psychiatric drugs and the fifth precept

[altar]

Hello, all,
This post is about taking psychiatric drugs (for instance antipsychotics or anti-depressants) and the fifth precept, which is to abstain from intoxicants. I don't know if someone can reach a conclusive "yes," "no," answer to this, but it could be discussed.
I know relatively less about anti-depressants than antipsychotics. But for those who don't know about antipsychotics, I'll put down some of their common effects. I won't distinguish between so-called side effects and main effects, because one doesn't get to choose which effects one gets, I'll just put down the common ones: Loss of energy, hallucinations, racing thoughts, dullness, anxiety, sleepiness, weight gain, perkiness, energy, less racing thoughts, less hallucinations, movement abnormalities, hunger, increased libido, decreased libido, mood alterations... these are the main ones I think...
I think this sila is based on cultivation of inner awakeness, non-negligence and laziness, the ability to be shameful and competent and moral and restrained, overcoming dependency on outside stimulants, and renunciation.
Coffee is accepted almost universally, I think, and that is an outside stimulant, but if it is used excessively to that effect, it might be considered a breach. These drugs, when used for stimulus, are generally quite potent, I think, so unless used with extreme moderation would likewise be a breach. Sometimes the drugs might appear to keep one more restrained, but I actually think if anything the opposite, even in those cases where it appears so. I think this because if one simply dulls their mind to prevent anger for instance from taking hold, it is not using restraint at all. One who develops restraint does so on the mental level.
It is kind of like the case of the monk who cut off his penis and the Buddha said he cut off the wrong thing.
Zack

[tiltbillings]

Hello, all,
This post is about taking psychiatric drugs (for instance antipsychotics or anti-depressants) and the fifth precept, which is to abstain from intoxicants. I don't know if someone can reach a conclusive "yes," "no," answer to this, but it could be discussed.
I know relatively less about anti-depressants than antipsychotics. But for those who don't know about antipsychotics,. . .

So, someone is actively psychotic, hearing command voices, violent, a danger to themselves and others, what would you recommend?

Or someone who is in a full-blown manic episode, putting themselves in dangerous situations without any control over their behaviour, what would you recommend?

[altar]

So, someone is actively psychotic, hearing command voices, violent, a danger to themselves and others, what would you recommend?

Or someone who is in a full-blown manic episode, putting themselves in dangerous situations without any control over their behaviour, what would you recommend?

Well, Tilt, it is not the case that simply because I can't come up with a another recommendation, these drugs do work. For instance, I might say, sex isn't a cure to anxiety. And you might say, well, what's a different recommendation? Just because I can't come up with one, doesn't mean sex works.
But in any case my best recommendation would vary circumstance to circumstance quite a lot, but I would tend to say, association with good people, patience, metta, etc.
But in any case, it is a different scenario when someone is in a full-blow episode. In this case the drugs are usually given forcibly. In this case, another forcible method of subduing them, one that doesn't tamper with their brain, like physical restrictions, might be preferable. There is evidence that introducing people to these medicines short term decreases their ability to function well off of them. Here is an article on the subject: http://www.scribd.com/doc/19458201/The- ... t-Whitaker
from,
Zack

[tiltbillings]

In this case, another forcible method of subduing them, one that doesn't tamper with their brain, like physical restrictions, might be preferable.

The pysch drugs have gotten better, more refined than the sledge-hammer approach of the phenothiazines; however, the non-medicative approaches before the phenothiazines was the standard, which gave us the insane asylums. The anti-psychotics often allow people to gain control of their lives in ways that they would never have been able to do before. These drugs, the older ones as well as the newer one are not perfect and the side effects can be quite awful. If a non-drug modalities works for some, good, but having seen full blown psychotic episodes, how devasting they can be, these drugs do have there place.

[Laurens]

It's a tough question, because while anti-psychotics do intoxicate, you have to consider which type of intoxication is worse, the intoxication of psychosis or the intoxication of anti-psychotic drugs?

From what I have seen the intoxication of psychosis can be more dangerous, but obviously it varies between the individual in question. The fifth precept allows for medicines.

Personally my opinion is that these drugs, if the person in question is at risk of harming themselves or others then these drugs can be helpful. However I don't think they should be handed out willy nilly.

[altar]

The pysch drugs have gotten better, more refined than the sledge-hammer approach of the phenothiazines

While many people suggest these newer drugs are better, there is much evidence to the contrary, both from patients and studies. Regardless, if they are a little better, lsd might be better than heroin, that doesn't mean we should advocate it. http://www.askapatient.com seems like a good website where you can find user reports from thousands of people about these drugs. Some common "newer" drugs to look up are seroquel, abilify, and zyprexa.
It may be that full blown episodes can be devastating. That doesn't mean one should look to drugs--which can also be devastating--for the answer. Maybe in this case they can be given--maybe.
I think that in looking for someone's benefit, it means we should be looking for someone's long term benefit, not merely allaying the symptoms of the moment, especially in cases where it could cause long-term brain damage.
But this deviates from the question, somewhat, because sila isn't as much of an issue when it's out of your hands what happens; if someone is in a state where restraint is necessary, be it drug-induced or physical, they don't breach sila one way or the other, because it's not them acting.
Many people may claim that lots of sex, lots of alcohol, lots of marijuana, or lsd have been great for them. These are still breaking the fifth precept--with the exception of sex, which is just another example.

[Cittasanto]

First we have to ask what its it for?
why is it being prescribed?
what are the risks both if prescribed and if not?
what are the known effects?
do the benefits out way the disadvantages?

So if it is necessary then Yes! beside the fact medicines are not a breach of the precept, and even alcohol can be taken in some instances according to the vinaya (I have been told but not seen this specific exception to clarify its usage.)

as for your comment on physical restraint being an alternative?? the methods of manual restraint used can dislocate joints or break bones (which can happen in the training never mind real life situations, and I know one nurse who was stabbed by a patient trying to butter some toast after breaking into the kitchen), and patients have been known to be harmed themselves due to the bed restraints and toppling beds over! you can not ask someone to put themselves in harms way, or put someone in a dangerous position because you don't agree with drug use in any circumstance.
a better alternative than sex for anxiety would be mindfulness based approaches but if someone is having an acute episode they can't really be taught it properly, and schizophrenic patient don't tend to stay in the relaxation sessions especially if they are hearing voices.

[Monkey Mind]

So here's my biases before I jump into this thread: I'm a mental health professional, and I am living with mental illness.

1) the lessens I learn from dhamma study/ practice have helped me to manage my own mental illness.
2) the lessens I learn from dhamma study/ practice have helped me to be a better therapist.
3) the lessens I learn from dhamma study/ practice have helped me to be a better teacher for students entering the mental health profession.

Anti-psychotic medication is a misnomer, it does not stop the delusions and hallucinations, but causes the patient to "not care" about the symptoms. Remind anyone of anicca and equanimity?
The best gift the dhamma has for those with psychiatric issues: learning to obseve phenomenon without reacting to it. For people who are experiencing psychotic events, for example, there is the experience and there is the fear and suffering that one has related to the experience. Paradoxically, practicing radical acceptance for the hallucination often results in a major decrease in frequency/ intensity of the hallucinations. Some cutting edge research is finding therapies that have mindfulness and acceptance components are more effective in treating psychotic symptoms than anti-psychotic medication. [Disclaimer: mentally ill people need to work with someone who is trained in these modalities. Trying to manage hallcinations and delusions without trained support is at least scary, if not dangerous.]

[LauraJ]

[Monkey Mind]

Zachary, I was also reading your post about mental illness and TOS. I think the mental health professions embraced psychiatric medications and placed an unrealistic emphasis on meds, and several decades later are just starting to realize how misguided that was. So here's to a new era of compassionate care that respec's patient's autonomy and dignity. However, they do not have a roadmap. I think Buddhism can offer a great road map, but the field needs people to translate dhamma into mental health practice.

[tiltbillings]

Anti-psychotic medication is a misnomer, it does not stop the delusions and hallucinations, but causes the patient to "not care" about the symptoms.

And this is based upon what, exactly? That has not been what I have had patients tell me.

people who are experiencing psychotic events, for example, there is the experience and there is the fear and suffering that one has related to the experience. Paradoxically, practicing radical acceptance for the hallucination often results in a major decrease in frequency/ intensity of the hallucinations.

Sounds nice, but the reality is often something else; the thinking so disordered, so out of control, there is no way the individual could possibly put any space around one's experience; rather, they are swept along by them as if they were in a riptide.

Some cutting edge research is finding therapies that have mindfulness and acceptance components are more effective in treating psychotic symptoms than anti-psychotic medication.

That would be true of someone who has some degree of control, not someone in an actute psychotic break.

[tiltbillings]

The above and this thread viewtopic.php?f=11&t=2963 make it quite clear that the TOS in place here on DhammaWheel are appropriate.

[Monkey Mind]

Anti-psychotic medication is a misnomer, it does not stop the delusions and hallucinations, but causes the patient to "not care" about the symptoms.

And this is based upon what, exactly? That has not been what I have had patients tell me.

15+ years clinical experience working with severely mentally ill patients. It is absolutely what patients tell me, consistently. Perhaps you ask the wrong questions? Or maybe we disagree about the definition of hallucination/ delusion. It's all good, I agree with you that the TOS are both wise and appropriate.

[tiltbillings]

Anti-psychotic medication is a misnomer, it does not stop the delusions and hallucinations, but causes the patient to "not care" about the symptoms.

And this is based upon what, exactly? That has not been what I have had patients tell me.

15+ years clinical experience working with severely mentally ill patients. It is absolutely what patients tell me, consistently. Perhaps you ask the wrong questions? Or maybe we disagree about the definition of hallucination/ delusion. It's all good, I agree with you that the TOS are both wise and appropriate.

It not a matter of having asked questions. It is a matter of patient narrative.

[LauraJ]

Although I really don't want to debate this in public, I'd like to make the remark that I don't see how taking medications as they're prescribed could be a breach of the 5th precept. If a person with diabetes needs to take insulin would anyone suggest that there's something wrong with that? If psychotropic medications help to clear a person up in any number of ways, that can only assist in practicing Buddhism imho.

Thanks,
Laura

[Bonsai]

Altar, you left out a fundamental part of the fifth precept.

"I undertake the precept to refrain from intoxicating drinks and drugs which lead to carelessness."

If the drugs prevent carelessness (seeing things, hearing voices, wild imaginations), then I don't see how they are against the 5th precept.

I am also getting the impression in my readings that Buddha wasn't concerned with making a thousand little rules to govern people's lives. These precepts were meant to help them follow the middle way. For example, there is a difference between drinking once on your birthday and drinking everyday to drown out your problems. I am not saying the first does not come from craving just as the latter does, but Buddha didn't seem concerned much with making rules for the smallest of cravings. If he was, then we probably would have 1000+ precepts.

Moderation is key. And if you are mentally ill, and drugs can bring back some sense of sanity, then I think Buddha would have approved.

[mikenz66]

Hi Laura,

What you say is completely relevant. Medicine is not considered a breach of precepts, and, to take a reasonably common and non-controversial example, if a Bhikkhu has certain health problems and is advised by a doctor to eat in the evening it is not considered a breach of his precept to not eat after noon.

altar's claims that current treatments for certain problems are not particularly helpful may well be true, but I see no point in getting involved in such a discussion on a Buddhist forum any more than I want to get involved with debates on global warming. The helpfulness/correctness or not of these things is a technical matter, not a matter of Buddhist practise. [This is just my choice. Others, of course, are welcome to discuss such things...]

Metta
Mike

[pink_trike]

"I undertake the precept to refrain from intoxicating drinks and drugs which lead to carelessness."

If the drugs prevent carelessness (seeing things, hearing voices, wild imaginations), then I don't see how they are against the 5th precept.

Moderation is key. And if you are mentally ill, and drugs can bring back some sense of sanity, then I think Buddha would have approved.

Hi Laura,

I just have to note here that seeing things, hearing voices, wild imagination, unmanageable levels of fear, etc...aren't "carelessness"...they are a medical disorder - sometimes genetic, sometimes due to environmental toxins, sometimes related to severely dysfunctional family situations, some due to unknown causes...many factors that can't be described as "carelessness". I only comment because someone reading this that is/has experience with any of the many serious mind/emotion medical disorders might feel blamed and responsible for their condition seeing it described as "carelessness".

I too think the Buddha would have approved of mindful medication use...what good are the precepts if there are shrieking voices in the mind, or if one believes that the CIA is following them and monitoring their communications? There are lots of problems associated with meds, but meds have also enabled countless thousands of people with mental dis-ease to function relatively normally. As a former psychotherapist I've met many of these people - their relief and gratitude for the meds is obvious.

[Cittasanto]

There are a few things worth noting.
1 - people react differently to different stimuli, acute for one person may not be for another:
2 - people have different ways of expressing themselves, and this can cause some confusion at times, in other words the meaning seams clear when it isn't, an example could be - I could say your an arse to 'Henry' and that could be misunderstood as friendly banter, but if I said it to 'Lisa', she could misunderstand and think I was sexually harassing, or insulting her, what is meant is not always exactly what is understood:
3 - the precepts say 'refrain', not 'thou shall not', we need to use Panna = wisdom; discernment; knowledge; insight, the first group of the eightfold paths three trainings, for the appropriate practice of Sila = morality:
4 - Both the medical professionals and the patients are human and prone to making mistakes in communication, and reaction, they have to work with what they have at hand:
5- people who are demonstrating, or going through an acute episode of a severe mental condition have demonstrated that they are less likely to benefit from mindfulness or acceptance training at the time, but have also demonstrated that if they have been given this training during milder phases or when the symptoms aren't present when the symptoms return the training has shown to be beneficial.
6 - Testing and communication between people from different backgrounds is demonstratively problematic, take IQ tests of African Americans as an example, the African American tests demonstrate a lower intelligence to white Americans and only when the wording was changed for the African American participants did the tests show a more equal IQ range.
7 - Even actions done under severe delussions have a kammic consequence, the consequenses are not likely to be as great as ones done with a sound mind, but these would fall (I think) under dark & bright kamma, with dark & bright results.

[Bonsai]

"I undertake the precept to refrain from intoxicating drinks and drugs which lead to carelessness."

If the drugs prevent carelessness (seeing things, hearing voices, wild imaginations), then I don't see how they are against the 5th precept.

Moderation is key. And if you are mentally ill, and drugs can bring back some sense of sanity, then I think Buddha would have approved.

Hi Laura,

I just have to note here that seeing things, hearing voices, wild imagination, unmanageable levels of fear, etc...aren't "carelessness"...they are a medical disorder - sometimes genetic, sometimes due to environmental toxins, sometimes related to severely dysfunctional family situations, some due to unknown causes...many factors that can't be described as "carelessness". I only comment because someone reading this that is/has experience with any of the many serious mind/emotion medical disorders might feel blamed and responsible for their condition seeing it described as "carelessness".

I too think the Buddha would have approved of mindful medication use...what good are the precepts if there are shrieking voices in the mind, or if one believes that the CIA is following them and monitoring their communications? There are lots of problems associated with meds, but meds have also enabled countless thousands of people with mental dis-ease to function relatively normally. As a former psychotherapist I've met many of these people - their relief and gratitude for the meds is obvious.

Well, I have serious Anxiety and Depression issues which I take meds for, and I can definitely say (with my own experience) that they do cause carelessness. Now, maybe it's just me, but there have been many times that I haven't been 'careful' because of the way my mind works. I shouldn't have said that 'hearing voices and etc' were carelessness since you are right and the sick person isn't in control of them (outside of medications).They can definitely cause carelessness though.

Basically what I am saying is that you need mindfulness to practice Buddhism, and people with mental illnesses often lack mindfulness because of the way our minds work. If Drugs help you become mindful and sane, then I think Buddha would have approved (or at least not disagreed with). I think he was more concerned with people who abused intoxicants in his time and ours, not with people who took intoxicants in a modern world to keep them sane thousands of years down the line.

Of course I still have a lot more to learn. This is just the feeling I'm getting from reading through what Buddha said.