Monday, September 17, 2007

Will This Medication Help Me?


I've been asked this question twice this week. I think the question is more interesting for the reason why it is being asked than for the actual answer. Even after I've explained the diagnosis and what it means, discussed my treatment recommendations and the risks and benefits of treatment, even after the patient has agreed to try the treatment, they still have to ask if the medication will work.

In prison the obvious reason why someone would ask me this is because it's a prison. Inmates inherently aren't going to trust what they're told or the people treating them. When I hear this, I know that what the patient is really saying is: "Are you telling me the truth? Or are you just giving me something to placate me and get me out of your office?" At other times they are asking this because underneath it all they worry that they may never get well. By the time I see some of these guys they have already been treated by with a list of medications the length of your arm. They may be frustrated and nihilistic about trying anything new, or anything they think they've tried before. Remoralization is the key here, to remind people that they should never give up or lose the hope of getting well. Building trust is a secondary issue, one that may not get accomplished during a single incarceration. Trust is an individual issue that is built up gradually with each patient contact. It can also be fostered (or undermined) by your reputation within the facility. My patients talk to one another, sometimes because they're celling together. The trust question is usually settled before they come to my office on that basis alone; it usually is only an issue nowadays for the guys who have never met me before.

When I am sked, "Will this medication help me?" I know the best answer I can give is, "I believe it will. I know I will do my best to help you."

26 comments:

Midwife with a Knife said...

I don't know... I ask my doctors that same question or variations on it frequently, and I'm not in jail (although... one could argue that my fellowship is a kind of a sentence, only 21.5 months left!).

Anyway, my primary care doc suggests antibiotics, and I say, "Do you think I need moxifloxacin?" Or when my GI doc suggests Imuran (as I suspect she will at my next visit), I will say, "Do you think I really need it?".

I don't know if that's about trust, or if it's about not really wanting to take unnecessary antibiotics or unnecessary immunosuppressives or whatever.

Anyway, just my thoughts...

dinah said...

I would trust you more if you weren't such a chatterbox!

Okay, so it's exactly the same in private practice, same question, same long list of what's already tried, other docs they've seen, same issue of looking for hope.

My answer is vaguely different cause hey, I don't know if it's going to help. "It's more art than science," and so far that's kind of true. "I think it will help, there's not a way to know without trying, if this doesn't work we'll try until something does." I don't know what someone will respond to, and then the next question the patient asks is, oy..oy..and double oy...."Will I have side effects?"

Can you do a post on that for us ClinkShrink?
Happy to have you back. And pick another night for pizza.

ClinkShrink said...

MWAK: Good point. Some guys are reluctant to admit they have problems that require medication, although for the most part by the time they walk into my office they already know that medication is a likely recommendation.

Dinah: Yakkety yakkety yakkety yakkety....at least I don't talk more than the parakeet. He may make more sense though. Did you see the article in the Sun today about the Segway tours? When is a good alternate night for pizza?

Dr. A said...

The most cynical of my patients ask me, "How much does Pfizer pay you to prescribe this?" This usually sparks a spirited conversation...

ClinkShrink said...

Dr. A: My variation of that is, "So, you're giving this to me because it's cheap, right?"

Michelle said...

First time reader, love the blog!

Part of it is the uncertainty of seeing yet another med fail. It's hard to deal with that disappointment time after time. You feel so hopeless and helpless after a while. It's not that we mean to be annoying or that we don't trust you, we just need a little reassurance that something will work. It's basically telling me that you're doing your best to help and if this doesn't work, you'll keep trying.

Now the side effects question...that's harder. Just be straight with me. If it's going to make me fat, bald, give me the shakes, and make my liver toxic, tell me. At this point, I'm pretty much aware that the side effects of psych meds are the $hit. Just let me know what I'm really up against so that when it happens I don't think I'm really crazier than I actually am;).

dinah said...

Michelle, welcome to the blog and thanks for the compliment.

I wrote a post back on 3/27/07 on Side Effects:
http://psychiatrist-blog.blogspot.com/2007/03/medicines-good-bad-ugly.html

The second paragraph under "The Bad" address your question...

Roy said...

Michelle, that's the gist of what I hear from most patients. I look at it as a "what are the odds" type of question. Roughly. Is it 50-50? Is there an 80% chance that this will work. 20%? Is there a 10% chance that my skin will slough off in nasty, huge blisters? 1 in 100? 1 in 1000?

People will have different thresholds to determine if a chance of a risk or benefit is worth the roll of the dice. The more they know, the better choice they can make. That's why it's important to know why people gave up on other med trial. If I know that they stopped the Paxil due to weight gain, I might want to avoid a Remeron trial, unless they point out that the insomnia is ever more of a concern. I think pharmacogenetics has the potential to give us much more accurate odds.

When is pizza?

Anonymous said...

Prison may be different-in a private practice when every medication has been tried with every other medication and the only noticable change in the individual is gross side effects, when do you say enough is enough. A friend of mine had been on medications for years-the last couple years 13 different medications-she finally said no more-she could be just as unhappy off medications-since going off all medications she has not stepped foot in a psych hospital (2 yrs)-prior to that she averaged maybe 3 months between hospitalzations. She and I feel she is much better off without the medications and all the side effects-sure she still thinks of sucide, isolates and is basically miserable-same as on medication-but she is 30 pounds lighter, the ticks in her face aren't nearly as noticeable and her blood sugar is much easier to control. The biggest difference though is her behavior during times she isn't feeling so depressed. Now she isn't too tired or to zoned out to actually have fun. Shouldn't people be allowed to have some enjoyment, even if it is only once in a while? Maybe when someone asks "do you think I really need it" they are really asking just that "do I really need it"?

michelle said...

P.S. You guys probably don't hear this enough, but...

Thank You

I don't know if you really have a good idea how much of a difference a good psychiatrist can make. When you listen to your patients and take the time to treat them as a whole person, it can have a tremendous impact. It might even save their life.

Because I found one of the good pdocs, I was correctly diagnosed with bipolar disorder and put on Lamictal. I'm one of the lucky ones. I was caught early at age 23, and I'm a "good responder" to my mood stabilizer. Lamictal has been a virtual miracle. It does have its annoying side effects (language, memory, & concentration difficulties), but it really does a beautiful job stabilizing my moods, and all in all, I consider it to be much more tolerable than either Lithium or Depakote at this moment. I'm eternally grateful to my pdoc for prescribing it.

She really helped give me a second chance at life. When the really bad episode hit that landed me in her office, I flunked an entire semester of college and became ineligible to return. I ended up dropping out. She got me stable again though, and I returned a year later. I graduate with honors and went to graduate school. I'm starting my thesis for my Master's degree now.

To me, she will always be like a hero. She changed my life because she took the time to really listen and care. I could still be struggling but instead I get to move forward.

So, thank you.

ladyk73 said...

....munch munch munch....
****yummy cookies**** Munch munch munch ***pizza**** Munch munch munch ***french fries***** munch munch munch...

AAAAGGGHHHHH!!!!!

Did you say side effects? A month on Seroquel and I wake up craving Little Debbies.

It is awful! I must have gained 5lbs...

Between the drugs, the PCOS, and PMS.....

Maybe I should just paint the crisco on my butt.....

munchchewmunchswallowmunch -crumbs- munch munchchewmunchmuch

The Shrink said...

I'd agree with Midwife with a Knife that often it's a question that's asked to clarify rationale and necessity than to query efficacy.

There're lots of ways to skin a cat.

It may be that medication will help through reducing intensity of symptoms some of the time and this reduction in symptom burden will effect meaningful functional change. That's the guess we're making in thinking medication can "help" someone.

But it may be that folk could cope without that medication and the world wouldn't fall apart, it's isn't trult needed and simply is seen as proffered as something that could p'raps help.

in such scenarios, if patients prefer other coping strategies, it's right to pose the question and think if medication will help or if alternatives could be considered first.

Anonymous said...

"since going off all medications she has not stepped foot in a psych hospital (2 yrs)-prior to that she averaged maybe 3 months between hospitalzations."

There's data showing that psychiatric medication increases chronicity. I bought into the medical model whole heartedly and the medication and the medication alone destroyed my life. I went from being a Ph.D. candidate to a neurologically ravaged recluse in a matter of weeks. I am now 2.5 years clean and I can barely function because of terrible neuro symptoms that I NEVER experienced prior to medication. I'd do anything to go back to the moderate depression that brought me to medication in the first place. At least I have a full range of emotions and some of my humanity back after getting off of that God-awful dope.

DrivingMissMolly said...

Michelle, I was glad to read your story.

Let's see....I've been on practically everything. I refused to try atypicals.

Now my regimen is 50mg paroxetine, 600mg lithium and 1 mg clonazepam at bedtime and up to two .5 alprazolams per day.

I also have to take Benadryl to help me sleep sometimes.

I am usually still miserable. I sleep well about once a week. I am fat. No motivation. Anxious. Unhappy.

My psychiatrist never seems hopeful. I don't get it. I think all of the three of you are too good to be true. Going to see him is a chore and I wonder if he feels the same about me. Periodically I try to get off my meds, but I go downhill pretty fast. Is this as good as it gets? 'Cause if it is, it really isn't good enough. I briefly considered ECT but that psychiatrist's sect'y never called me back. My doc referred me to the ECT doc. How do you not call someone back about something so important? I'm tired of the drugs, the appointments, the bureaucracy, the expense and the apathy. Not mine--his.

No one talks about the patient that is compliant, is in therapy, and does try, but DOES NOT get better. Does not do illegal drugs, drinks minimally to not at all, and forces herself to exercise, even if it is just walking the dog.

The dog, the dog, the dog. The only reason I'm alive.

I hope all of you are being honest about how caring, hopeful and nice you are because you're making a lot of shrinks look very, very BAD.

Lily

jcat said...

"I'd do anything to go back to the moderate depression that brought me to medication in the first place"....

Mmm, and with what you describe as a moderate depression, maybe a bit of thought and research before you dived into the psych meds, would have been a better idea? And maybe some therapy, or something. It's not all up to the doctor to decide - as a patient, unless you are trying really experimental stuff, there is enough info available to everyone to help you make an informed decision about what you choose to take.

Psych drugs ain't fun. But, when they work, it's a whole lot better than having killed yourself in the meantime.

As Michelle says, what really helps from your doc is being straight and not giving up. Especially, after about 3/4 of a page of meds in two years, the latter.

michelle said...

miss molly--

I'm glad if my story helps. There really are good pdocs out there who can help. Don't give up trying. Sometimes it takes a little searching before you get the fit right.

I should tell you about the bad ones. I didn't get it right on the first try. About 3 years before my A+ pdoc, I saw another pdoc for depression. She put me on Paxil and *crazy* side effects happened. It reeked classic bipolar (plus I described a similar episode as a teenager), but she completely missed it because it didn't fit her very rigid diagnostic criteria to a "T". It basically came down to me missing one symptom: spending gobs of money. Well, lady, I'm a college kid, I don't have a dime to my name! If I did have money, I'm sure I would have gladly appeased her. I think she saw me for 5 minutes, barely listened to what I said, and then practically shoved me out the door with a script for another SSRI... I never went back to her. I went another 3 years before I was properly diagnosed.

In the meantime, my nurse practitioner took over my care because I trusted her and she listened. She did what she could until I had a very severe episode (we didn't know it was BP yet). Despite resistance, she convinced me to see another pdoc. She made some phone calls and found a good referral. And that's how I got my good pdoc.

I've since moved 200 miles away from that city. I've been floating for a year without an official pdoc. I've been hunting though, and it isn't easy. I've fired two pdocs for being less than competent and/or rude, and I had one decide he he doesn't like my insurance (can't blame him, my insurance is a PITA).

I'm putting my money on the fourth pdoc I saw last week. We had a very pleasant conversation, and he seemed to give me equal footing in the relationship. He made some med suggestions, told me to do a little research to decide if it's something I'd like to try, and let him know at my next appointment. He recommended a local support group, gave me the titles to some specific books on BP, and suggested my therapaist (who recommended him) teach me meditation. The whole experience just "clicked". I think I'll keep this one.

I've learned that the fit of the relationship really matters to me. Telling someone you're suicidal or having hallucinations takes PROFOUND trust. If I can't tell my pdoc that, then I'm not getting the full benefit out of treatment (or maybe not even the right treatment). And sometimes I need someone who's willing to reassure me when I ask if this medication help me? :)

Sorry this got so lengthy and off-track...

ClinkShrink said...

Michelle: Not off-topic at all and thanks for the comment.

Midwife with a Knife said...

ladyk73: We should meet for a midnight snack sometime. I'm on prednisone, and that does the same thing to me. I'll bring the ice cream if you'll bring the cookies? Midnight snackers should ban together (or nail the cupboards closed, which is the other option)

enrico said...

This is absolutely not to be taken as a slight against psychiatry at all, but one of the sticking points is that psychiatry, unlike many other disciplines, relies much more on plain luck to get a med/dosage just right. Obviously, it takes a trained individual to get the basic dx right, as well as all the factors unique to that patient's situation that makes drug A a more rational choice than drug B, even though they are both, say, SSRIs.

You really have no idea when they walk out of the office if drug A will be any more effective than drug B or C because of their individual neurochemistry, etc. With perhaps the exception of the oncologist with chemo drugs, most other clinical situations have far clearer, consistent frameworks WRT to drug therapy.

There is a certain innate despair when given a drug that is "supposed" to work, only to have it not work, and repeat the process with no good explanation as to why. You as clinician understand exactly why A was chosen before B and B was chosen before C, but the patient just knows that they aren't getting better and there isn't a "definitive" answer as to why.

Roy said...

enrico, I hear what you are saying, but I can't say that I agree with the sentiment. I think one could say the same thing about choosing an antihypertensive or a statin for cholesterol.

One's choice is guided in part by one's prior experience with that drug in pts with similar stories, in part by desire for side effect avoidance (I tend to run low potassium anyway, so avoid HCTZ), and also by patient choice (my mother's friend's sister takes Norvasc and it works pretty good for her, so I'd like to try that one).

Sure, these other two illnesses have more measurable outcomes, but that is irrelevant here. Pt saying "my depression is much better" is same as a BP of 125/80. Pharmacogenetics will help us get to where you'd like to be.

enrico said...

Dr. Roy,
If you can indulge one last comment on this from a new (and returning!) reader, I'd appreciate it. :)

"Pt saying 'my depression is much better' is same as a BP of 125/80."

I agree WRT "goal achieved," but the definitiveness of the process--not just the measurable result--is not the same. I know I painted with a really wide brush in my last comment, but let me be more specific.

Giving a pt a b-blocker might work better in one person than another (all other things being equal). There are choices, 1/2-lives, selectivity,etc. Regardless of drug, if you block b1 receptors, your BP/HR will go down, guaranteed. Wherever a statin takes effect, HMG-CoA reductase WILL be inactivated, and the cholesterol machinery will shut down.

Contrast that to a [hypothetically] measurable blockade of 5-HTx (and for that matter, NE) reuptake, and the pt might feel better after x weeks, might not. Why? No one can say. It's the subjective nature of the measurement independent of what is going on--or the degree--physiolgically and biochemically that makes the whole process so much more subject to chance than a highly predictive, objective measurement in the other situations that you listed.

I've been the psychiatrist's patient a couple of times in the past, so a good portion of this comes from my personal experience and emotions, filtered through more recent training. I know I'm leaving a lot out of the equation as an (older) MS3, but I feel strongly about the core of what I'm trying to get across, even if I'm not doing a good job of it here.

Thanks for hosting a great site which I really did just find recently. :)

Roy said...

enrico, right, so the problem you are pointing out is not that the drug selection process appears to be a crapshoot for depression but not for HTN, but that it's the understanding of the mechanism of action that is so poorly understood. Is that it?

I agree with you there. It may have little to do with serotonin reuptake blockade. Or 5HT2 antagonism. It might actually be increased cell number or connectivity within the hippocampus and limbic system. Or increased levels of BDNF. Or even elevated levels of promycin.

Glad you found us. Thanks.

Stage Left said...

What if the medication CANT help me right now even if I needed it to?

Given where I'm at, the decision to fall pregnant again for the sake of my daughter not growing up an only child is a matter not to be taken lightly.

Dicing judgement against conscience is no easy feat! And I wish it were, but time is just not on my side.

NeoNurseChic said...

As a headache patient and someone who has also studied headaches extensively, I would have to say that it can become increasingly more complex and more unknown. Try having a field of beta blockers, calcium channel blockers, antiseizure drugs, SSRIs, TCAs, atypical antipsychotics, old and traditional antipsychotics, steroids, ergot alkaloids, triptans, and I could go on with several more categories. What do you pick? What do you try? What works for what patient?

And then you have an entire category of headache patients, which I unfortunately happen to be in, who have New Daily Persistent Headache, which is named as the most treatment-resistant type headache. So that means that I get a new preventive med to try every so often, and I hope like hell that this one will help, and invariably a few months later after I've given it a decent trial and increased on the dose quite a bit, I report that the only effects I've had are negative side effects - no headache impact. This has happened to me over 50 times with just prevents alone. At various times, I've been on 5 different types of prevents. At present, I'm revisiting the calcium channel blocker Verapamil because it's supposed to reduce clusters and can help with migraine (And I believe migraine to be different from NDPH, even though the symptoms are very much the same). I have to slowly go up on the verapamil by a total of 120mg a month until I reach some peak dose before we determine it's a wash. That means months of pain before determining that nothing has happened and then I'd slowly come off and start this all over with the next drug.

That has been my life for over 6 years now.

I feel very fortunate for the doctors that I do have. My first neurologist who was a headache specialist was so great - and part of the reason was because he never gave up hope. My biggest fear was that I'd go in for the appt, and he'd say, "Well unfortunately, we've tried everything there is to try - you're just going to have to deal with it now, I'm afraid..." Never did that. Always had something new to try. Even now, I email with him periodically - the other day I asked him about a med I want to try, and he wrote back asking if I'd tried aricept or namenda. So after I finish the verap trial, I think I will try namenda next, since I haven't tried that one yet.

CCBs to NMDA receptor antagonists - all for the same disease!! There's an exact science for you!!

What *I* want to try, is Enbrel, based on observations found in this paper by one of the few doctors who actually studies NDPH. Not that the paper is definitive about anything much, but I'm already on methotrexate, and my rheumatologist has said that if my neuros feel that trying something like Enbrel would be worth it, then she would be willing to look into it from the rheumy perspective, too. This falls in with my sentiments that NDPH is an autoimmune neurologic disease and requires DIFFERENT treatement than migraine. I'm perfectly willing to try this.....but thus far, the neuros are a little hesitant to say "sure, go ahead" because they've never worked with it for these purposes and feel that there are certain unknown risks. Sure, this is true - but I'm willing to try it, and shouldn't that be enough?

So will this medication help me? I ask that at every single appt I go to. And I continue to hope that the answer will be "yes". Necessity is not really the question for me. Some of us truly want to know if it will help - we want you to become fortune tellers and say that it will. I already know I need it. After 6.5 years of one failure after another, I really really really want something to help.

--Carrie :)

Roy said...

I saw this and thought it timely.
How can clinicians help patients to take their psychotropic medication? Invited commentary on... Why don’t patients take their medicine?
by Robert Chaplin

ABSTRACT: Enhancing a patient’s adherence to psychotropic medication regimens is one of the challenges facing all mental health professionals. Medication is part of an overall care package that often depends on patients’ engagement with the clinician or service. The therapeutic alliance might be improved by more active listening to patients. A reduced capacity may limit a patient’s ability to make a treatment choice. This can be improved by provision of more time and information. If these techniques are insufficient, closer monitoring may be achieved by working with relatives and carers, or more frequent visiting. Strategies to avoid covert non-adherence could include checking for picked up prescriptions and the use of depot preparations. Finally, the use of compulsory powers may be appropriate, with attention to preserving or rebuilding the therapeutic alliance.

michelle said...

Neunursechic--

Oh, I am in the same boat as you! Chronic daily migraines on top of tension headaches. I've tried so many drugs in so many classes and nothing seems to work. It's like a guessing game. I try so hard not to pepper my migraine specialist with, "will this medication help me?" every time I see him, but I really need his reassurances that something is going to work. I need a little hope because it's running out and my sanity is wearing thin. Hey, if he's got a crystal ball that predicts the future though...I'm all for it!

P.S. I just tried Namenda, I didn't make it past the side effects, but I really wanted to give it my best shot. Darn!