Work Text:
“Of course someone from the Federation wouldn’t understand. You have to meddle, don’t you. You have to make people better. You can’t leave anything in its natural state. Perhaps I don’t want you to improve me, Doctor. Perhaps I’d like to be left as I am!”
“Are you done?”
Nothing, just the glare.
“All right. Now, listen. First of all: there is no such thing as a natural state for a living, breathing being– No, I’m talking now, you be quiet. You need things. You breathe. You eat. You have to do those things or you die. So what is your natural state, Garak? Is it suffocation? Is it starvation? Is it self-hatred? Or does your body need something else? Do you need to be changed?”
“I cannot believe that you, of all people, would dare stand there and tell me that I need to be changed!”
“Garak. Don’t you dare.”
“You hypocrite–”
“Changed only with your consent, Garak. And only in ways that can be stopped at any time. You can always go back to how you are now. Nothing will be taken from you or given to you that you cannot have back at any time with a word. So, again, don’t you dare compare my situation with yours. I’m offering you an option, not a diktat.”
“Oh, I don’t think so, Doctor. This is ‘change, or suffer the consequences’.”
“Just like anything else in this universe. And I’m not entirely sure you understand what consequences would apply in either case–”
“You think I don’t understand consequences?”
“Not fair ones, no. If anything you’ve told me of your life is to be believed, you’ve spent your time either being shielded from the consequences of your actions, or having outsized consequences imposed upon you. I think part of you believes that if you don’t get away scot-free, then you should be executed. I’m not sure you know that there’s a middle ground.”
“This is drivel.”
This time Julian’s the one who doesn’t respond; he just waits, arms at his sides, being calm with his patient, and if it’s a performance, well, they’re both adept at that, and Garak can’t say much about it.
"What else should he be taking?" asked my friend, as we discussed Mister Garak's train wreck mental health. And... welp...
Welcome to "You have asked the hospital pharmacist with special interests in mental health and addictions a Very Bad Question!" There will be no special prizes! There will be no bonus round!
OKAY SO
First of all we must assume that the medicine we would be using is 21st century medicine. I’m not going to suggest 50 ccs of triptacederine because that’s *absolutely nonsense*, how are you subcutaneously giving 50 mL of anything, unless the hypospray goes right into your jugular vein?? Maybe?? Anyway, bull-hockey. We will stick to meds and regimens we have available right now.
Looking at Garak around the time of DS9 through this narrow lens, I feel that our boy has some conditions that can be treated with drugs (yay!) and some conditions that can be treated with therapy (yay!) and some conditions that can’t be treated at all (oh well!). Let’s break these down under the axis system. (We don’t use the axis system anymore since the DSM-V came out, but I still like it because I like lists to help me understand a situation.) Keeping in mind that I am not a diagnostician, just someone who hangs out with them…
Axis I: Mental Health and Substance Use Disorders
These are what we can generally treat with medications (and therapy and changing one’s environment and and and - but generally this is the first place I can help as a licensed drug dealer).
I think good arguments could be made that the Garak we see on DS9 is dealing with:
--at least some type of depressive disorder. Probably something like a persistent depressive disorder, which waxes and wanes but is never quite gone. I don’t think he has bipolar disorder, even though he can sometimes seem a bit manic; I think that’s part of the front he puts on, and also partly due to the induced endorphin drip (like a mild opioid high all the time; makes you pleasant and smiley and actually evens you out a bit, which suggests that the Garak who was not previously on ‘drugs’ was even more manic). I think he’s miserable and has given up hope. Now - is that situational or is that genetic? I can’t answer that. We’d find out by starting medication and therapy, and working to ameliorate his situation (see more below).
–similarly, some level of anxiety disorder. Phobia, certainly: our lad is definitely a claustrophobe. I don’t know that he has constant underlying anxiety; that often manifests somatically anyway; rather than actually feeling “scared” all the time, the person has a lot of stomach aches, or diarrhea, or headaches, or similar relatively minor-seeming body issue. I think he might have some of these but the wire smoothes them away. I bet he would get a lot of headaches, wouldn’t he? Particularly post-wire. Again, can’t tell if this is genetic or situational; it’s definitely been made worse by the situations he’s been put in, and we’d see how much we can help with appropriate meds and therapy and situation-improvement.
–post-traumatic stress disorder, absolutely. Trauma up the hoo-hah for this lad, starting as a child, and continuing as he moved into a career as an Obsidian Order operative. Garak startles easily. I think his claustrophobia shades into PTSD trigger territory - there’s mildly uncomfortable and then there’s dissociating, and we’ve seen both from him. I do not imagine our boy sleeps well. This is a bit of a tough one, too, because we don’t actually know a lot of Garak’s history, so it’s hard to tell exactly what symptoms/behaviours he exhibits could be due to PTSD vs. a co-morbidity vs. he’s a pain in the ass sometimes vs. he’s faking because he thinks it’s funny. But I’m putting it here because if he were a real guy, he’d have PTSD.
–definitely a substance-use disorder! This one seems like it should fit somewhere else, doesn’t it? But DSM-IV considers SUD to fit best with mental health issues, and who am I to argue. (This is apparently one of the reasons the DSM-V got rid of axes - sometimes they just didn’t seem to fit.) He has a fun futuristic substance-use disorder, all glamourous and set up by his former spymasters and implanted in his brain, but at the end of the day it’s an endorphin-inducer that reroutes pain to pleasure, and that’s close enough to an opioid use disorder that I’m going to call it roughly equivalent.
…wait! Wait, I just remembered - he seizes when the implant fails - oh my god, maybe it’s a GABA issue too! Maybe his brain is being regulated in the same way alcohol would regulate it! Alcohol withdrawal can definitely cause seizures… oh, Garak, you get to go through opioid and alcohol withdrawal at once… what good choices you’ve made! I’d pat your shoulder but you’d bite me…
Our Mister Garak is what we call a functional addict: he can get by in day to day life just fine as long as he has what he needs. I actually don’t think he’s high all the time, despite what fandom likes to imagine. Maybe when he started, maybe when he was activating the implant for occasional relief from his dreary life, sure, that was probably a kick… but the thing about substance use disorders is that the brain adapts to the stimuli it’s receiving. This is where the functional alcoholic lives: wake up, have a drink - why? To get drunk? No, because otherwise you *shake* and you feel *nervous*, because alcohol is neurologically a lot like a brain substance (GABA) that slows and calms the brain and now the brain is making less GABA and you have to make up the difference with a drink… Similarly, endorphins are the brain’s natural pain control, both for active painful stimuli and for the day-to-day-drearies, and if one starts supplementing them, pretty soon the brain down-regulates its own endorphins, and then… well, then Garak is going to start needing to turn up the implant. Even when it’s on all the time, it won’t help. Everything will hurt more, feel more miserable. He’ll be nauseated. He’ll have bowel trouble (stating it lightly). He’ll… well, if you actually want to know, read about opioid withdrawal here. And it looks like this is where we find him during “The Wire” - he hurts, something is Wrong, things are just starting to destabilize…
–*possibly* an impulse-control disorder? He certainly loves to lie for fun. He likes to stir things up and gets punched an awful lot, and I don’t buy that it’s just to end up in Sickbay to flirt. He likes a certain element of risk - although he’s able to control it enough to know that he shouldn’t, oh, go to Cardassia on a whim to rescue a Bajoran officer. Risk is fun, dead is not. And his childhood was tumultuous and traumatic enough that he definitely could’ve picked up a deep-rooted urged to Punch Back, however he could. That said, he isn’t destroying his life over it, and if one’s life isn’t disrupted by the symptoms, it ain’t a disorder, It’s Just How He Is. So maybe no disorder, just a predilection towards being a little shit. Which takes us nicely into…
Axis II: Personality Disorders and Intellectual Development Disorder
These are not treatable with medications but hugely inform how the person responds to their life in general and can lead to development of Axis I disorders.
I absolutely *DO* think Garak has a personality disorder or two. We categorize the personality disorders in 3 clusters: A, B, and C (I learned them as ‘weird, wild, and worried’, which is not very nice but does help one remember). I think Garak falls right into the cluster B category: dramatic, emotional, and erratic.
Personality disorders are not something testable. You can’t biopsy or blood-sample this one. This is - we think - both nature and nurture; narcissistic parents (for example; this appears to go for all PDs) are more likely to have narcissistic kids both because of their genes and because of how they are more likely to raise their kids. We can’t touch these with meds; however people with these types of disorders do tend to end up with axis I disorders because having a personality disorder can make your life lonely and uncomfortable, and you end up with depression, anxiety, etc.
Mister Garak strikes me very much as having:
–a shmeck of antisocial personality disorder - “Individuals repeatedly engage in unlawful activities (e.g. - drug use, assault, or theft), endanger the well-being of others, and frequently lie. [...] Contrary to the name, having antisocial personality does not mean the individual does not have friends; on the contrary, they may have a superficial charm and be very deceptive.” People with this disorder often end up imprisoned. If they make it to their 40s they tend to have fewer problems, and this is a commonality across most personality disorders - you can overcome the disorder’s negative effects by learning how to live in the world, how to resist the unproductive impulses, how to behave ‘appropriately’ in different situations, but that takes more time because it’s not innate to someone with a disorder the way it may be to someone neurotypical. Also - “Other factors including child abuse or neglect, unstable or erratic parenting, or inconsistent parental discipline increase the likelihood that a conduct disorder diagnosis will evolve into ASPD.” Uh HUH.
–some degree of borderline personality disorder - particularly as it pertains to “identity disturbance, and chronic feelings of emptiness”. This may also be where the impulsiveness kicks in. Our Mister Garak feels things extremely intensely, and needs to be around others to be reassured that he is worthy/worthwhile. (At least that's my headcanon; your mileage may vary.) He can also dissociate when under stress, and can become extremely paranoid. People who weren’t able to feel safe in childhood can end up with this one, although it can also be genetic of course. A better name for this disorder might be “emotion regulation disorder”, and that’s how I try to teach pharmacy students to think of it.
–I flirted briefly with histrionic personality disorder for Garak, but I think that’s just his front. It’s not an innate need to be the centre of attention. He doesn’t think everyone is in love with him. He just likes being distracting, both because it’s very effective cover, and because it’s ~~fun~~.
(Having fun yet? Aren’t you glad you clicked? I’m having a whale of a time~~)
Axis III: General Medical Conditions
These may be treatable with medications as well as lifestyle modifications. They may also be untreatable (eg. genetic conditions).
Garak gets beat up a lot. Ribs broken, eyes blackened. He’s had brain surgery; after “The Wire”, he’s post-brain-surgery, and I don’t know how that works in the future, but it ain’t great here. Let’s leave that for now, though, and give him only the standard aches and pains that a Human his approximate age would have: he’s probably got some mild arthritis of his knees and back, and almost certainly of his hands. His close-up eyesight may be going (how frustrating for a tailor!). He's putting on a bit of weight (doesn't help the arthritis). And we know he avoids going to doctors, so it’s very possible he has other relatively mild conditions that irritate him but don’t cause enormous strain (eczema, toenail fungus, all the really fun gross stuff you usually just buy stuff for at the pharmacy, ask me how I know). So let’s call him a relative nil on the Axis 3.
Axis IV: Psychosocial and Environmental Problems
LOL, yeah, can’t treat these with medications - but if you don’t address them you may as well flush the meds right down the toilet, along with everything else you’re trying to do.
And this is the big, big, big issue isn’t it? He has been exiled from his home world. He is away from any family or friends he might once have had - in fact, for a while, he figures they all hate his guts. He’s stuck on a space station (claustrophobe, remember?) which has its life support set up for a completely physiologically different species. He says it himself: “Living on this station is torture for me, Doctor. The temperature is always too cold, the lights are always too bright. Every Bajoran on the station looks at me with loathing and contempt.” (source) And as far as he can see, there’s no way out. This is his life now, until he ends it or it’s ended for him. Why *would* he be happy? Why *wouldn’t* he be scared all the time? And with the way his personality has been moulded/inherited, he’s not equipped to see the bright side, to make friends, to hold on to any kind of moral goal. He can’t even turn to a god. There is a half-joking, half-serious term thrown around in psychiatry: Shit Life Syndrome. Sometimes you admit a patient who’s in a terrible state, making what appear to be awful choices, and then you look at the situation they’re in and go, well, yeah, of course you made these choices beause these are the only options you have. These are the people who have SLS, and Garak’s got a bit of SLS, at least from his point of view. (The Bajorans might disagree…!)
Axis V: Global Assessment of Functioning (GAF)
Yes, it is funny that the abbreviation is GAF. "On the give-a-fuck-scale, where does this person fall...)
The GAF is a zero-to-one hundred rating of ‘how well is this person coping/managing/surviving’, with 100 being ‘no symptoms’ and 10 being ‘Persistent danger of severely hurting self or others; persistent inability to maintain minimal personal hygiene; or, serious suicidal act with clear expectation of death’ (source). (Zero = 'no information'.)
I think Garak usually sits at an 80 to 90 for much of DS9. He’s managing. Spite is a powerful motivator; so is the possibility of revenge. But as he loses contacts, loses the wire, loses his father, loses his mother, nearly loses his entire planet… yeah, that drops. The lowest we see him during the show is, I think, during “The Wire” (where I’d venture he drops to a 10-20) and “Afterimage” (about 20-30 here; also that episode suuuucks).
SO! Now we’ve done our workup! Now we start picking treatments!
And this is the bit where I disappoint you a little and remind you that I, a humble pharmacist, cannot do the work that a psychiatrist, psychologist, counsellor, social worker, personal support worker, or any of the other myriad folks working in mental health & substance use disorder can do. I just sell mind-altering substances. Garak needs therapy of a variety of types (dialectical behavioural therapy would help; group therapy would help although I pity both the group and the facilitator; CBT *might* help although he might just find it insulting - he fancies himself too smart for ‘mind games’ which is the joke of the century).... He needs warmer clothes, darker quarters, friends, hobbies (aside from reading maybe? Something that he can *work on* that isn’t work. Something he can build and feel good about building).
But I myself would like to give him drugs!
So: let’s look at what we think he may be dealing with that drugs can actually *treat*. Right now I’d call that persistent depressive disorder, some flavour of anxiety, a substance use disorder (which we are going to pretend is opioid use disorder and alcohol use disorder), and PTSD. Some good places to look for options for these therapies are the Harvard Psychopharmacology Algorithms (US) and psychdb (Canadian). I also like the Maudsley guides (UK) but my copy is at work, sigh… so let’s use what we’ve got.
One thing to remember here is that although we’ve sieved out all these potential disorders, these little nuggets of disease - the brain *doesn’t work like that*. All these things are happening simultaneously in Garak’s brain and nervous system. You can’t point to one set of neurons and go ‘depression’. And all these co-morbidities are feeding each other. So we look for medications that can treat multiple things at once, both to minimize what we call ‘medication burden’ - having to wrap your life around your twenty different meds - and to minimize duplication of function that can lead to adverse effects.
I’m also going to treat Garak as if he is a functional outpatient, not an inpatient - GAF 51 or higher, noticing problems but not coming apart at the seams. Under 51 is a candidate for inpatient management, and I don’t think DS9 is equipped for that, not with just Bashir and a few others doing day-to-day emergency-level medicine. (Don’t get me started on Federation mental health management…) There is one exception here: alcohol withdrawal management that has resulted in a seizure is a reason for inpatient admission, but given that Bashir has decided to monitor around the clock, I’m willing to compromise and start an inpatient protocol on an outpatient basis *with close monitoring*.
For his depression and anxiety, I think I’d recommend sertraline, a selective-serotonin-reuptake-inhibitor, which can do double-duty for both indications. What it seems to do in the body is prevent the quick reabsorption of serotonin, a neurotransmitter that, for our purposes, regulates the ability to feel content. Not happy, not ecstatic or manic or overjoyed. Just… content and stable. An SSRI, to me, is the life ring you throw to someone who’s drowning: it won’t teach them to swim, but it will keep them alive and functioning until they can figure it out.
I'm picking sertraline because it's been around forever and because we have good evidence for it. Yes, there are lots of sexy antidepressants, but when someone is drowning, I don't want to try out something new - I want something I know has a good chance of working. So: we start with sertraline. Because he’s an outpatient, I’d start him on 25 to 50 mg (depending on his medication sensitivity) and titrate it up at one-week intervals until we see benefit. If there’s no benefit in 4-6 weeks, or if he has adverse effects he can’t tolerate, I’d switch to escitalopram (another old-ish reliable). We sometimes have to go through multiple SSRIs until we find the right one. The odds are about 90% that by the time you’ve tried the third one, you’ll hit paydirt. Most people show benefit by #2.
For his PTSD, one issue is that his brain’s epinephrine (adrenaline) management is dysregulated. (There’s a lot of really complex stuff going on here; I’m focusing on what I can treat with drugs). So the first thing we recommend is an alpha-blocker - a medication that blocks an epinephrine receptor in the brain. Epinephrine downloads are what, as far as we know, trigger nightmares and… well, trigger trigger-responses, too. So if we block those effectively, the person is less subject to sudden, uncontrollable blasts of fear. We can also recommend adding a mild sleep aid, trying to stay away from those that are habit-forming (most of them); I’d probably consider trazodone, which can also be an antidepressant, but makes people so groggy that we mostly now just use it at ‘low’ doses to make you go to sleep. SSRIs can help here too, so the sertraline is now doing triple-duty. There are lots of places to go should these firstline meds fail, but these help a tremendous amount for a lot of people.
And last and oh god not least… the wire itself, in its guise as substance use/abuse. Garak, for god’s sake, why go cold turkey? In “The Wire” he has the implant deactivated and then he goes cold turkey which I think is borderline *negligent* of Bashir. I suppose Garak wouldn’t permit anything else… still, this would definitely be extremely uncomfortable, and by uncomfortable I mean agonizing, and also potentially life-threatening. Again, it makes sense why Julian’s by his bedside: if he's going to sign off on this brand of bullshit, he needs to keep watch.
When we’re working with people who are trying to manage substance use disorders (SUD), we have a few options. We have harm reduction (continue to use, but use more safely, and use from a supply that’s known not to be adulterated); we have Opioid Replacement Therapy and what is effectively Alcohol Replacement Therapy, although we don’t use alcohol, where we start prescribed medications with long durations so the patient doesn't have to hunt for drugs all the time; we have both; and we have neither. Garak clearly can’t stay on the implant, as it’s broken and damaging his brain. That leaves us with OAT/ART or nothing. We saw the nothing option; it sucked. It’s also life-threatening (in case of alcohol).
If Garak is willing to work with us on this, I’d like to recommend starting him on a benzodiazepine for the GABA deficiency (from alcohol withdrawal), both to protect him and to minimize the withdrawal. Usually this would be something like diazepam, which has a nice long half-life (the time until half of it is broken down and not effective in the body); even if it's stopped as well, it will taper itself off to some degree via its slow metabolism. In an inpatient setting (or with Bashir watching very closely) we'd at first give 10-20 mg of diazepam every hour on the hour as long as he’s having withdrawal symptoms (measured usually via something like the CIWA protocol). Once his CIWA level is consistently under 10 for a certain number of measurements (depends on the institution), we cross him over to a scheduled diazepam dose, perhaps 10 mg by mouth four times a day. Over time we taper this down to three times a day, then two, then one… If required, we make the doses smaller instead: 10 mg to 7.5 mg to 5 mg… We go at the pace the patient can tolerate; rushing this can put them back into withdrawal and increases the risk of relapse. (We also usually add on vitamins to compensate for alcohol’s metabolic effects but we won’t bother with that here as it doesn’t quite apply.)
For the opioid withdrawal, one common approach for a patient presenting in withdrawal is Suboxone initiation: buprenorphine, which is an opioid that binds so tightly to the opioid receptors that it kicks any other opioid off (sometimes combined with naloxone, an opioid blocker, so it’s less likely to present a high if injected). It can reduce the risk of overdose, as most/all other opioids won’t be able to bind if it’s present in the patient’s system. This is great for a lot of folks, but not ideal if the quantities/potencies of the opioid(s) they’ve been consuming exceed buprenorphine’s max dosing threshold. Another option is methadone, which is an opioid with a long half-life that can be given once a day, rather than most other opioids which have short half-lives, leading to quick onset of withdrawal. Methadone is great stuff in terms of maintaining stability, and we can taper it over time. There are some catches: it’s very dangerous in overdose, it's very dangerous when combined with alcohol or benzodiazepines (wuh oh), it can cause heart arrhythmias at high doses, and it caps out in terms of safety at about 150 mg/day, which is often not enough for today’s opioid users and I can’t imagine would be enough for our Mister Garak, who can shoot back 30 mg of triptacederine like it’s nothing.
So: instead I’d like to go to safer supply, which means providing the patient with slow-release oral morphine (SROM) and immediate-release hydromorphone on a daily basis. SROM daily administration is witnessed by a health care professional, usually the pharmacist at which the script is filled. The hydromorphone is taken home by the patient to be used as they require - ideally by mouth, but some patients may choose to inject, snort, or administer via other methods. “But that’s just supplying them with drugs!” some cry. Yeah - but they are *safe drugs*. They’re not adulterated with anything else, like many drugs in our current supply might be. And this method has the advantage of, theoretically, no dose ceiling. You can increase the dose a little every day until you reach a point at which the patient has no withdrawal. Now they can function in their life. Now they don’t have to spend every waking moment sick, feeling like they’re dying, trying to get the next dose of dope so that they can go back to some kind of normalcy for a few hours. Garak could run his shop again on this regimen. He could manage his own withdrawal with dignity. And now, over time, if he wishes, we can taper the dose down.
We actually don’t taper the dose down for a lot of people for a long time, if ever. First of all, we want them to get their life in order, to deal with the problems they’re facing. This means a lot of therapy; it can mean moving; it can mean breaking up relationships; it’s never fun. And once things are more in order, okay, yes, we can taper down the OAT - but the brain’s ability to produce endorphins may be forever impaired. We just don’t know. Sometimes people find they have to stay on OAT just to be functional; otherwise their brain can no longer produce sensations of comfort or pleasure, and pain is amplified by an unimaginable factor.
But Garak gets the magical Star Trek Cure and never has to deal with any of this, so it’s moot for him. Hooray!!!
I hope you have enjoyed my imaginary presentation of treatment options for our favourite hot mess. Get yourself a hot beverage of choice; you've earned it. Rounds will be in half an hour and we have two more patients to work up...