Gait, Gait, Do Tell Me

Two sisters (religious order, not biological relation, as far as I know) live in one of the condos across from us. They are very nice, older ladies, warm and pleasant, always ready with a kind word and a smile as they see others in the complex come and go. They seem, at least on casual observation, to lead very busy lives. They rise early, heading out to do whatever it is sisters do in the world nowadays. One drives a minivan, one a small nondescript sedan. All pretty ordinary, I suppose, except for one thing that always strikes me about one of them.

Sister gets up early most mornings. She almost always beats me out of the parking lot, and I’m an early riser and starter myself. When she exits her front door she heads for her minivan, parked about fifty feet away if that, with the speed of a sprinter and the determination and conviction (again, at least as I perceive it) of a person who is going to change the world. She is diminutive, casually dressed, doesn’t stand out, but she is driven to get to her vehicle and start the day. She walks determined, rapidly, not wasting a moment of her early morning time. If I am leaving at the same time and she sees me, she will offer a cheery hello and a wave. Then she is off.

Now, come with me to my office a little later in the morning. We walk up the clinic hallway to the waiting room up front, open the door, and call out a name. The patient is in her mid-twenties, somewhat disheveled, is chewing gum, and has earphones in her ears connected to an oversized phone. She saunters to the door from the couch on the far side of the room. She is wearing dark sunglasses, which she does not remove.

I have never met this young woman, so I welcome her, introduce myself, and thank her for coming to see me. She makes no eye contact, looks straight past me, does not acknowledge my greeting, and continues her slow roll through the door and into the hallway. We stroll, no other word for it, down the hall to my office at the far end of the building. As I begin my usual interview questions, she looks at me blankly, shades still hiding her eyes, offers one word answers, and looks quite bored. This young lady does not appear to be the least bit interested in being here, in acknowledging me, or in moving the process along toward any definable goal.

What would you say about these two women, knowing only what I have told you? Granted, we acknowledge that there is  lot more about both of them, their stories, their motivations, that we do not know. However, I am being intentionally superficial in my description of them for the purpose of this post.

What does physical gait, movement, and apparent drive tell us about each other?

Of these two women, who do you feel is most likely to have set a goal, or multiple goals, for herself for the day? Which of them is more likely looking towards accomplishing something measurable before lunchtime? Of the two, which one knows what she is trying to achieve by being in the physical place she occupies this morning?

We telegraph our demeanor, our intentions, our plans, our desires, and our energy levels  to others all the time. Without saying a word, we look motivated, driven and highly focused on whatever is coming next, or we appear tired, bored, lackadaisical and aimless.

How will you present yourself to your coworkers, your boss, your spouse, your friends and to strangers today?

Will they see you as leaning into the day, full of energy and vigor, ready to accept whatever challenge comes your way?

Or, will they see you as someone who has no plans, no energy, no spark, and no reason to move any faster?

 

 

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Smallville

“No, I cannot forget where it is that I come from

I cannot forget the people who love me

Yeah, I can be myself here in this small town…”

Kenny Chesney, John Mellencamp
When I began my psychiatric training in earnest thirty three years ago, after a challenging rotating internship, the indoctrination that began was regimented, sanctioned, scripted and complete. I knew from a very young age, training-wise, that my job was to ask a few very open ended questions, listen, formulate my thoughts about my patient and his reason for coming to see me, and then to discuss this with my supervisors in order to come up with a treatment plan. A plan that sometimes was, oddly enough, kept a secret from the very person it was supposed to help. The name of the game in those days was to figure the patient out before he did it himself, and then to guide him with judicious rigor and well-timed and brilliant interpretations toward increased insight and mental health. Yes, I was trained in a predominantly psychoanalytic program that was only beginning to bring in the psychopharmacologists, who would later dominate the agenda. 

I was taught to be the proverbial blank screen. I was to show little emotion, offer little to no spontaneous conversation or banter, and to never divulge anything of note or merit about myself except under the direst of circumstances. I embraced the psychiatrist persona that was the norm for that time. This therapeutic stance was just that, but it was not real or fun to me to practice that way. I will never forget how shocked, and yes, maybe a little hurt, I was when one of my long term psychotherapy patients (a lady who had a panic disorder that would be quickly and fairly easily treated today) blurted out, ” I might as well be talking to that doorknob over there as to be talking to you. You never say anything!” When I took this to my supervisor, a prominent psychiatrist who had literally written the book on these kinds of interactions, he praised me for maintaining my therapeutic distance and stance through this obvious transference-based outburst by my patient. He gave me pointers on how to proceed from there, mapping out a strategy for the next several months. I dutifully went back to work. The patient came to see me one more time and never came back. She was not getting what she needed to get better, and she quit. 

Today, I am working in a small South Carolina town. One of my duties this morning was to go over to the probate court at the courthouse building, five minutes away from my office by car, and testify about an evaluation I did a week ago. On arriving at the probate court office, I encountered the judge sitting at her secretary’s desk, taking  phone call. 

“Aren’t you in the wrong place?” I teased her. “Your office is in there.” 

“I know! One of my staff had a death in the family and the other one had already planned a vacation, so I’m doing it all today.” 

Soon afterward, we entered the hearing room, which is just that, a room with one long wooden conference table, a dozen mismatched chairs, a wall full of musty bound county record ledgers, and us. The judge was joined by me, a clinician, the patient, her appointed attorney, and an unsmiling bailiff. 

The format, unlike the proceedings one county up in another courthouse, was informal. Information was shared, the usual legal wrangling was dispensed with, and we all made it clear to the patient and each other that we cared about her, wanted her to get treatment and supported her in doing this. Even in her pre-psychotic state she seemed to grasp the feeling in the room, the common sense of purpose, and the unification of all involved. We even joked and laughed together a few times, which felt wonderfully good and real to me. I realized, mid-hearing, that I was doing something in this sunny small town courthouse that was going to make a real difference in someone’s life. 

I will always be grateful for my training, my supervisors, my colleagues and the experiences and baseline knowledge and skill set they imparted to me. I use those skills every single day. 

However, that can never hide the fact that “I can be myself in this small town”, and it feels good when I am. I’m proud of what I can do to help people here,  and that’s exactly the way it should be. 

Stuck in My Craw

One of the things I was taught in medical school: common things are common. 

These things have been more common lately. I know I’m starting the grumpy old man phase of my blogging life, but good grief, people. Really?!?

Disrespect: 

No direct eye contact. No acknowledgement, verbal or otherwise, when greeted with a cheery good morning. Annoying behaviors designed, quite consciously, to actively annoy and derail the time in the office. Texting, typing, talking and playing games on phones in the office when active input would be appreciated! Ignoring questions outright or refusing to answer. 

Sullen mood: 

No, I’m not talking about serious depression or active psychosis. I’m talking about deliberately hostile, staring, scowling, defiant presentations designed to minimize communication. Really?

Lack of responsibility: 

“I don’t know why I had to come here.”

“I’m not sure how that gun/knife/weapon got in my gym bag, but it’s the kid’s fault that found it and turned me in that I got in trouble.”

“My teachers suck. They don’t know how to teach. They’re stupid.”

“Because I don’t like to do chores, that’s why.”

“I just don’t do the work. I don’t feel like it. No, I never turn my homework in.” 

“They can’t do this! They can’t take away my iPhone/iPad/Gameboy/PlayStation/XBox/flat screen TV just because I have four Fs and a D!”

Blaming:

It’s the teacher’s/principal’s/parents’/other kids’/government’s/doctor’s fault.

Anger for anger’s sake.

Refusal to problem solve or to see anything positive at all in a situation. 

Adversarial stance (kids and parents both!)

“Fix me!”

“We’ve tried everything and nothing works for him.”

“Nothing you can do will help.”
This was a week, friends. 

This is not entirely a mental health crisis. 

This is a crisis of investment in parenting, house rules, expectations, empowerment, upbringing, respect for elders, and establishment of normalcy in childhood. 

Enjoy your weekend. 

Next week, we all have more work to do. 

Why Do We All Want to Die?

I use an ongoing spreadsheet to keep track of and to report my demographics and stats for each telepsychiatry consult shift I do.  I’ve done thousands of consults in over two dozen South Carolina emergency departments over the last half-dozen years. We have now gone over thirty thousand consults as a group.

It never ceases to amaze me, as I fire up my computer, log on to my systems and bring up that spreadsheet for the shift ahead, that one column is remarkably uniform and consistent, sometimes for days at a time. It is the column that asks for an abbreviated reason for the consultation request. It usually looks like this:

SI

SI

SI

SI

SI

SI

SI stands for suicidal ideation, and that is one of the most common chief psychiatric complaints that we see in the emergency department.

Sometime I am simply so busy trying to see all of these people (there was a multi-day stretch recently that we had up to thirty different consults queued up waiting for one of us to see them) that I cannot afford the luxury of slowing down, looking for trends, trying to analyze why we might be so busy during that particular weekend, and the like. There is just not time. However, it is hard not to see the obvious pattern created by the number of people who come into the EDs and state to a staff member that they want to kill themselves.

Why do we all want to die?

Sure, the world has its ups and downs and stresses, but there seem to be so many people who are bent on their own destruction lately that it is mind-boggling.

Allow me to posit some reasons for this disturbing trend.

We do not feel that we belong.

I heard something on the way to something else the  other day that stated that folks who are forced to check that box called “Other” on standard forms do not feel special when doing so. They actually can be made to feel apart, cast out, cut off from the mainstream, in that they do not fit any of the standard groups listed on such forms. To be “other” is to be different, odd, not a part of the group. It is socially and emotionally ostracizing. It means that we do not belong. That hurts.

We do not feel loved.

Okay, okay, I know that is shrink talk and too touchy feely for some of you, but hear me out. I hears over and over from folks in the ED that they do not feel loved by their parents, their spouse, their children, or anyone else. Once again, whether it is feeling like the “other” or not loved by anyone at all, it is a massive cause of self loathing, isolation and hopelessness that will drive someone towards not wanting to exist at all.

Everything seems too hard these days. Nothing is guaranteed.

It used to be if you went to school, graduated, kept your nose clean and played by the rules, you would almost certainly succeed in life. You would be able to find a job, you would have a place to live, you might find love and even raise a family. Today, it seems that none of this is guaranteed, and that for some it all seems just out of reach. Sometimes, people who appear at first blush to be lazy are just depressed, unmotivated, not well-trained, not educated, and simply down on their luck. They see little hope for success no matter how hard they try, so they don’t try. It is sometimes easier to just give up, find someone or something to blame, and give up, rather than really working to make things better.

We feel hopeless.

Hope keeps us getting up in the morning. Hope keeps us going to school, working our way up the ladder, doing the jobs that no one else wants to do, taking on challenges that we are afraid of. If we lose hope, we have lost our will to challenge ourselves. We have lost our dreams for the future. We have lost our ability to see ourselves in the distance, happy and healthy and successful.

What exacerbates these core states and feelings? What makes it hard to fight back and move past them? What do I see most often in the emergency department when someone has come in after cutting, swallowing a bottle of Tylenol, or drinking themselves into oblivion?

Relationship problems are always in the mix. A teenager breaks up with the love of her life and now thinks that life is over. (She cuts herself on the arms and legs where no one can easily see her attempts to deal with her pain). A middle-aged man is a raging alcoholic but has no insight into how this is devastating his family. His wife leaves him, taking their three small children with her. He comes in with a blood alcohol level five times the legal limit. An elderly man has just lost his wife of sixty years to cancer. He is quite literally lost without her, and he does not want to go on. He is a retired police officer, owns several handguns, and knows how to use them.

Financial problems and reversals can produce high levels of anxiety that seem insurmountable. Some folks are almost paralyzed by just not being able to buy gas for the car or groceries for the kids this week. Others may be more well to do, but the shock of losing value in their retirement portfolios or not being able to make the mortgage payment on a huge house that they really cannot afford leads to guilt and shame and feelings of failure. Both can feel like the easiest way out is to simply not be here any more.

Some patients are dealing with chronic mental or physical conditions that they are simply tired of. The ups and downs of bipolar disorder, the pain of congenital spinal malformations, the physical and emotional trauma of cancer and its treatment can all lead to feelings that it would just be better to end things on your own terms rather than waiting on the  diseases to decide when it is time for you to die.

Perceived failures and disappointments (both disappointing yourself or others) often leads to the mistaken notion that if you kill yourself, the problem goes away for not just you, but everyone involved with you. The thing that most of these folks have not thought about to any degree is the pure devastation that is left in the wake of a suicide. The family members, spouses and friends who must live on after you are gone must ask all the hard questions, the “what ifs”, the whys. The guilt and emotional suffering they feel is tremendous and it never really, truly goes away.

Fear and anxiety drive many suicide attempts. Odd, in that most people think that only those who are severely depressed kill themselves. Anxiety, severe and unrelenting, actually leads more folks to actually successfully complete an attempt than depression. The underlying shame, guilt, or other emotions that drive the anxiety are often not discovered in time, or are so well hidden by the patient that it is only after the successful suicide that these are uncovered and better understood, often from the note or other communication left by the deceased.

What is the common feeling that weaves its way through it all? Hopelessness. If you think that there is no way out, that there are no viable solutions left, that you have exhausted all reasonable possibilities for making your situation better, then that gun or bottle of pills or telephone pole look like rational and logical answers for your unanswerable questions. You give up. You quit looking for answers. You feel lighter, happier, more confident because you have made that decision to just let it all go. If there is no intervention, swift and appropriate, you will die.

What are all these stresses and problems complicated by, as if it could get any worse?

One of the most common accelerants for suicidal ideation and attempts is intoxication with alcohol and other drugs. Decreased inhibitions, poor judgment, impulsivity and poor decision-making all lead to potential problems when one is already contemplating self harm. If you are already stressed, at the end of your rope, and contemplating ending it to escape the anxiety and pain you feel, reach out and get help. Drinking, smoking and popping pills rarely makes things look better.

Poor social support is another major deficit that exacerbates suicidality. I see countless patients who truly do not have family, friends, church or anyone else they can call on in time of need. They are really, truly alone. Isolation and disconnection from other people kills.

Lack of access to care also makes things worse just when the help is needed the most. The shrinking of available mental health resources in this county has lead to a dearth of programs that address acute illness and this does not bode well for someone who needs help now, not three weeks from now or at the next available appointment time.

Concomitant mental and physical illnesses can spell disaster. Those dealing with longstanding cardiac disease, severe diabetes, metastatic cancer, and other devastating illnesses may be overwhelmed with the emotional counterpart of the illness and if not noticed or addressed, it may steadily worsen and become malignant itself.

What to do if you find that you are one of those people who is thinking that death looks like your only option?

Call 1-800-273-TALK.

Talk to your family, your girlfriend, your husband, your minister or priest.

See a psychiatrist or other qualified mental health professional right away. If you are turned away when you call, call somewhere else. Don’t accept anything less than an option for immediate assessment. This is your life in the balance, and it is important.

Suicide kills over forty-four thousand people in the United States every year. For each completed suicide there are twenty-five attempts. On average, there are over one hundred twenty suicides per day in the US.

There are many reasons that many of us really want to die.

The job for the rest of us is to convince those folks on the edge that there is help.

There is treatment.

There is hope.

 

 

Too Ill to Treat

rAn article posted in the Augusta Chronicle newspaper on January 13, 2017 by Bianca Cain Johnson, Staff Writer, has left me no option but to write this blog post today. I would like to quote some parts of the article, then address some of the comments in turn, as they are provocative or distressing to me.

I should say right away that this is my personal mental health musings blog, and that my opinions are my own, in no way reflecting the policies or procedures or opinions of my employer. I should also state that there was very little factual or historical information in this article about this particular case, but for me it just brought up several broad issues of the treatment of mentally ill persons, our approach to violent behavior and other broader issues that I wanted to address.

From the article:

“According to a sheriff’s office incident report, the 31-year-old had been at the hospital for several days, but because of his mental illnesses and history of being violent, the hospital was having trouble finding a mental institution to take him.” (italics mine)

“A doctor re-evaluated him on Tuesday morning and determined he could be released.”

“…the patient stated, “the only way to get attention is to show out”.”

After he had allegedly injured a guard and nursing staff, “the patient was restrained and given medication to calm down, (and) employees heard him comment “this is what I wanted”.

Remember “too big to fail“, as it pertained to banks or motor vehicle manufacturers? Well, in mental health nowadays we run up against admission and placement issues for those patients who are “too ill to treat”. It may be because they have some element of intellectual disability. It may be that they are floridly and actively psychotic. They may be actively suicidal with access to a lethal method and a serious, specific plan. It may be, like the patient in this article, that they have a previous history of violence. For these and other related reasons, what you find is that some facilities among our dwindling number of mental health hospitals now cherry pick the patients that they want to take. If patients are too sick, too acute or too potentially violent towards themselves or others, they are denied admission and treatment, and are often stuck in emergency departments for days or weeks.

Can you imagine the outcry if a patient with chest pain that was too severe was denied admission to a cardiac care unit, or if a patient with a stroke that left him prone to emotional outbursts was denied neurological treatment?

A doctor re-evaluated the patient and made the determination that he was ready to be released. We do not have nearly enough information about that determination to be able to comment on it all, but we can say that we as physicians are notoriously bad at using our (non-existent) crystal balls to predict violent behavior. Of course, there are known risk factors, characteristics, static points of history, and previous episodes of violence that might sway one towards thinking that there was a better than average chance that some violent behavior or acting out was coming, but to be able to predict that with any significant degree of certainty is fraught with problems.

Please see this article on mental illness and violence for more detail about these related issues.

The issue of the patient knowing or learning or figuring out that in a busy emergency department the best way to be heard or to get drugs or to be assessed is to act out is another huge issue. This involves separating out acutely ill patients who act out unwittingly or because of lack of control, versus those persons who know exactly what they are doing and plan to be violent or agitated with a specific goal in mind (to be separated from the general population or to be given injectable medications, for example).

The comments about this article, which I will leave you to read on your own if you wish, were predictable. This issue is politicized, psychiatric patients are called nuts and commenters express nostalgia for the days when they could just be locked up “for a long time”. One commenter stated that the evaluating doctor should have his license pulled immediately. In my opinion, none of these kinds of comments is helpful.

What do I see going on here as a medical director for a mental health center, and even more so as a telepsychiatrist who sees patients in over two dozen South Carolina emergency departments? What did this particular case make me think about?

First of all, we know that deinstitutionalization was a real thing. Hospitals were closed, patients were discharged to their families, to supervised living situations, or to the streets, and the local mental health centers were supposed to pick up the slack and treat them as outpatients, all in the name of streamlining care and saving money. When I started medical school thirty eight years ago and did my very first psychiatric rotations as a junior and senior student, state hospitals, VA hospitals and mental health nursing homes were still very full of patients who were too ill to function well in society. Many were there for long term stays of weeks, months or even years.

Gradually over my career I have seen many inpatient facilities cut back and close beds and finally close their doors entirely. The ones that survive are much smaller, treat patients for much short length of stays, and are run via much more stringent business models than ever before.

Many patients now get their medical care and most of the psychiatric care in an emergency department, not from their own personal doctor. Once admitted there for evaluation, it can sometimes be a very difficult and complicated ballet to assess the patient for his primary illnesses or presenting problems, available resources, need for inpatient versus outpatient treatment, payor sources and requirements, and family involvement. Add to that the hospital administration’s take on treatment, as well as pressure from ED doctors to get patients in and out as rapidly as possible, and it becomes somewhat overwhelming.

In those past years, patients who were truly psychotic or actively suicidal or a danger to others could simply be committed to the state hospital and held there as long as necessary to achieve remission, or as close to it as possible. This is not nearly as easy or smooth a process now as it once was.

As I mentioned above, we do not have crystal balls, but we do have fairly detailed screening procedures for harm to self or others, for example. We can assess, apply evidence based guidelines, offer the best recommendations we can based on these parameters, and decide if a patient must held or can be released. Recommending and treating based on numbers alone, administration goals, or by algorithm rarely work well.

If a patient is acting out of his own volition, is cognitively processing things appropriately, is not overtly psychotic  or in withdrawal from substances, and he still destroys property or intentionally  hurts others on the staff or other patients, then he should be charged for these actions accordingly and would perhaps be better served in the county jail than the emergency department.

I would welcome stories of  your own experiences in this area, your opinions and ideas for how to make these tense situations more rewarding and beneficial for both staff and patients.

 

 

 

 

“And, by the way…”

He came in for his routine yearly visit with me, stable for the most part in that he was living with his chronic psychotic illness and moving through the world in a fairly normal, logical way most days. He was in his mid-twenties, neat, clean. He was attending to his personal hygiene and wearing rumpled but passable casual clothes. His hair was combed, but it had not been cut or even trimmed in quite a while.

“I don’t think my antidepressant is working,” he announced matter-of-factly.

Like many of my patients, he was and has been subject to that best of all psychiatric interventions, polypharmacy (Yes, I AM being sarcastic), whereby if a patient tells you they are having an exacerbation of symptoms on their current regimen of drugs you simply add another one and hope that augmentation is a real phenomenon. (The drug companies assure me that it is.)

“Oh.”

I waited.

He waited.

“Tell me more.”

He did.

His change in symptoms was both vague and intriguing, troublesome and irksome. We’d been down this road before, he and I, several times.

He thought it was the medicine.

I did not.

Ninety-nine per cent of the time it was not.

Medicine is just an easy target. There it sits, on the nightstand, on the window sill above the kitchen sink, in a purse, under the bed. In a brown bottle, with a white childproof cap, neatly labeled,  it is the best absorber of causation ever devised by modern medicine. If something is not right, if something is difficult to figure out, if something is not working or responding the way we all think it should be at week one, week four, or week eight, then it must be the medicine. What else could it possibly be?

“I’m more depressed. I don’t want to do anything. I don’t leave the house. I have no interests. I don’t sleep. I don’t eat.”

We chatted. He weaved and bobbed. I confronted and clarified.

“Maybe it’s the medicine,” I offered, not wholeheartedly but with some degree of inevitable resignation.

“I told you it was the medicine,” he said, triumphant.

We talked about a dosage change. A small increase. A homeopathic sacrifice to the gods of common sense and exasperation.

“There,” I said. “Anything else you think  I should know before we stop?”

He was silent.

I typed in the new dose of the medicine and sent it on its way to the pharmacy in electronic form.

I got up, proffering my hand.

“And by the way,” he said, a calculated afterthought. “I’m very lonely, you know. I’m very lonely. Do you think I’ll ever have a girlfriend?”

I sat back down.

My next patient had already canceled.

I had not been able to do psychotherapy, even rudimentary, time-limited, short-term psychotherapy, in such a long, long time.

I laced my fingers in my best Freudian way, stroked my white goatee, and crossed one leg over the other.

“I’m listening,” I said.

 

Would You Like Sides With That?

SIde effects are weird things. 

Now, when I prescribe medications for patients, one of the things I always do, after talking about the reason for the med, the dosing, the cost and the the like, is to discuss the most common side effects that I expect they might experience. Why? Because they are likely to have one or more of these obnoxious effects, and if I predict them in advance it makes me look like a smart guy. 

I was taught in medical school that “if you hear hoof beats, look for horses, not zebras”. Or, stated another way, “common things are common”. 

I always tell patients NOT to go home and Google the drug I have prescribed for them. They will be hit with every side effect in the book, legalese out the wazoo, and they will come away afraid to take not just that medication, but any medication that anyone might prescribe for them in the future, ever! I ask that they trust me to give them the lowdown on how the medication should work, how long it will take, and what very common side effects they are likely to see. 

Dry mouth, dizziness, weight gain or weight loss, hair loss, dry skin, sedation and confusion are all side effects that I might mention to a patient. 

Note that these are side effects of the medication itself

But what about side effects of another kind? Side effects of the treatment as a whole? 

By this I mean, what if the patient, after adequate treatment, starts to evidence behavior that he or his spouse or family is not expecting, and even dislikes? What do I mean by this?

Well, if a very depressed woman starts to get better, feels like going out and demands that her couch potato husband take her to dinner and a movie once a week, when he’d rather stay at home, that might be a problem. Her treatment has been very successful, she is more energetic, her interest in doing things has picked up and she is more assertive in asking that her spouse accompany her to do these things that she wants to do. He got used to the “old” her, the person who was lethargic and passive and never made demands on him. He does not like this “new” less depressed wife he now has. This is a side effect of the treatment that is unwanted, in the husband’s opinion.

What if a young woman who has schizophrenia is put on medications and in therapy groups that begin to slowly help her get out of her social isolation and enjoy being around others, even members of the opposite sex? Once again, her parents have gotten used to her being at home,  watching TV on the couch all day, for the last decade. Now, she wants to get out and go places, see people and even date. They are worried that she might even want to have (gasp!) sex! To them, she seems manic, out of control, hyperactive, when in fact she is now able to act like a normal young woman her age and experience things that she never expected to again. 

Side effects can come from medications, from the treatment as a whole, and sometimes can be seen as negative, even when to the patient thinks things are going much better. 

As in many aspects of mental health care and treatment, communication about these kinds of effects and behavioral changes should be attended to early on so that doctor, patient, and family are all on the same page.