Thursday, November 13, 2008

It Could Happen To You, Too


ClinkShrink and Roy would like me to shut up already. One more thought, and then I will, I promise. I know, I'm getting everyone stirred up about the question of whether docs respect when patients say they have side effects from meds. It's an issue that's come up over and over on Shrink Rap.

So Anonymous (one of the many) wrote as a comment:

Maybe if psychiatrists put themselves on meds as this doctor did with Wellbutrin, your perspective would change. After she suffered horrific side effects and withdrawal symptoms, she is a lot more empathetic when her patients complain about side effects.

Thank you, Anonymous, for the comment-- it's a topic I've been wanting to write about for a long time and you've provided a spring board.

So when people have a problem or a solution, it's normal to think that other people might have the same reactions. Many of the anti-anti-depressant (or anti-AnyDrug) comments on the internet have the overtone that these medicines hurt me, they should be banned, or no one should take them. I'm an offender: if you tell me you have back pain, I'll be the first to ramble about how my back spasms have been totally cured by swimming (sub-text: swimming might fix you, too).

Psych meds: They work for some people. They don't work for some people. Some people have side effects. Some people don't. It's quite clear that many people simply don't tolerate them. And I do believe that some docs don't 'believe' their patients when they describe unusual side effects or reactions or that they may believe the patient but respond in a way that feels dismissive to the patient. I also know that I sometimes wonder if a side effect is from a medication or from something else (another illness, another medication, something else going on at the same time) . I see a fair number of people who return and say "I didn't like how I felt and I stopped taking that stuff" and usually that means that trial of that particular medication is over. I also see a fair number of people who say medication helps and they've had no side effects from it, at all. Or medication doesn't help and they have no side effects from it-- it's feels like they are taking a sugar pill.

So the idea that shrinks should try taking an antidepressant so they can empathize with the patient's response -- there is one important assumption here: That the shrink would have side effects! What if the doc, any given doc, goes on Wellbutrin like the doc in the article and unlike that doc, doesn't have any side effects? By this logic, wouldn't that make them less empathic? Huh, that stuff is hell on you, can't be, I tried it myself and I was fine. By the same token, if the doc pops a pill and has awful side effects, might the doc never be willing to give it to anyone? After all, it caused awful things to happen, and might the doc therefore deny a certain treatment to his patients who might benefit from it? I think such things happen all the time: doctors are human, it's hard to ignore your own experiences, especially the extreme ones.

I'll shut up now.

12 comments:

Anonymous said...

Dinah,

Thanks for using my previous post as a springboard for your current discussion.

Robert Hedaya, author of the Anti-depressant Survival Program, who is definitely not antimeds, says that depending on the survey and side effects being reported that 30 to 80 per cent of people on SSRI medications suffer side effects so severe that they are impaired in their jobs or relationships.

In my opinion, the chances of that shrink, who self prescribed a med, of having side effects is high.

I greatly doubt that even if psychiatrists suffered side effects on a med they self prescribed for themselves, they would stop prescribing it for their patients. Just a gut feeling

You said:

"I also know that I sometimes wonder if a side effect is from a medication or from something else (another illness, another medication, something else going on at the same time)"

The problem is that most of your colleagues if they can't automatically attribute it to the medication such as Wellbutrin causing tinnitus will automatically dismiss it, especially if it is something they haven't heard about. They attribute it to the patient's label. This happened to someone I know who ended up forcibly committed. And this is a person who had been med compliant in spite of devastating side effects.

When I reported many years ago that a med was causing foot pain, it was blown off even though I was perfectly healthy and had no medical conditions that could be causing that.
If my doctor had asked if I was taking any other meds or had any other medical conditions, I wouldn't have been offended. But that didn't happen as I was just dismissed. Funny, when I went off the drug, the foot pain disappeared.

So how do you sort out what is what?

Also, when you say that patients don't have side effects, how do you determine that? The reason I am asking is until I started tapering off of meds, I didn't realize that I had been dealing with some side effects that the meds were causing such as severe apathy and bone wearing fatigue.

Also, what is the average length of time your patients have been on meds without side effects? I personally think it is impossible to be on these meds long term without having some side effects. Since patients are now on these meds for awhile, I think simply saying that your patients don't suffer side effects doesn't tell the whole story.

Anyway, I appreciate you continuing this discussion and allowing a free exchange of ideas. Not sure why Roy and Clink wanted you to stop but I am glad you didn't listen to them:)

AA11

Anonymous said...

Dinah,

One more question which maybe would more appropriate for another blog:

Is there ever a point in your practice where you and the patient jointly decide that the cure is worse than the disease? If so, how do you proceed from there?

AA11

Novalis said...

Your point is a good one, but there is also the problematic insinuation--that I keep seeing again and again in various places--that one cannot relate to another person unless one has had virtually the same experiences, that is, good will, curiosity, and empathy can never bridge the gap.

By this standard, I may as well stop treating women, African-Americans, and people who are significantly older or younger than myself. Oh, and those from a different socioeconomic group, those who have been grievously abused, or veterans.

By this standard, only those with heart disease or cancer should be allowed to practice cardiology or oncology.

If my doctor has to medicate or otherwise inflict unnecessary treatments upon himself to have some grasp of what I'm going through, I'll get another doctor.

AnoninAus said...

These recent entries have been both fascinating and entertaining. As a client with chronic, severe, treatment-resistant depression with possible psychotic features, I have often wondered whether the psychologist or psychiatrist who is treating me truly understands my experience. Especially since my family cannot grasp it at all. I believe that the question of whether a doc appreciates one's experience of side effects applies equally to the illness/injury itself. If a person is unable to eloquently describe what they are experiencing, what sort of signs/symptoms can help get the doc into the patient's shoes, especially with psychiatric conditions?

WRT docs trying drugs to see what the side effects are like, I'd LOVE to see receiving a course of 2-3 ECT treatments added to all student psych training ;-) I'll be suggesting that to my psych on Monday when I'm hospitalized for another course of ECT after exhausting all the drug classes/combos/augmentations we could think of. The hardest part is weighing up the negative side effects of the therapeutic treatment (memory loss/cognitive damage) against the effects of the condition (also memory loss/cognitive damage and eventually suicide). I guess this balancing act is tricky for all branches of medicine.

Anonymous, very interesting question. I believe it is possible to rationally say in my situation that suicide is better than unrelieved anhedonia, despair + all the rest. It'll be intriguing to see what the docs say - can a psychiatric condition be considered terminal?

Thanks Shrink Rappers, I've learnt a lot from your blog and the comments!

a psychiatrist who learned from veterans said...

I think the hardest thing in learning medicine is comprehending that there is not a unitary outcome. In pharmacology, the doctor to be learns the mechanism of efficacy. He/she should really learn how to find the side effects as well or even that bad can come with the good. Conceptualizing this is hard also for patients.

Case example, I was called, on the medicine service, to consult on a patient with abdominal pain, right upper quadrant. As a 'medical explanation' wasn't found in radiology or endoscopy, the docs concluded that they'd come to a spook problem and a spook drug like Cymbalta was called for for the unknwowable Freudian secret. This turned out to be potentially a tragedy of the possible hypothesis. I reviewed her drugs on Micromedex; Lamictal had a 16% incidence of abdominal pain and the pain went away when I stopped lamictal. some patients get 'the minor statistical effect, a 'side effect,' rather than the main effect which leads to a drug indication.

Roy said...

I didn't tell Dinah to shut up, but I did comment that she sometimes posts about those docs-vs-pts topics that tends to get folks stirred up and defensive, and for which there is never any resolution (but often increased understanding, so that can't be bad).

Re the docs should take a dose of their own medicine to understand issue, I think that this speaks to compassion, empathy, and listening. The docs who have more of these attributes going for them don't need to take the meds. The ones who don't would probably have these tools sharpened for them with a little SSRI withdrawal brain zaps, but such an approach seems very inefficient given the large variety of side effects possible for any drug.

I tend to take the more likely/less likely approach when discussing whether a side effect may be from a drug. I'll ask about how bothersome it is and if the benefit they get from the drug outweighs the possible side effect. We'll sometimes try a period off the drug to see if the side effect goes away (which doesn't clinch the cause-effect relationship), and if it does go away but the benefits are lost as well, a re-challenge may be done to see if the effect returns (which does clinch it for me).

Aqua said...

This is a great post. I have not had much luck with meds, but I know many people whose lives have been improved so much by th right medication.

A case for your example of how the pdoc might take the med and feel fine is how differently a friend of mine and myself reacted to Olanzapine. She takes a large dose everyday and it takes her symptoms away. On a miniscule amount I could not even function, drive, stay awake the whole next day.

Also, I find it very difficult to differentiate some of my med "side effects" from my mood disorders side effects...things like fatigue, concentration, memory etc.

I had those problems when I was on no medication too, so is the increase of those side effects the meds, or my longterm treatment resistant depression? Again, great post

Midwife with a Knife said...

The "Welbutrin Experiment" may likely backfire. I've been well served by my citalopram (which I wasn't initially eager to take, but I was at a point where I had to try something....). It's been effective and well tolerated and this actually makes me much MORE likely to recommend/endorse SSRIs for patients.

BTW, my word verification is bakery.... it's as though blogger is trying to torture me about the fact that I'm going to be at work for another hour and I'm hungry. ;)

Anonymous said...

Of course, Novalis good will, curiosity, and empathy can bridge the gap. The problem is there isn't enough curiosity and empathy when patients report a side effect.

That is why I said if psychiatrists were forced to take the same drugs that they prescribe patients (of course, that isn't going to happen) with the odds pretty good according to Dr. Robert Hedaya of them sufferering side effects, they might not be so quick to dismiss their patients the next go around.

Novalis, when my mother was alive and dealing with being nearly blind, I was very empathetic. But there was no way that I was going to understand what it was like unless god forbid, the situation ever happened to me.

I didn't suggest that you stop treating different groups of people from yourself. You sorta of jumped from point A to point C.

Anoninous - I am pained by what you wrote even though I totally understand your despair.

You might want to look at this site by a scientist who totally relieved his depression with magnesium.

http://tinyurl.com/2pougg

It takes alot of effort wade through but if you click on his links on the left, it makes it easier.

I would also try increasing your vitamin D. Right now, the minimum suggested requirement is 400mg. But there has been some thought that 1000mg would be helpful.

I would also try fish oil capsules. There have been a few studies done that show that supplementing ADS with fish oil really helps.

Sorry for getting off topic shrink rappers but I wanted to help out this person.

AA11



AA11

ladyk73 said...

Over the counter meds can have nasty side effects....

I am so THANKFUL that there are antidepressants and whatnot on the market.

Without Effexor, I would most likely be dead.

I am actually on Effexor, lamictal, and seroquel. My new psychiatrist (new insurance) didn't really like the cocktail, neither did I.
The seroquel was making my skin crawl. We halved the dose and the skin-ickliness wnet away...but then I dived back into a episode of depression.

I am in a bind...to go back on it, or not? I decided to not raise the dose back up...
But I am still pretty blue.

It really does suck to have depression that seems to be resistant to meds.

Oh...yeah...I have anxiety too!
Yuck

I actually wonder how much hopelessness/suicide is caused by people with hard to treat depression.

If you look at suicide sites...there is always some bit about DEPRESSION CAN BE TREATED!!!! And if you are suidical, but have already a boatload of meds....that "hope" that is advertised on those sites can just really suck.

So I wonder how much "hopelessness" is in regards to the treatment of depression itself.

Anonymous said...

I would back up what anon said about nutritional treatment. My personal experience is that not eating well does not enhance my sense of well being and makes my depression worse. I recently was able to eliminate anxiety attacks by taking magnesium, and have added the fish oil and vitamin D. This is under the supervision of an MD who does preventative medicine. That isn't going to fix everything of course but it sure helped me and got me down from 2 antidepressants to one.

Anonymous said...

LadyK73, you make a good point about supplements having side effects. But I would still take them over med side effects any day.

One way to lessen the risks is to buy high quality items. For example, if you buy fish oil capsules at your local drug store, you might as well not buy them as the quality is so poor. I stupidly bought some one time at a grocery store when I ran out of my regular supply and had one of those nasty side effects you talk about. I have never had any problems with good quality fish oil capsules other than if I take too many.

Anyway, I am sorry that meds aren't helping your depression. I totally understand the desperation.

What do you have to lose by trying things like magnesium, fish oil capsules and vitamin D? It might not work and you might be out some money but isn't your mental health worth taking a shot especially since you feel so blue. And it might be helpful although of course, I make no guarantees.

To the other anonymous - I am so glad that the supplements have helped you. Continued good luck.

Finally, just so people on these boards know, I am not in any way shape or form affiliated with the alternative health field or supplement industry. I am just a satisfied customer.

AA11