drugs (neuroleptics, SSRIs and tricyclic
antidepressants) are chemically derived from the antihistamines,
which were themselves derived from dyes such as 'summer blue' and
'methylene blue' [2] and [18]. The long term reputation of
antihistamines as relatively safe drugs has been established over
many decades of OTC availability. This gives these old drugs
certain advantages compared to the more recent SSRIs -- for
instance some appear to be safe to take during pregnancy, and are
indeed prescribed to control pregnancy sickness [17].The effect of SSRIs on anxiety seems different from that of
alcohol or benzodiazepines, which are muscle relaxants and tend to
diminish tension rapidly to give a pleasant warm 'glow' and (in
small doses) a state of greater emotional responsivity [3]. SSRIs,
by contrast, act more like emotion-buffering agents, making the
user feel less emotional, more 'serene' or 'indifferent', and less
likely to respond strongly to the ups-and-downs of life [9], [16]
and [22]. An anxious person who was hypersensitive and prone to
mood swings might find this emotion-buffering pleasant, even
though they would probably lose the 'highs' as well as the 'lows'
(e.g., SSRIs probably make some people fall 'out of love' with
their partner [22]). But a lethargic or un-reactive ('melancholy')
person might find SSRIs quite unpleasant, cutting them off from
the experience of everyday life, rendering them 'cold' and
unemotional, perhaps demotivating them [22]. When self-monitoring
the use of diphenhydramine or chlorpheniramine on anxiety, the
user might therefore focus on evaluating the effect of these drugs
on emotional responsiveness.Another possibility for treating anxiety is St. John's Wort [7]
and [8]. At present it is hard to know precisely what this agent
does in a subjective sense, but probably it has some of the
emotion-buffering effects of the SSRIs, combined with a more
stimulating, motivating or energy-boosting effect (a bit like the
caffeine in strong coffee) -- this would fit with the finding that
it may act both on serotonergic and dopaminergic systems [23].
Nonetheless, even when used for the same indications as SSRIs, St.
John's Wort may be at least as effective and considerably more
tolerable [8].Conclusion
This article has done no more than indicate the vast possibilities
for self-management of psychiatric symptoms using OTC drugs and
other therapies available without prescription. There are many
other psychiatric symptoms, and many other potential strategies
for treating them with OTC drugs and other forms of
self-management. A more comprehensive account would take a whole
book [e.g., reference 16] -- or indeed a library of books.It is important to emphasize that knowledge of drug effects alone
is insufficient for effective and safe self-management of symptoms
-- there also needs to be a therapeutic model to guide
self-management. This model may be explicit, like the S-DTM
approach to conceptualizing therapy, or implicit as for the
current self-treatment of physical symptoms using analgesics.
Indeed, S-DTM is essentially a formalization of the practice of
'palliative' medicine as applied to psychopharmacology [1]. The
advantages of an explicit model are that it enables more effective
individual learning and allows for more precise sharing of
experience.A self-management model is clearly not appropriate for all the
population. Introspective, abstractive and analytic skills are
required, as well as knowledge. Yet with ever more of the
population (around a half) now receiving college-level education
in many countries, it is likely that an increasing proportion of
individuals would be capable of deploying the S-DTM model, if they
wished to do so. But perhaps the ideal for health care would be a
synthesis, with professional psychiatric treatment providing a
framework for detailed self-management.Furthermore, the internet is a superb media for making available
scientific (and other types of) information on drugs, and serving
as a forum for sharing personal experiences of OTC
psychopharmacology [24] and [25]. The S-DTM therapeutic model
might be a useful guide and safeguard for individuals in their
trail-blazing experiments in psychiatric self-management.Acknowledgement
My thanks are due to David Pearce for inspiration and critical
discussions on this topic.References
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Acta Psychiatrica Scandinavica
Volume 112 Issue 4 Page 323-323, October 2005
doi:10.1111/j.1600-0447.2005.00610.x
Letter to the Editor
Self-management and pregnancy-safe interventions for panic, phobia
and other anxiety-disorders might include over-the-counter (OTC)
'SSRI' antihistamines such as diphenhydramine and chlorpheniramineBruce G Charlton MD
Editor in Chief, Medical Hypotheses
Reader in Evolutionary Psychiatry, Henry Wellcome Building, School
of Biology, University of Newcastle upon Tyne, Newcastle upon Tyne
NE1 7RU, UKBarlow et al. recently described a range of self-management
psychological therapies which were an effective treatment for
anxiety disorders such as panic, phobias and obsessive compulsive
disorder (1). This principle of self-management might be extended
to include some of the early 'first generation' antihistamines
which probably have properties similar to the selective
serotonin-reuptake inhibitors (SSRIs), and which have been
available 'over the counter' (OTC) for many decades -- used mainly
in the treatment of allergies such as hay fever, and as cough
suppressants.Most modern psychiatric drugs are derived from antihistamines,
which were themselves derived from products of the chemical dye
industry (2). The first 'SSRI' was zimelidine, which was
synthesized by chemical modification of chlorpheniramine which had
serotonin-reuptake blocking properties (3,4) -- chlorpheniramine
is reported to be effective in the treatment of panic (5). The
second SSRI was fluoxetine, which was structurally-based on
diphenhydramine (4) -- an antihistamine with 'selective'
serotonin-reuptake inhibiting properties (i.e. it blocks reuptake
of serotonin much more potently than noradrenaline).It is probable that many conditions which respond to SSRIs,
including milder depression and many anxiety states (4), would
also respond to diphenhydramine or chlorpheniramine. These drugs
have the advantage of availability OTC which means they are
suitable for self-management.While chlorpheniramine and diphenhydramine have anti-cholinergic
and sedative side effects, the SSRIs are not without their
problems (4). Furthermore, these antihistamines have a good safety
profile based on long-term usage, and they are generally regarded
as being safe to use in pregnancy (6).Bruce G Charlton MD
References
1. Barlow JH, Ellard DR, Hainsworth JM, Jones FR, Fisher A. A
review of self-management interventions for panic disorders,
phobias and obsessive-compulsive disorders. Acta Psychiatr Scand
2005; 111: 272-285.2. Healy D. The creation of psychopharmacology. Harvard University
Press: Cambridge, MA, USA, 2002.3. Domino EF. History of modern psychopharmacology: a personal
view with an emphasis on antidepressants. Psychosom Med 1999; 61:
591-598.4. Healy D. Let them eat Prozac. New York University Press: New
York, USA, 2004.5. Hellbom E, Humble M. Panic disorder treated with the
antihistamine chlorpheniramine. Ann Allergy Asthma Immunol 2003;
90: 361.6. Gotomydoc.com. All about pregnancy: safe medications: cold
medications: antihistamines.
http://www.gotomydoc.com/pregnancy/safemeds/learn/cold (accessed
on 24 May 2005).------------------------------------------------------------------
http://www.blackwell-synergy.com/
Acta Psychiatrica Scandinavica
Volume 112 Issue 4 Page 323-323, October 2005
doi:10.1111/j.1600-0447.2005.00611.x
Reply
Letter to the Editor
Julie Barlow
Professor of Health Psychology, Interdisciplinary Research Centre
in Health, Coventry University Priory St, Coventry CV1 5FB, UKDear Sir,
The principles of self-management are useful for changing
behaviour. Hence, in theory a self-management intervention could
be developed to assist people in learning more about when and how
to take medication for given conditions. This holds true for
medication prescribed by health professionals or available
over-the-counter (OTC).Charlton and colleagues suggest in their response to our
publication in the Journal earlier this year (1) that drugs
developed for hay fever, etc. could be purchased OTC for the
purpose of self-managing mild depressed and anxious states. It is
assumed that some form of training for potential 'consumers' would
be needed. It is not clear how a self-management intervention
based on OTC drugs would be safely implemented. How would people
at risk of mild depression and anxiety be identified? What would
the intervention comprise? How would it be delivered? Who would
deliver it? How would it be funded?The notion that people can self-prescribe for mild depression and
anxiety states seem to miss the point somewhat. Self-management is
more than simply encouraging people to take medication to treat
their symptoms. Self-management encompasses the promotion of
responsibility and confidence in one's own ability to manage
symptoms and the wider impact of symptoms on daily life. Indeed,
many self-management style interventions do not cover medication
at all, rather they focus on providing participants with the tools
to change their behaviour, such as realistic goal setting, problem
solving and social skills. Self-management participants often
chose to focus on behaviours such as exercise, following a healthy
diet and learning to relax. In addition, the most effective
interventions address how people feel about living with a
condition -- this can involve emotional expression and emotional
validation for example. Thus, for people with mild anxiety or
depression, learning how to make exercise and cognitive
restructuring part of their daily routine may be beneficial and
for many, may be preferable to resorting to medication. Indeed,
some primary care practitioners now write prescriptions for
community-based exercise and dietary advice rather than doling out
medication for certain conditions. This seems more in keeping with
the ethos of self-management than advocating the purchase of OTC
drugs.Julie Barlow
Reference
1. Barlow JH, Ellard DR, Hainsworth JM, Jones FR, Fisher A. A
review of self-management interventions for panic disorders,
phobias and obsessive-compulsive disorders. Acta Psychiatr Scand
2005; 111: 272-285. Synergy, Medline, ISI, Chemport
poster:alan2102
thread:788458
URL: http://www.dr-bob.org/babble/20071009/msgs/788458.html