Is medication necessary for mental health treatment? with Dr Ken Ung — Podcast Shownotes
Is medication a cure-all for mental health conditions? At what point should you consult your medical professional about starting medications? And what might we expect when starting on medication for the first time?
In this episode, we demystify medication as a treatment for mental health conditions with Dr Ken Ung, a leading psychiatrist in Singapore. Interviewed at CalmCon well-being festival on 13 November 2021 by Nicolette Yeo (Nikki), host from Calm Collective Asia.
Podcast Excerpt
The following interview has been edited for brevity and clarity
Nikki: What is a typical day for you in the clinic or in the hospital? Are there any specific areas of speciality that you have in your practice?
Dr Ung: My typical day usually starts around 9 am. I’d drop by the clinic. It’s been quite busy — one of the things with COVID has been that the number of new referrals has shot up. So I generally try to work through lunch, it’s just a bit easier. Otherwise, there’ll be a long queue and big jams where people might get disgruntled. So I’ll usually work till about six and then I’ll pop by the hospital if I have an inpatient.
Nikki: You talked about having a lot of new referrals recently due to COVID. Did you do a transition to telemedicine during that whole circuit breaker period? How was that process like for you?
Dr Ung: We didn’t because we are considered an essential service, so we were still seeing our patients but we did do more teleconsulting through Zoom, WhatsApp, Microsoft Teams, through the phone and email. The patients wanted to do remote consulting and then have their medications delivered to them or send someone to pick them up. During the circuit breaker period, although we were open, we were doing a lot more tele-consulting.
Nikki: Why is medication important in treating mental health conditions?
Dr Ung: Medications are not always necessary. For example, if I’m seeing a primary school kid, I’d probably not want to use medicines unless I really have to. I’d far prefer to use psychotherapy, counselling and working with the parents or school to help the kids.
But there are certain conditions where medications are going to be very important because psychotherapy might not work well. For example, ADHD, Bipolar Disorder, Schizophrenia or severe depression. For these, medication becomes essential.
There’s also a big group of conditions where both counselling and medication can work. For those, we try to work with people’s preferences. Some may not like medications so if there is an alternative like psychotherapy, we will offer that. On the other hand, some may find psychotherapy rather cumbersome and find medications more convenient, so we’ll go with that. Quite often, we end up combining both. There’s a myth that psychotherapy and medications clash but they don’t. They actually complement each other. A lot of referrals come to me through psychologists and therapists because they themselves see that when somebody is quite ill, they’re not really going to get much out of therapy. When medication is given concurrently, then it works a whole lot better.
Nikki: Some say that mental health conditions can be caused by a chemical imbalance in the brain that can be treated or regulated by medication. Is that correct?
Dr Ung: Yes. Medications are artificial chemicals. They work primarily by chemicals in the brains which we call neurotransmitters. The common ones are serotonin, dopamine and adrenaline. So what they do is they try to normalize the chemical balance in the brain. When an illness occurs via depression, anxiety, ADHD, schizophrenia, bipolar disorder, there are some kinds of changes going on at the chemical level of the brain. So medication works through chemical means to try and restore the normal balance.
Nikki: What is the diagnosis process like for a first-time patient?
Dr Ung: Usually they will come with a bunch of complaints or changes that they have noticed (also known as symptoms). If they come with somebody, then that person can become an important source because we also want some information from an informant, who can be a spouse or friend. Sometimes they might notice things that perhaps the patient themselves don’t. From the symptoms, their medical and past family history, and questionnaires like the PHQ-9, we can pull together all the information to make a working diagnosis. Upon sharing with the patient, if they agree with the description of that condition and that is what’s going on, we then talk about possible treatments and preferences and we go from there.
Nikki: Can you name some of the main classes or categories of medications that you prescribe for some of the more common mental health conditions?
Dr Ung: We commonly prescribe medications that help people sleep. This could range from sedatives to sleeping pills and medications for anxiety. We have a range of mild medications that are not addictive at all to some that are more powerful which could potentially be addictive if one is not careful.
Antidepressants are used to treat depression as well as anxiety. We also have a group of medications called antipsychotics — these are more powerful and we use them to treat schizophrenia and bipolar disorders. We have medications for ADHD which are meant to help people to focus and be more alert. We also see elderly people and have medications that help with dementia.
Nikki: How would you deal with the side effects that your patients are experiencing? Is there a titration process to start?
Dr Ung: That’s absolutely right. So let’s say we start an antidepressant. We’d usually start low at half a dose at least for a few days. We want to make sure that the person who’s taking the medication is tolerating it well. If they’re okay, then we can tell them to increase to a normal dose after 3-5 days. We see them back about 2-3 weeks and by then, we should be able to have a good grasp of any side effects.
If there are side effects, we have to then decide what to do with it. Sometimes, when we lower the dose, the side effects may go away and doesn’t come back after increasing it back because the body gets used to it. If it’s really a concerning side effect to the patient, we may suggest a switch in medication. This may not be the most ideal situation but we may also use another medicine to neutralise the side effects. But this is more common for conditions like schizophrenia where we put them on antipsychotics. For example, sometimes they get tremors which are more seen in older medications (newer medicines generally have lesser side effects), we may give them an antiparkinson type of medication to neutralise that side effect.
Nikki: Another myth that people have about medications is that they can work overnight or they start feeling better immediately. How long is the window for medications to start taking effect?
Dr Ung: It is and also isn’t a myth because it really depends on the condition that we are treating and the medicine that we give. For example, let’s say we treat ADHD which is highly responsive to medications — the effects are pretty immediate. Sometimes to a person, within 15 - 30 minutes we will know if it works or it doesn’t. Therefore, in certain conditions and medications, the effect can be quite rapid. Some of them are sleeping pills, ADHD medications and anti-anxiety medication.
Meanwhile, that’s not the case for antidepressants. You’d typically have to wait 1-3 weeks for the medicine to work but that’s about how long you need to wait. If a person is no better after 3 weeks on antidepressants then we should be prepared to accept that it’s not working.
Nikki: How would you find the right cocktail of medication for someone who might be suffering from multiple mental health conditions?
Dr Ung: If we can use one medication on its own, we rather do that than use a combination but sometimes we have to because one may work only partially. In general, if we use a single medication, 2-3 weeks would give us a fairly good clue whether we are on the right track; if the patient is getting better and whether they can tolerate it well.
Assuming that doesn’t happen, then we may have to resort to maybe adding medications. How long it would take is a good but difficult one to answer. We’re all like jigsaw puzzles and we’re all different. Medication is just one piece of that puzzle so it would be difficult to give a specific timeframe. The more medication that one fails to respond fully to, the longer it will take to find the right cocktail. If we know the past medications one responded to or that family members respond well to, we can often short circuit the process and use those that is already made known as opposed to selecting by chance.
Nikki: What advice do you have for someone who may be struggling with their mental health, and might be considering seeking help from a psychiatrist?
Dr Ung: I understand that it takes great courage and it’s a big step. Most of us in the healthcare profession are trying to make things as easy as possible for you. Ultimately, we can’t force people. So my advice is if you’re struggling, get some help even if it's on a remote platform. If you’re scared, maybe speak to someone who’s been through some of this. That’s why platforms like Calm Collective are great because their people have gone through the process themselves.
I suppose people could question my credibility because I haven’t suffered the way they did before — which is fair. When they hear from people who have gone through it, then sometimes they feel like it’s a bit easier to hear “I went through what you did, I sought help, it wasn’t so horrible, it really helped”.
So I would say, start the journey. If you’re scared, do it remotely. If you don’t feel like it, join a platform like this to see what others have to say about their experiences and to help you feel less alone in this journey.
Help is available but ultimately, you have to take that leap of faith to trust a healthcare professional to help you.
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Calm Conversations is a podcast series launched and facilitated by Calm Collective Asia. As a means of sharing personal experiences, lessons, and advice, we speak to people from all walks of life about topics that are universally relevant yet often still taboo in the hope of normalising conversations about mental health.
Available on Spotify, Google, and Apple, you can tune in whenever and wherever. We hope that by listening in, you feel less alone, learn something new, and find the courage to continue these conversations with the people around you. Stay calm!
Read more from Nicolette Yeo:
How to talk about mental health at work without just virtue signalling
How to approach a loved one whose mental health might be in a downward spiral