Abstract

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 symptom 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.

* * *

There 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 the 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, 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, 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.

S-D: 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, 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 relevant, 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 symptoms 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 monitors 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: ie. 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, 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 symptoms, and tolerable. The focal symptom (fatigue) 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. Furthermore, because alcohol produces cognitive impairment, it diminishes the capacity to function at a high level (eg. 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, 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 (eg. one well-known formulation is called Benylin). Diphenhydramine was, indeed, the root molecule from which fluoxetine/ Prozac was originally synthesized [2, 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 [2,18]. 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, 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’ [2,18]. The long term reputation of antihistamines as relatively safe drugs has been established over many decades of OTC availability. This offers 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, 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’ (eg. 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, 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 [eg. 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 of 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, 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.

Bruce G Charlton.
Editor-in-Chief – Medical Hypotheses

Reader in Evolutionary Psychiatry
Henry Wellcome Building
University of Newcastle upon Tyne
NE1 7RU
UK

Correspondence: bruce.charlton@ncl.ac.uk

References

1. Charlton BG. Palliative psychopharmacology A putative speciality to optimise the subjective quality of life. QJM 2003; 96: 375-378

2. Healy D. The creation of psychopharmacology. Harvard University Press: Cambridge, MA, USA. 2002

3. Charlton BG. Personal freedom or public health? (Book Chapter). In Marshall Marinker (Ed). Medicine and humanity. King’s Fund: London, 2001. Pp. 55-69.

4. Charlton BG, Andras P. Medical research funding may have over-expanded and be due to collapse. QJM 2005; 98: 53-55

5. Charlton BG. Diazepam with your dinner, Sir? The lifestyle drug-substitution strategy: a radical alcohol policy. QJM 2005 98: 457-459.

6. Eagles JM. Seasonal affective disorder. British Journal of Psychiatry. 2003; 182: 174-6

7. Linde K, Ramirez G, Mulrow CD, Pauls A, Weidenhammer W, Melchart D. St John's wort for depression - an overview and meta-analysis of randomised clinical trials. BMJ. 1996; 313: 253 - 258.

8. Szegedi A, Kohnen R, Dienel A, and Kieser M. Acute treatment of moderate to severe depression with hypericum extract WS 5570 (St John's wort): randomised controlled double blind non-inferiority trial versus paroxetine. BMJ, 2005; 330: 503.

9. Charlton B. Psychiatry and the human condition. Radcliffe Medical Press. 2000.

10. Charlton BG. The malaise theory of depression: major depressive disorder is sickness behavior and antidepressants are analgesic. Medical Hypotheses. 2000; 54: 126-130.

11. Charlton B. Treatment of chronic fatigue with analgesics. www.hedweb.com/bgcharlton/fatigue. Accessed 25 July 2005.

12. Charlton BG. Psychopharmacology and the human condition. JRSM 1998; 91: 599-601.

13. Whitaker R. The case against antipsychotic drugs: a 50-year record of doing more harm than good. Medical Hypotheses. 2004; 62: 5-13

14. FDA Public Health Advisory. Deaths with Antipsychotics in Elderly Patients with Behavioral Disturbances www.fda.gov/cder/drug/advisory/antipsychotics.htm. Date created: April 11 2005

15. Healy D. Let them eat Prozac. New York University Press: NY, USA, 2004.

16. Healy D. Psychiatric drugs explained. 3rd edition. Churchill Livingstone: Edinburgh, 2002.

17. Charlton BG. Self-management interventions for panic, phobia and other anxiety-disorders might include over-the-counter (OTC) ‘SSRI’ antihistamines such as diphenhydramine and chlorpheniramine - Correspondence. Acta Psychiatrica Scandinavica. In the press.

18. Domino EF. History of modern psychopharmacology: a personal view with an emphasis on antidepressants. Psychosomatic Medicine. 1999; 61: 591-598.

19. Hellbom E, Humble M. Panic disorder treated with the antihistamine chlorpheniramine. Annals of Allergy, Asthma and Immunology 2003; 90: 361.

20. Huf G, da Silva Freire Coutinho E, Fagundes HM Jr, Oliveira ES, Lopez JR, Gewandszajder M, da Luz Carvalho A, Keusen A, Adams CE. Current practices in managing acutely disturbed patients at three hospitals in Rio de Janeiro-Brazil: a prevalence study. BMC Psychiatry. 2002; 2: 4. Epub Jan 22 2002.

21. Vishne T, Amiaz R, Grunhaus L. Promethazine for the treatment of agitation after electroconvulsive therapy: a case series. Journal of ECT. 2005; 21: 118-21.

22. Sobo S. Psychotherapy perspectives in medication management. Psychiatric Times. www.psychiatrictimes.com/p990423.html. 30.01.2003

23. Rodriguez-Landa JF, Contreras CM. A review of clinical and experimental observations about antidepressant actions and side effects produced by Hypericum perforatum extracts. Phytomedicine. 2003; 10: 688-99.

24. Hsuing R. Psychopharmacology tips. http://dr-bob.org/tips/ - accessed 25 July 2005.

25. Pearce D. The responsible parent's guide to healthy mood-boosters for all the family. BLTC Good Drug Guide. www.biopsychiatry.com – accessed 25 July 2005.

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also by Bruce Charlton
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Palliative psychopharmacology
The Malaise Theory of Depression
Public Health and Personal Freedom
Psychiatry and the Human Condition
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Injustice, Inequality and Evolutionary Psychology