Friday, April 05, 2013

Cosmetic Psychopharmacology?


We read everywhere that psychotropics are over-prescribed.  The DSM guidelines have pathologized normal reactions and  DSM-V promises to make this even more so.  For example, over 11% of children are now diagnosed with Attention Deficit Disorder.  Our friend, Dr. Mojtabai, tells us that many patients who are given antidepressants by primary care doctors don't have a psychiatric diagnosis, our colleague, Dr. Frances (and many others) doesn't want normal symptoms of grief to be diagnosed as major depression after 2 weeks of symptoms, and our readers have written in saying that there are effective psychotherapeutic treatments for schizophrenia.

Why the push to give so many people a diagnosis, and then a pill?

I'll venture some guesses here.  These are only guesses:

~ Psychiatric disorders were previously under-diagnosed and with the broadening of diagnostic categories, and the promise of relief, more people go to the doctor seeking these diagnoses.  In order to get a diagnosis of ADD, you have to point out the symptoms to a doctor -- a doctor doesn't just know that you can't concentrate, focus, and lose things all the time (to name a few symptoms) and if you think this is normal, you won't tell the doctor your problem.  So greater public awareness and desire for diagnoses and treatment.
~A desire to blame problems on biology and therefore not have to own them.
~Treatments with fewer perceived side effects.  Many people have no side effects to the medications, and so the risk/benefit tradeoff is low.  I left it as "perceived side effects" because some of the treatments include risks that may not initially be felt as such by the patient, such as the risk of addiction or of metabolic problems which may not have obvious symptoms.  But some people truly get benefits from medicine with no untoward side effects.
~A push by the pharmaceutical agencies to sell their wares to doctors and consumers.  Funny, we have villainized physicians who let drug reps give them pens or feed them sandwiches or pay them thousands to peddle their product, but it's fine that drug companies now advertise direct-to-consumers in 30 second bytes.  I'll leave that one for another day.
~Sometimes these medicines work and provide tremendous relief and then they become their own advertisement.  My friend feels great on Drug X and I want some, too.
~Who doesn't like a quick fix?  I believe medications work best in combination with psychotherapy, and it's not an either-or proposition.  Some people get all the way better by simply popping a pill, others don't get better with all the drugs and all the psychotherapy there is in the world. 
~While a trial length for medications is clear, we don't have a definitive time frame for how long one needs to go to therapy.  Do you get better after 4 sessions or 4 years?

That's for background.  Now for today's blog post:

So with a push to accurately diagnose, and to reserve treatments for only those who meet diagnostic criteria, I'm going to ask a question: What's wrong with cosmetic psychopharmacology?  Why is a problem to give someone who doesn't meet criteria for a disorder a pill, provided the patient comes looking for help (I don't advocate sending psychiatrists to knock on doors), provided they are made aware that the medication has risks, provided the patient has some form of free will and can stop the medications at any time?  And given the fact that "meeting criteria" is about diagnoses that are decided by a committee and not based on something hard and fast and scientific, for example the presence of a large tumor.  The issue, of course, gets sticky when the treatment includes medication with the potential for addiction, but let me give you some examples, and you can comment as you will.  Keep in mind, I'm asking to be provocative, not to say it's fine.

~ A patient comes in with 4 weeks of  profound sadness, feeling hopeless and suicidal.  There are no neuro-vegetative symptoms (meaning no change in sleep/appetite/sex drive) and he's a couple of symptoms short of "meeting criteria" for Major Depression.  There are no clear precipitants to the episode, both parents and one sibling have had treatment for depression, and the patient is willing to come for therapy, but he's also requesting medication.
~ A patient requests a single tablet of Valium (or any of it's relatives) to take before a flight.  The patient has flown before and gets very anxious, but has no psychiatric diagnoses.  His flight is next week and he has neither the time, funds, or propensity to undergo desensitization training.
~ A college student comes in requesting a prescription for a stimulant.  He has been taking a friend's and finds it to be very helpful.  He only takes it before exams or to write papers and he feels it gives him an edge he wouldn't otherwise have.  He has no history of addiction, no blood pressure problems or arrhythmia, he is requesting a low dose and only wants a small supply.
~ A woman is a wreck 2 weeks after her mother dies.  She has every symptom of depression and wants medication.  She understands that her symptoms are from grief, but she wants to see if a medicine might help mitigate some of her misery.
~ A gentleman with a family history of Alzheimer's has noticed some age-related changes in his memory.  A neurologist has told him that he doesn't not have Alzheimer's disease.  He wants to start Aricept as a prophylactic medication in the hope that if he were to get Alzheimer's disease, this would slow it's progress.
~ A man took an SSRI for a single episode of depression and made a full recovery quite quickly.  During the episode of depression, he was seen weekly for psychotherapy, since then he has come in for monthly sessions.  After a year, his psychiatrist took him off the medication.  He has not had a relapse and is doing well, but is requesting to resume the medication because he just feels better on it, but can't articulate why other than to say he feels calmer and more resilient.   He has no side effects to the medication, and it does not make him complacent or unmotivated.
~ A patient has trouble sleeping and wants Ambien to take once in a while.  Then he wants Ambien to take every night. It helps him sleep and he has no side effects from it.
~ A patient has trouble sleeping and has a history of addiction.  The psychiatrist is worried about starting Ambien or a benzodiezepine.  The patient did not have a good response to trazodone or benedryl.  His insurance won't pay for Rozeram.  He found Seroquel to be helpful, his insurance will pay for this, and he understands that it might cause weight gain and metabolic issues, but he's young, healthy, slim, exercises regularly and willing to take the risk with monitoring of his weight and labs, but it's not indicated as a sleeping pill. 

Go for it.

72 comments:

lyrea said...

I am going to assume you have heard of the patients who died due to liposuction. I don't know how to read this post. If you were a dermatologist, would you prescribe Accutane to young fellow who had two small zits but who could not cope with even that? Even assuming his blood tests were fine and he was warned about side effects and screened for psych side effects, is it responsible medical practice?
That slim guy who wants Seroquel will pack on the pounds in no time before he even knows what hit him. Medicine is not a game. I hope you are joking.

Anonymous said...

We live in a society where the gun,
tobacco, alcohol and drug industries
legitimately peddle life-threatening products. Physicians should
play a public health role vis-a-vis
harmful products and adhere to medical guidelines for prescribing drugs.
If they decide to forego that role, they should assume no authority in opposing laws like Oregon's assisted-suicide laws

Joel Hassman, MD said...

Least to most invasive. Aren't medications more invasive than therapy, again, depending on the acuity and intensity of symptoms and duress?

The road to hell is paved with good intentions. Maybe it is time for med schools to have that tattooed to every students wrist, just to remind them of the next 40 years of effort!

Anonymous said...

College student wants small supply of stimulants to stay up and party, but only on Friday nights, so just needs small amount. Tired from studying all week. Doesn't drink, just likes to stay up late and socialize, building important lasting networking connections. What's the difference? Lets just sell the stuff over the counter and put a warning like they do on cigarettes. Patients tell you what you want to hear to get rx. Legalized drug dealing? Baz-

jesse said...

And should you add to the provocative nature of Dinah's questions that the the insurance company will pay for it only if there is a diagnosis, and so the prescriptions require one?

Anonymous said...

You have ADHD, only when you have a paper due? Then you don't have it. You should pay full price, over counter for generic and stop increasing everyone's ins premiums for your performance enhancing drug. Not any difference then Lance Armstrong, except that was banned. Good Point Jesse, rx's are driving the dx. Backwards. Baz-

mctps said...

In the ideal world, potential patients would be perfectly aware of the risks and capable of making informed and rational decisions unmoved by peer pressure, advertising, popular misconceptions, confirmation bias, deceptive or ignorant psychiatrists, and so on.

Back here in the real world, I'd focus on attacking the psychiatric community, the FDA and similar gate keepers, and the drug companies until they are incentivised to push for the development of drugs that are safe and effective, or failing that, effective, or failing that, safe. Currently, the most important drugs are neither safe nor effective (linking to studies concerning potential efficacy, because lack of safety is well known):

http://www.nature.com/mp/journal/v14/n4/pdf/4002136a.pdf

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003012.pub2/abstract

http://www.nejm.org/doi/full/10.1056/NEJMsa065779

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006918.pub2/abstract

To summarise: antidepressants are scarcely more effective than placebos in trials using active placebos. This suggests that unblinding effects play a role in inflating apparent efficacy in most drug trials. Antipsychotics are not (significantly) more effective than inert placebos, when all studies of a single drug are meta analysed. Remarkable publication bias has been uncovered regarding trials of antidepressants: facts say antidepressants aren't effective, popular ideas say they are very effective. I'd say such bias likely affects perceptions about antipsychotics as well.

I also don't understand the popularity of maintenance drug treatment for schizophrenia. Even if the dopamine hypothesis were correct, the brain would still adapt to the medication in a couple of years, signifying that the only logical course of treatment would be administering the drug only during acute psychoses. I mention schizophrenia in particular, because schizophrenics are so often coerced into using such medications.

Nathan said...

Dr. Hassman,

Lots of people find many psychotherapies to be more invasive and intensive than many medications. I think that's a fair reason why people rationally often prefer medications, especially given the expectation of lower cost, quicker effect, limited effort, and presumed safety. While risks and safety of many psychotherapies are not well studied either, if you think that psychotherapy is anxiety-inducing, costly, takes a long time to see effects (if effects at all), meds seem like a more reasonable idea.

Dinah said...

You can see pimples, you can't see psychic suffering. And you can't see pain -- which is the basis for many prescriptions for narcotics.

That said, how many pimples warrant accutane: 6? 8? 12?

So doctors should say no to liposuction (you can die), no to nose jobs, facelifts, boob jobs and tummy tucks? Should we formally make them illegal?

No valium for a flight? Or an MRI? Only illnesses that meet criteria for a DSM diagnosis because we know that volume has perfected the line between valid suffering and those who should pull up their proverbial bootstraps?

None of this is easy, and I did mean to provoke (hmmm, how'm I doing?). But if we say that the only suffering is that allowed by DSM criteria -- and really only then if you're hooked to a polygraph machine because people can lie and say they have symptoms when they don't -- then we discount the concept of any patient preference and the doctor becomes all powerful.

It's funny that those who are most against psychiatry and all it's pitfalls (including it's sordid history of misguided paternalism) are also the ones who think psychiatrists should never respect patient preference and prescribe medication because a patient is suffering. I think our enemy has become us.

Anonymous said...

Is term paper help suffering? By the way, I am not anti psychiatry at all. But I have seen people abuse the system as well as get great benefit from the system. I never would have thought to see a doc when I was in college if I needed a bump, but I did buy NoDioz a couple times! Baz-

mctps said...

Dinah,

I think the logic you are overlooking is that I'm not interested in abstract speculations seasoned with utopian rhetoric and wrapped in self-referential sophistry. Alas, your provocations have little to do with the real world. Which is the only criticism of them that I expressed. Everything beyond that is your own imagination.

That being said, you're probably about as good a psychiatrist as a modern psychiatrist can be without standing knee deep in spent shell casings calling for a revolution. I prefer attacking psychiatry as a whole, certainly not one specific individual who is honorable enough to allow open discussion of these topics to this extent.

If pushed, I would say that what you seem to have argued for is just another reason to revise the FDA approval process, because currently a drug could cure cancer and blindness and still have been approved only for insomnia if that's all the drug company sought an approval for. I think non-profit government institutions, not private corporations, should be responsible for drug development, and I certainly think drugs should be used as liberally and freely as possible provided that they are suitable for the purpose and reasonably safe and harmless. In fact, I think any adult with an IQ over 115 and no criminal record should be allowed to purchase cocaine over the counter for private use regardless of motive, but then that's just another funny thing about me.

Alison Cummins said...

Thanks, Nathan. So many people give psychotherapy a free ride, as if it were risk-free and always good. Which is absolutely not the case.

Dinah,

The Valium for the flight seems like exactly what Valium is good for. That should be an easy yes.

As a (bipolar-ish) depressive who had trouble getting meds when I needed them, all the depression-related requests seem completely reasonable to me.

As someone who has always slept easily, the insomnia ones seem more questionable to me. Seroquel is big guns. (On the other hand, sleep-deprivation is very damaging.)

As someone who has several trials of stimulants and loved them for the two weeks it took for irritability to become a bigger problem than the wooly-headedness I was taking them for - and who has never had trouble with studying or exams - I'm dubious about the Ritalin.

The Aricept? I don't know anything about it, how effective it is or what the side-effect profile is. If the guy's neurologist told him he might have Alzheimer's, wouldn't Aricept have been discussed at the time if it were at all reasonable to consider? But this is fairly abstract to me. I have a game plan for Alzheimer's and since I don't have children it doesn't involve sticking around to see if therapy helps.

What is clear to me is that my thoughts on your scenarios are all about me and my personal experience. Since I don't have your second-hand experience of other people's experiences all I can do is see if your judgement aligns with mine on the antidepressants and if it does, accept your judgements on the rest.

Anonymous said...

These drugs are nothing to mess with. Four years ago my husband was complaining to friends he was having troubled concentrating. They all said, you have ADHD ho get adderall. He met doc who gladly gave him increasing doses. Doc never bothered to ask about family history which is riddled w bipolar. I think you know where story ends. Within two years an upper middle class family was bankrupt, we lost our house, basically destitute and took my husband almost two years to get his mental status back. Was he sick to begin w/? Probably. But a careful fox not trying to please would not have prescribed stimulant so readily to 40. Adult onset? Are we to blame for not noticing? Sure. But I put a lot of stock in that MD degree, back then. Docs, it's nothing to be casual about.

Dinah said...

To the anon who thinks the kid who wants stimulants for tests and papers is lying and really wants them to party: should we presume our patients are lying? How do we police this? What about the pain patient?

To mctps who wants to legalize cocaine to any non-criminal with an IQ over 115: What's the magic of 115? What if someone tests at 114 and insists it was a bad day, they had a horrible headache but the doctor wouldn't give them any percocet, and if they'd have felt better (or had some stimulants like all the other test takers), they would have had an IQ of 119. Why should only smart people be allowed to use/abuse or get addicted to cocaine? Can you take the test repeatedly and average the results?

So do we leave the first guy with the miserable mood and the suicidal thoughts, we tell him that while my clinical experience is that anti-depressants work quiet well, but sometimes you have to tweak, or try different meds, or augment if you want to exceed that 30-40% response rate, and sorry the studies say his parents and relatives did not get better from their medicines and if they say they did, then it's all a placebo effect, so let's not give him meds?

And what about the guy who has to fly for work and is very anxious? Do we say no to his 2 tablets of valium? And what reason do we give for this? What about the guy who's very anxious about his MRI? Do we give him something to get through the test? And when he can't sleep because they found a fatal brain tumor, do we say of course you can't sleep, totally natural. 2 years of psychoanalysis and maybe you'll be cured, but since this is not a disease, no sleeping pills for you and pull yourself up by those $^$!!*@ bootstraps?

Find me the line. You're doing great.

Anonymous said...

Past hats from Baz-

Anonymous said...

So what if they are writing paper or partying? Either way it's not ADHD? Do you ever feel used for drug prescriptions such as this? Just curious? Honestly.

Anonymous said...

I don't think a kid who left his term paper to last minute is suffering. I don't compare him to a pain patient; maybe a spoiled child?

mctps said...

"What's the magic of 115?"

One standard deviation above the average. Other than that, the magic is the same as the magic of 13-25 and 55-75 when it comes to deciding the age of consent, adulthood, retirement, and such things. Obviously, one wishes these figures were based on serious studies comparing the effects of fine tuning and different alternatives. My 115 figure is in good company in being no more or less based on careful analysis than any other prominent law, the difference being it is openly elitist and almost naughty in its pro personal liberty stance. Just a personal preference, at the end of the day.

lyrea said...

Dinah,

No one said to make boob jobs illegal if performed as cosmetic surgery, why should insurance covered it?Mine does not. I don't know anyone who had a nose job covered unless their face was smashed in a car wreck and it was reconstructive surgery. We can't see pain. Two zits might be keep the kid in his room hiding under covers. Or six or eight zits. That does not warrant the prescription of a dangerous drug. Valium for an MRI? It is pretty standard and so i Valium for an anxious flyer. If someone came in saying they had to fly or have an MRI,every second day the person who needs that many MRIs probably also has an awful medical condition. You specialist who booked those MRIs can give them the Valium, you can stay out of it. The frequent flyer needs some of that CBT. If not, don't worry since he or she will buy a few drinks from in flight service.
Seroquel for the former addict with trouble sleeping. If he thinks he cannot sleep now, tell him the truth--he will have terrible insomnia when he ever decides to get off the Seroquel or it becomes medically necessary to do so. The grieving woman whose mom died two weeks earlier does not need an antidepressant. Tell her they take about 3 weeks to start working anyway. There are support groups. Grief is painful but not an illness. By shutting down her normal emotions you will only help her put off the grieving and that is not a shrinks job. A shrink's job is not fix everything that hurts in five minutes. Life hurts. What do you do for a patient who has only just begun to feel the pain of an abusive childhood after 60 years of not dealing with it. I doubt you hand them a bunch of pills. Normalize the experience of emotional pain and offer some hope. The patient who is suicidal and hopeless with no neuro veg states, needs to be monitored. An anti depressant will not take away his suicidal thoughts tonight or tomorrow. You need to spend more time figuring out what is going on or you risk giving a guy who actually has a brain tumor, an antidepressant to treat it.Aricept as a prophylactic? I don't know, my mother had breast cancer but I know I do not carry the gene and neither did she. After all the regular tests, no abnormalites detected. Should I ask my doctor to remove both my breasts because I am worried I might get it some day? Should you give your 10 year old prophylactic accutune so he or she never has to develop a bad case of acne? The truth is that some doctors who use their judgement do refuse to perform nose jobs on people in great psychological pain who also happen to believe that the surgery will turn them into a top model. It is about managing expectations. But you know all that.

jesse said...
This comment has been removed by the author.
jesse said...

This blog by Dinah is absolutely brilliant. She might have named it "You Be the Shrink!" By posing these real world examples we see what us shrinks deal with everyday. The world does not fit into precise categories and almost always there are intricacies that are resolved by experience and careful listening, not by rules.

So Dinah creates these vignettes and we see the difficulties of absolute positions: do you listen to your patient vs. medications are bad vs. psychotherapy is harmful.

Alison Cummins hit it on the head when she wrote: "What is clear to me is that my thoughts on your scenarios are all about me and my personal experience. Since I don't have your second-hand experience of other people's experiences all I can do is see if your judgement aligns with mine on the antidepressants and if it does, accept your judgements on the rest." Her first sentence is a key to psychoanalysis and interpersonal psychotherapies. How often are our thoughts about others and their intentions really projections of our own beliefs?

But the second sentence is also important: each patient's judgment on the antidepressants is the result primarily of his own experience. Sometimes here on Shrink Rap it reflects "they did not help me, therefore they are worthless."

An important part of being a good psychiatrist is being able to see the largest picture and greatest experience in order to help others. There are few cookbook answers.

As Hamlet said, "I could be bounded in a nutshell and count myself king of infinite space - were it not that I have bad dreams."

Liz said...

valium for a flight? sure. a stimulant to study? sure. i wish ssri's did not exist and i don't ever think they should be prescribed.

HIGurl said...

Sorry Dinah...didn't realize that I responded to the wrong post! See what happens when you're not paying attention, lol. Anyhoo, I'm just gonna repost to the correct one. You may wanna delete the comment I posted in your "Medical Necessity" blog - apologies again!

Dinah,

Gotta love the challenge here! I honestly feel that the decision to dispense drugs (in each of these dilemmas) comes down to ethics. Bottom line.

The impasse is that we tend to take a look at the whole picture and then decide 'yae' or 'nae'. Does the risk outweigh the benefits?

For example, let's take the patient requesting the Valium. Is he healthy? Why is he asking for a specific drug, is there a hidden reason? Did he have this particular drug or a similar one before? Does he seem like the kind of person to sell his prescription? Will he be back for more meds? Can it contribute to more anxiety later? What if I decide not to prescribe it? (BTW, if this scenario what genuine, I think this person would ask for two pills, not one - because he needs to fly back).

In this case, I would ask him to go see his primary care physician. I mean, you don't see any presentable mental health issues, right? Be like some politicians/legislators and throw the responsibility/liability to someone else! Lol. Well, you could contact his previous physician who prescribed it before and decide then dispense (if applicable).

Again, a scenario such as this presents much dilemma. It's like being a Becker's MD patient with great cholesterol and blood pressure numbers who needs a new heart or defibrillator implant - "Do I want a donut or a fruit salad for dessert?" Isn't life full of choices? Decisions, decisions, decisions.

I'm not trying to go off the beaten path but following DSM guidelines must be frustrating for situations similar to what you presented. It's not like you can stick someone with a needle and come out with a clear-cut diagnosis. Now wouldn't that be great?!? Less paperwork and headaches. But then again, it would make psychiatry less interesting!

Anonymous said...

Geesh Liz, what if other people found/find SSRIs to be helpful or even life-saving, even with side-effects and unknown long-term effects and discontinuation syndromes? I'm glad you're not my psychiatrist.

Dinah said...

A few people have suggested sending the patient to his primary care doctor for a single dose of a benzodiezapine for an acute event (a flight, an MRI). Benzodiezepines are psychotropic medications which psychiatrists prescribe, a psychiatrist wouldn't refuse this and suggest it is more appropriate for a another type of specialist to prescribe this any more than a primary care doctor would tell a patient to get a refill on their medication for hypertension.

I didn't want to be snarky about this, and knowing which medicine is in which specialist's domain is not something the general public should know, so I'm just informing here.

Liz: if you have a bad reaction to SSRI's, then you shouldn't take them. Some people do find them life-saving and feel much better on them, as Anonymous has pointed out. Some have side effects, some don't, so essentially, for some people, it's all good or all bad, others have a tradeoff if the medicine helps, and if there is no benefit and all side effects, the decision to stop gets very easy.

I think Alison and Jesse have noted that readers seem to extrapolate their own experience with a medication to what is appropriate for others. Psychiatrists (indeed, all medical doctors) do that as well, but we have a bigger sample of people to draw our conclusions from.

p said...

Dinah: you aren't being snarky here. YOu're also not based in reality, which is the bigger problem.

Most GPs would certainly prescribe single doses of benzo for acute events. Just because yours doesn't....

Again, you are not based in reality. Reality may suck, but it's reality.

Anonymous said...

A PCP would not suggest that a psychiatrist prescribe a drug for hypertension but many PCPs have to prescribe psychotropic drugs or follow patients on them long term because of difficulty in finding access to a psychiatrist for many people.It is easier to find a PCP knowledgeable about psych meds than a psychiatrist knowledgeable about non psych meds.

Dinah said...

L: you don't like me. Find another blog.

Yes, GPs do prescribe psychotropics. I was assuming that I'm sitting with a patient I know well, having a regular therapy session, and the patient mentions being anxious about an upcoming flight. It would seem odd to me to suggest the patient call another doctor to get a prescription for a psychotropic while I'm right there, it's for anxiety (perhaps not an illness, but a psychiatric symptom) and I'm in a position to know the situation, the patient, and the risks and benefits.

I'm enjoying the reader input!

Steven Reidbord MD said...

I agree with @jesse: This is a brilliant post. I've run into every one of these scenarios in practice, or something very similar. They put the lie to one-dimensional declarations that "Psychiatrists should simply do X!"

Clinical practice constantly demands tricky line-drawing. Would I give the scared flyer a Valium (or 5)? Sure. It's a whole different thing than an ongoing prescription. The depressive who doesn't meet criteria? I'd probably prescribe -- after explaining that doing so isn't supported by research. The stimulant-seeking student: Sorry no. I draw the line at addictive performance enhancers (and frankly wish such folks would simply obtain them from friends or the internet and leave me out of it). I'd likewise decline the recently bereaved woman, the fellow scared of Alzheimers, the SSRI sought for ill-defined reasons, and the Seroquel for sleep. I'd prescribe the Ambien for the other insomniac while continually advising alternatives; while not harmless it's much much safer than Seroquel.

I wouldn't expect any other psychiatrist to exactly match my choices, and I also reserve the right to change my mind in all these cases depending on the actual person sitting in front of me. This is what makes psychiatry, even the medication part which doesn't interest me as much, a thoughtful and creative endeavor. And even fun sometimes.

Steven Reidbord MD said...

Oh, I also wanted to mention that several of these examples aren't "cosmetic." The stimulant and SSRI requests are; the others are clinical judgments about risks and benefits for treating a complaint. I decline those who want me to rubber-stamp a prescription without doing a clinical assessment -- "just give me what I want." As just mentioned, I don't object to self-medication in general, I just prefer not to be involved lest I take responsibility for a decision that wasn't actually mine.

HIGurl said...

Sorry Dinah, didn't mean to imply that psychiatrists should refer such a patient. I'm just making light of the situation. Why run with everyone else when you can run the other way?

Yes, benzodiazepines are commonly prescribed by psychiatrists - and a psychiatrist may refuse to prescribe it under certain circumstances. I'm just saying that if you as an individual think something doesn't feel right about the situation, you need to decide what to do next. Maybe it's getting some advice from colleagues, referring that patient to another physician, or refusing to prescribe meds.

Really, it would just come down to the exact details of the situation. If this patient knows the side effects/risks of taking the Valium and you know there are no other possible/presentable interactions (i.e., alcohol/drug use) and you feel comfortable, then by all means prescribe it. You're the expert of your own self, and it doesn't matter which specialty/branch of medicine you practice.

Again, I'm not trying to imply anything (towards you or any specific person).; it's just a general response to the post--something to think about. We're all human, having both similar and different views/beliefs. I'd like to think all patients have good intentions, especially if they're coming in for help. You have to have a lot of trust, towards your patients and towards yourself. It just sucks that there's all these criterium for providing a diagnosis, especially when the patient has something acute that doesn't qualify him/her.

Anonymous said...

Liz, while i hear you, bc I too had a terrible response to ssris, your response is invalidated by ok ing stimulants etc. people too have had terrible responses to stimulants, benodryl, penicillin,etc. so you are only speaking of your solitary response. On your behalf I don't think docs empathize w how terrible these side effects are for some, I think dr. Haussmann called them annoying. I found them almost life threatening. However, had my pdoc been a bit more understanding, would have been nice and I have moved on to other drugs more cautiously as an informed consumer (and my doc is more cautious too). Ps hope Dinah isn't kicking you off but the rude "p".

mctps said...

I have a friend who was on antidepressants for 10 years, approx the same amount of time he was on disability. When I asked him a couple of years ago whether they helped at all, he stopped to think for a couple of seconds and said, no, they didn't.

Similarly, there are millions of people on longterm disability who take antidepressants. Nobody stops to think, hey, if these medications were effective, those people wouldn't be on disability.

I think the really important questions are related to why people are taking all these medications when the meds aren't doing anything for them or for society, unlike advertised. The popular idea is, if you get depressed, just take a happy pill. The reality is, if you get depressed, expect to be on disability for years, maybe the rest of your life.

I also just read an excerpt from a peer reviewed article that speculated that antidepressants may cause brain damage when used for long periods of time due to something to do with energy deprivation in mitochondria (I think). I've forgotten everything I ever learned about biochemistry, but it sounded like the concern was grounded on solid science. So all these millions of people who are irrationally taking antidepressants may be getting brain damage as the only thing they get out of it.

With antipsychotics these sort of social phenomena are worse because the meds are often so expensive, and the side effects tend to be worse and the administration of the meds coerced.

This is the reality I see. Everything else is remarks on the margins.

Anonymous said...

Just to give some perspective to mcpts quip: "there are millions of people on longterm disability who take antidepressants"

2011 number of former workers on SSDI: 998,979

2011 number of former workers on SSDI for mood disorders: 101,554

2008 percentage of Americans taking an antidepressant: 8.9 [=27 million]

(References upon request)

Sandra Smith said...

The fact is that placebo pills WORK about 30% of the time to cure most peoples ailments.

So, simply convincing someone that something will work is at least a third of the battle to "curing" them.

Rather then giving people the "real" drugs, perhaps a better solution then would be to give them sugar pills (unless they are suffering from diabetes!)

That way you would probably cure just as many, but the costs would be kept to a minimum.

Then again I could just be being provocative as well :-0

Joel Hassman, MD said...

Nathan wrote this on April 5 to me:

"Lots of people find many psychotherapies to be more invasive and intensive than many medications. I think that's a fair reason why people rationally often prefer medications, especially given the expectation of lower cost, quicker effect, limited effort, and presumed safety. While risks and safety of many psychotherapies are not well studied either, if you think that psychotherapy is anxiety-inducing, costly, takes a long time to see effects (if effects at all), meds seem like a more reasonable idea."

Thanks for validating my ongoing point to the fallacy to the quick fix/biochemical model that has ignored the less to most invasive premise to care. ANY TREATMENT can have exceptions to serious consequences, take penicillin for instance, as I am on it for a strept throat right now. About 10% of our population have serious reactions, including anaphylaxis, so would we just take it off the market for that 10%? Yeah, my bet is your rationalization if 10% of people have alleged negative reactions to therapy, and it assuming completely responsible and efficacious types of therapy has negative outcomes of severity you infer, then let's dismiss the intervention!

Gimme a break, the point to responsible and attentive psychiatry is to assess the individual in front of you and offer a treatment plan that will impact on the provisional diagnosis from that evaluation. My ongoing point is still this: some people need meds up front and immediately because the severity of the illness requires meds, but I think a sizeable portion of people, even if it is just 33%, need therapy first. And it is more than 33%, maybe not more than 50%, but, as a psychiatrist in typical outpatient psychiatric care settings, therapy ain't gonna pay the bills, eh?

And to tie in the antibiotic point, if everyone who comes in with a sore throat should be sent out with an antibiotic prescription, that means everyone who comes in with an anxiety problem should leave with an anxiolytic script too?

I wrote about his exact point early on in my blog regarding the overprescribing of benzos by PCPs/other non psychiatric providers. Who then eventually dump these patients on providers like me to deal with the 8mg or more xanax users and other reckless scripts in place for other benzos.

Hey colleagues, do you really have no reaction or opinion seeing a patient for an eval who comes to you on high dosages of benzos prior prescribed by a PCP who realizes how out of control they have let the patient get?

Do you call the provider and thank said doc for the referral? So he can send you more??

Hey, isn't this an example of cosmetic psychopharmacology by less than trained prescribers!?!?!

mctps said...

Anon, if your statistics were relevant here, they would mean that my country (a modern Western nation) has a thirty-three times higher rate of disability for mood disorders than the USA. Itself a mystery worthy of Charles Fort.

As for your other point, maybe there are dozens of millions of people on antidepressants in addition to that who wouldn't be able to work if they weren't on medications. Maybe. Maybe not.

Probably not. Logic says if these drugs worked, they wouldn't just appear to work now and then, they'd work for everyone and they'd improve mood even in those who've never been depressed. Instead, serotonin doesn't appear to do anything for healthy people in terms of improving mood. So not very surprising I'm not feeling the difference when I'm depressed either.

Sandra, drug companies aren't typically aiming for full recoveries of patients when they put their antidepressants through trials and tests. The rule, as far as I know, is that rates of full remission aren't even reported. So instead, a reduction in symptoms is considered "efficacy" indistinguishable from 100% recovery, as far as anything getting through the pay walls is concerned. So reading abstracts of these studies you'd think that, well, at least some people are getting much better for some reason, even if half of them belong to the control group. The reality is they're probably still depressed, just a little less depressed according to what they reported under social pressure or due to some other human, all too human, quirk of their cognitive processes.

At any rate, there is some controversy over the meaning and implications of the placebo effect, and it's already clear that much of it isn't actually about people magically getting better due to strength of belief or some such thing. While I'm familiar with parapsychology and some truly spectacular cases of miraculous healing, such literature rather implies that they are rare events, unlikely to occur to every third or every second individual who can be convinced of the efficacy of some sham treatment.

That's not to say, given all this uncertainty, that prescribing antidepressants can't be a good thing in the absence of better treatments. However, listening to stuff people say, you'd think we're destined to go down in history as the generation who figured out the human mind and invented effective treatments for all of the worst mental illnesses, previously more or less untreatable. Like the generations before us, it turns out we got this stuff mostly wrong. A lesson in humility, perhaps.

Dinah said...

What Dinah would do:

The miserable, sad guy with 4 weeks of depression, hopelessness and suicidal thoughts, a family history, and no precipitant: therapy and medicines. He doesn't 'meet criteria' for Major Depression, but I don't sit with a check list or have a DSM in the office, so I wouldn't have known that. I Googled "major depression, DSM" to write the post. And there's no magic to the DSM determination of 3 vs 4 vs 5 symptoms. He'll get better and he won't go on disability.

~No one comes for to a psychiatrist requesting a single tablet of valium for a flight (it would be a very expensive way to get a medicine). Usually, a patient in therapy mentions they are anxious about a flight/ a test/ a short term issue. I do suggest the airport bar, but sometimes the patient asks for a medicine, and sometimes I extend the offer. 5 tablets of ativan: 1 to try before and make sure there isn't a bad reaction, 1 for each direction of the flight, 2 extras in case the dose was too low or there is another flight in the future. If I know the patient, there is no issue. I trust my patients not to sell their meds, and if they divert a few tablets of ativan, there is nothing I can do short of running a psychiatry practice devoid of trust.

College student who calls requesting Adderall for exams never gets an appointment. It's not the type of practice I run, and there are people in my town who specialize in ADD and are comfortable with this, I'm not your guy.

20 years and I've never seen a patient for uncomplicated grief. I see patients who grieve when it goes on for way too long (meaning years, not months and certainly not weeks), or if they've already been my patient and someone dies. People go to their family, friends, religious leaders and not psychiatrists for grief. So if someone did show up with acute grief, I would try to figure out why they chose to see a psychiatrist. There's not a pill for this. I would tell them that, but if they really wanted a medicine, or if they were suicidal, I might prescribe a very low dose of an SSRI because I believe that the risk is low and if the patient thinks it will help them, it might. It's not legal/ethical/feasible to prescribe sugar pills. I can't say for sure because this has never happened. There is no evidence that giving medications for low mood associate with grief prolongs or delays the grieving period. The one thing that absolutely helps is TIME, sometimes lost of it, and if medicines make life tolerable during that horrible time, then I'm okay with it. This is the patient's choice.

To be continued

Dinah said...

~I don't prescribe Aricept so I'm going to leave Alzheimer's prophylaxis and the risk/benefit issues to the neurologist. I would neither encourage nor discourage this.

~When a patient says they are more comfortable on a medication then off the medication, I leave that to them, particularly if it's a low dose, if the medication is not associated with any known long-term adverse consequences, and if the patient is doing well (able to Love and Work and feels emotionally comfortable). The case was based on a real life patient who has not had a recurrence of the episode of depression in a decade, however, the single episode was severe enough that the patient was hospitalized and was unable to function for a couple of months at a rather crucial time, so I honor the request to remain on a low dose of an SSRI.

Occasional Ambien for sleep, I am fine with. Nightly Ambien, I am more uncomfortable with, but I sometimes do prescribe it. No one comes to me with primary insomnia, so I see this issue only in combination with mood/anxiety disorders.

Seroquel for sleep. Again, I don't treat primary insomnia, most of the people I'm seeing where seroquel is in use for sleep also have a a co-existing mood disorder. So I give them a full accounting of the weight/metabolic risks, but I often think that a low dose of an atypical helps with mood stabilization, so maybe. If insomnia is the only issue, there is no question -- an atypical antipsychotic has far too many risks to make this a reasonable treatment for insomnia in the absence of a long-term mood disorder.


So on one hand, our readers tell us they want their doctors to hear them, to respect their wishes, and to trust them. On the other hand, we hear that doctors should stick to absolute criteria (even if the criteria we have is arbitrary) and say NO to prescribing medications outside that, even if a very capable, educated, distressed and suffering person comes to us saying they want a medication.

No, these aren't all cosmetic examples. And just as in real life, none of the scenarios are clean.

Anonymous said...

You don't like your readers very much.

Alison Cummins said...

To Liz, mctps and Joel Hasslema, MD:

SSRIs aren't for everyone, but they changed my life for the better. Psychotherapy harmed me because it was based on the presumption that I just had to get over myself, that I could get over myself but that I didn't know how or preferred to be disabled so that other people would feel sorry for me. The fact that I got over myself immediately upon starting medication suggests that I did in fact know exactly how to get over myself and that I did want to, I just hadn't been able to. With the medication I was able to and did. Years of paying qualified clinical psychologists with my grocery money (and having to get charity food and stay in an abusive relationship I couldn't afford to leave) so that they could tell me that I wanted to be disabled or that I wasn't disabled at all, didn't help me and was actively harmful. That doesn't mean I think psychotherapy should be illegal. It just means it is not for everyone, just as SSRIs are not for everyone either.

To mctps and Liz,

Yes, SSRIs work. It's less clear that they work for mild to moderate depression but very clear that they work for moderate to severe depression. There are problems with recruitment and with the depression scales so it's more complicatednthannthat, but they are effective. Not allof them for everyone, but they aren't just placebos.

No, they are not simply happy pills. That is why they don't make happy people even happier.

Yes, they have side effects, sometimes severe. That's why I prefer to see a psychiatrist rather than a GP even though I do not have severe disease and I love my GP. That's not always possible and seeing a GP is usually (not always) good enough for people like me.

Alison Cummins said...

Discussions of efficacy of SSRIs:

http://www.sciencebasedmedicine.org/index.php/antidepressants-and-effect-size/
http://www.sciencebasedmedicine.org/index.php/study-shows-antidepressants-useless-for-mild-to-moderate-depression-not-exactly/
http://www.sciencebasedmedicine.org/index.php/do-antidepressants-work-the-effect-of-publication-bias/
http://debunkingdenialism.com/2011/08/10/a-critical-examination-of-stefan-molyneuxs-claims-about-antidepressants/

jesse said...

@Alison Cummins: What you just described happens more than it should. The problem often is not psychotherapy per se, but how it is done. Sometimes even the most conscientious and well trained therapists have mistakenly thought certain problem could be helped with psychotherapy when actually medication was the more effective (and possibly only effective) route. And the opposite has often been true, in that at times medication is attempted to trreat problems that would better respond to other methods.

Further, there are often numbers of problems that overlap. A doctor/therapist may be paying attention to one while it is the other that should be taking precedence.

People are extremely complex, and what helps one person may not help another. So, yes, a therapist may be giving encouragement to keep trying to do something that might really be impossible, ignoring different approaches, and the patient could well feel that he is just not trying hard enough. One reason why a consult is at times an excellent idea. Get another opinion.

"The fault, dear Brutus, lies not in our stars, but in ourselves, that we are underlings."

Brutus should have obtained a second opinion. The one given him was even worse than if Prozac had been suggested.

jessa said...

I don't have answers. I don't think a hard line is possible or appropriate. I wish that each situation would have a relatively clear answer once it has been discussed more thoroughly with the patient, but I also know that won't always happen and that not all patients would be willing and/or able to engage in that.

I do want to throw out another way of thinking about this. Is it the job of the health care industry to relieve suffering, add to happiness, or both? I would think of cosmetic surgery after disfigurement as relieving suffering, but cosmetic surgery just to enhance as increasing happiness. Still, there will be borderline cases, including many of those you mentioned. To me, this is an easier way of looking at the idea of "cosmetic psychopharmacology" because I am of the opinion that it is the doctor's job to alleviate suffering, not increase happiness. For me, it also takes out some of the morality implications. Still, it does leave borderline cases, but possibly fewer of them.

Alison Cummins said...

Jesse,

You say, "Sometimes even the most conscientious and well trained therapists have mistakenly thought certain problem could be helped with psychotherapy when actually medication was the more effective (and possibly only effective) route."

There is also the assumption that Dinah makes, that if people continue seeing her it's because she helps them feel better.

If I were a clinically trained psychologist who had been referred a suicidal patient through a psychology clinic, and the patient kept her appointments for a year and a half, I might have several sources of input: a) the patient is obviously doing worse; b) the patient denies in therapy that the therapy is helping; c) the patient keeps her appointments. I might prioritize the input from c) as it's the most objective and reliable.

The patient might know or believe d) that she has no other options and accept on faith (though it certainly doesn't feel true) e) that it's her own fault she's not benefitting more from therapy and keep going anyway.

That's why I prefer psychiatrists to psychotherapists. A psychiatrist has a range of tools and can change approach if one doesn't seem to be helping. A psychotherapist has only one tool. If the patient keeps showing up, the psychotherapist will keep offering psychotherapy.

I understand that this isn't possible for most people and that some (many?) psychiatrists are dicks. But given a choice between an angelic GP, an angelic psychotherapist and an angelic psychiatrist, I would want to see the psychiatrist.

Exalya said...

I think that this post does a nice job of underscoring the point that medicine is not straightforward or easy, and psychiatry is no different. Every situation is unique and subjective; clinical decision making must take a whole slew of variables into account. I think that most people who treat patients are genuinely trying to do what they thought was right at the time - even if we may disagree with particular approaches, diagnosing and treating problems for patients is done with positive intent.

I do think that the impulse to treat the diagnosis of psychiatric illness as a series of checklists is a little concerning. I'm not sure that everyone who meets the checklist for ADHD MUST then have "the illness" (whatever that actually is), or that someone who doesn't meet the necessary criteria absolutely does not have it. I'm still very early in my training, so I'm sure these views will change with time... for now I'm trying to get as many perspectives as possible on the philosophy behind psychiatric practice.

PsychPractice said...

It's a fair, if provocative question. Reading through your examples, my feeling was, some yes, some no, some maybe. In ALL cases, I'd have a discussion with the patient about what I think, what I recommend, and what I'm willing to do. And I'd try to keep an open mind.
Does there have to be a line? Can it be case by case? Isn't that why we train so intensely, for so long- so we can develop good clinical judgement, as well as our own style?

jesse said...

@Alison Cummins: there is an old saying that when you are a hammer everything looks like a nail. One of the dangers of any field is that we see what we know and often think we should double up our efforts doing the same thing when we do not meet with success (this is even true in regard to those people to whom "what they know" is to always do something different). The question you are posing is both complex and intriguing.

Dinah and I spoke about this today. I am going to try to write a post on this subject. Stay tuned. You got me thinking. Thank you.

mctps said...

"No, they are not simply happy pills. That is why they don't make happy people even happier."

They are supposed to improve mood. Yet everyone seems to accept they don't do that in healthy individuals. I find it hard to believe there is a completely separate mechanism for the improvement of mood in depressed individuals and a completely different one in healthy individuals. Especially given that the only difference between low mood in depressed individuals is that it lasts longer. Think about it. (I'm assuming people think that mood determines motivation, desire to live, and such things, because if they don't, then I don't see why they expect a drug that is supposed to affect mood to fix those things as well.)

"http://www.sciencebasedmedicine.org/index.php/study-shows-antidepressants-useless-for-mild-to-moderate-depression-not-exactly/"

The writer there says that older antidepressants shouldn't be used to draw conclusions about the efficacy of SSRI's, because the latter are thought to have fewer side effects. Am I hallucinating or is that right? If both types of meds are based on the serotonin hypothesis, then it's not a far fetched idea that if the other are ineffective, then so are the latter.

Other than that, I don't care. It's not a study I've ever based any of my conclusions on. It rather looks like it was chosen because it was a relatively easy target. Even then, the debunking that website did wasn't all that hot.

Are the other three links more relevant and written with more integrity?

mctps said...

P.S. I recommend reading through this:

http://thelastpsychiatrist.com/2006/10/jama_deludes.html

The writer is a psychiatrist himself, and his blog is one of the most popular on the 'net.

It's a post that illustrates the subtle but very significant deception that real scientists engage in, that prestigious journals publish, that no one gets to comment on except in blog posts. It also happens to deal with antidepressants. I recommend reading it to the end. It's short.

Larry Melidis Siskin said...

i loved the term cosmetic psychopharmacology !!! first of all it could actually help people in the short term and most importantly de-stigmatize the use of psychmeds! people are doing it anyway in a vulgar unsafe way... kids at big colleges are on ritalin just to go through the exams and so many other things.

Mary K said...

Disclaimer: I think EVERYONE should be in talk therapy. It has virtually no side effects, no one gets enough validation on a regular basis, and none of us gets enough undivided attention from someone who WANTS to listen to us.

That said, the patient with profound sadness, the bereaved woman, the Alzheimer's guy, and the man who can't articulate why he wants to take an SSRI again all need to schedule appointments to talk. There is clearly something else going on.

The flyer? Yeah. One tab.
The college student? Absolutely not.

Ambien? No way. Cognitive behavioral therapy for insomnia (CBT-I) is the frontline treatment for primary insomnia, and behavioral modifications must be made (as well as a complete physical to determine any possible underlying medical causes for insomnia). I know Ambien has a low abuse potential, but it frequently gets to the point where patients CAN'T sleep without Ambien---it becomes their medical blankie. In older patients, it can result in falling, which can then result in broken hips and other associated dangers.

Seroquel guy? You've got to be kidding. That's like taking a cannon to kill a mouse. He needs CBT-I, too.

HarrietMD said...

There are many interesting comments to this post, but I don't think I saw a single one that involved any level of political analysis. In my opinion, as long as psychiatrists--and everybody else as a matter of fact--do not include in their evaluation and examination of the anxiety and depressive symptoms so prevalent in this culture the reasons for them, any discussion about what is happening is fairly meaningless.
The "problem with psychiatry" is that it equates emotional illness with biological illness, with genetic illness rather than with cultural social pressures and stress. In this way, individuals are encouraged to medicate their "symptoms" and to think of themselves as "ill."
I do not have any illusions about the suffering that mental illness involves but as psychiatrists (I am one) it used to be our responsibility, and our joy, to examine the complex causes of these phenomena rather than anesthetize people out of their symptoms.
We are living in a world very close to annihilating itself--sorry but that is a fact. We are poisoning our own wells, we are committed to resource wars that we pretend are benevolent; our government is lying to us, spying on us, and it is very possible that our children face a future of profound suffering.
Why shouldn't we all be depressed--I mean REALLY DEPRESSED. Does that mean that we should all be on antidepressants. Does it mean that we all have emotional illnesses. And does it mean that we should all be put on "medicines" that lessen the pain and the anxiety thus allowing us to do nothing about what we perceive and fear, and want to ignore.
If 30 million people in the united states were not on antidepressants because they are profoundly upset, maybe they would be organizing and out in the streets protesting policies that are designed to destroy our society, instead of pretending that they do not know what they do know: we as a culture are in profound trouble.
If depression is in any way about "learned helplessness", it is a lesson our society is learning very well. Are medications truly helping us, as a culture, to address reality? Well, it depends which ones.
But administering "medications" on masse to ourselves and our children will not solve the real problems that are terrifying us. In the larger sense, if we as psychiatrists have any real wisdom and courage, I believe that we should be helping people to find the courage in themselves to face the genuine causes of their fears.

HarrietMD said...

Again, just to be real clear as my previous post was written in haste:
if most of the people who are seeking treatment for emotional distress of one type or another are actually responding to REAL FEARS rather than FEARS IN THEIR HEAD what should psychiatrists be doing? And are psychiatrists really--professionals that they are and therefore fundamentally embedded within the value system of this culture--any less frightened, and therefore pretending to have an explanatory model and treatment which, like voodoo, makes terrible worries disappear.

Alison Cummins said...

Mary K,
I have had much worse side effects from therapy than from medication. There needs to be a balance of risk and benefit. If someone is functioning well on their own, or if they are not functioning well on their own and feel that therapy is sapping their resources and making things worse, then clearly the balance of risks and benefits is not in favour of therapy. It’s just as irresponsible to suggest that everyone should be in therapy based on the fact that you like it, as to suggest that everyone should take Zoloft based on the fact that I like it.

Joel Hassman, MD said...

I didn't respond to the Valium scenario until now because i just thought it pointless, but, then I thought of a couple of things that make it a bad choice:

Why valium and not ativan, which is sorter acting and does not have a euphoric effect, and, does the patient fly just 1 time every year or more, or will this deteriorate to a tablet for flightS a year and then proceed to meds for issues at work, at home, at play?

Cosmetic psychopharmacology is a poor term when you step back and think about it, because our job is not to beautify life, but to help patients restore health and function. You might as well write for prn benzos and stimulants if you rationalize a "cosmetic" role for the profession!

Alison Cummins said...

HarrietMD,

Am I to understand that you think I would be doing more to improve the state of the world if I were suicidal, or so irritable that I had alienated all my friends, or dead, or on welfare and unable to connect with my community, or living with an abusive lover and blaming myself? Because while it’s true that I got more worked up about Things Being Bad when I wasn’t on medication, I couldn’t look after myself or contribute much either and things were getting worse.

Now that I have medication, I have full-time work and donate money to social causes. I support people in my immediate network in different ways. I participate in political demonstrations organized by other people.

I would be a better person if I would only just be a better person, and I’m not. Still, I’m doing more than I used to and more than I would if I were dead (which is where I was heading). It’s not either/or.

Yes, of course, if I had only just been Ghandi I wouldn’t have been suicidal. But just as I’m not Ghandi now, I wasn’t Ghandi then either. So I’m not sure what your point is.

Anonymous said...

From harrietmd
My point is that psychiatrists should not be telling people that their anxieties and depressions are due to their genes and that if their children are unhappy and frightened it is because they have inherited a genetic diiathesis predisposing them to depression.
Because it is not a valid scientific argument and for that simple reason alone, we should not be making it.
And if people feel suicidal psychiatrists should become involved in exploring and exposing the social system and it's profound stressors as a major reason for these anxieties and for the emoous despair people are experiencing rather than ignoring the entire interface between human beings and the culture they live in as a reason for stress, unhappiness and rage.

Joel Hassman, MD said...

Another morning of being asked to medicate poverty. Yes, chronically ill people end up with comorbid socioeconomic strife, but, I firmly believe that close to half of what comes into CMHCs these days is primarily due to the consequences of being in poverty first. And not just financial limitations, but the combination of limits in educational, general resources, and supports from others in the community.

So, tell me colleagues, what is this cosmetic medication that will lift the burden of pandemic poverty, I really want to know?

All this talk of stimulus monies, I would bet that if you selected for those patients who really showed some responsible insight and judgment and accepted accountability for their actions, (which would dramatically limit the population for this offering) I would bet of the people who got a $20,000 one time offer to help with essential needs like housing, food, and supports to regroup for employment prep, half if not more would not come back for mental health care to the degree chronic patients need the follow up.

But, where did those monies go to from Bush and Obama? the very people who didn't need it!

And the disingenuous leaders from local, state, and federal levels don't want to acknowledge this.

You all keep on believing there are pills to treat your ills. After all, there are dozens of trials of meds to fail first, eh? New CPT codes to continue those q2week med checks, and come May, new DSM 5 codes and diagnoses to legitimize all those visits.

And I read at sites in mental health care how people are such fierce advocates for patient care.

Really!? With a meds first attitude? Letting patients go months without a therapy or case management follow up visit? Advocacy is about others, not yourself!

Joel Hassman, MD said...

by the way, what a hideous joke PAC coverage is for people. Let them access a CMHC and then give them minimal somatic care coverage.

It's like that commercial for state farm, when the girl without it asks for her money back gift and a guy appears with a dollar bill on a fishing line, and then he keeps pulling it away from the girl when she tries to take it.

This is the sheer cruelty of health care that only PPACA will enhance. Let people have some hope to access the services needed for treatment needs, and then tell them the coverage is inadequate. Oh, and really encourage providers to maximize diagnostic visits and then implement the standards of care.

Standards of care, wow, what a misnomer that word takes on now.

History does repeat itself, we will be back to basic leeching and skull burr holes in the next 5 or so years, just advanced to what is offered in the previous century, not 300 years ago.

We are back to writing for amitriptyline, thorazine, and carbamazepine like it was the 1980s again. You think this is so far from leeching and burr holes!?

I kid you not, i have gotten authorization challenges on fluoxetine and alprazolam lately!

Dinah said...

What a great conversation.

Joel, I'd like $25,000 while you're writing the checks.

Do we think that psychotropics numb people? Do we think they make them complacent? I don't think that should be a goal of treatment. I believe that with all medication effects, this is person-specific. But many people, like Alison, become more vital and feisty and able to enact plans to achieve goals, when they are better.
Complacent should never be a goal.

Is it bad to take a medicine if it makes you more comfortable?

Is it bad to take a medicine if it makes you more effective?

Amanda said...

Love this!

Looking at Dinah's last two questions:

1) Is it bad to take a medicine if it makes you more comfortable?

2) Is it bad to take a medicine if it makes you more effective?

No and no. Isn't that part of the point? Better living through chemistry...
Of course risk vs benefit and normal reactions to life vs "abnormal", but we treat symptoms, not diagnoses, right? They may not meet full criteria, but still warrant a medication. And what about that whole part about "significant impairment" in the diagnostic criteria? By whose standards? The provider's or the patient's? What I think is significantly impairing may not be what someone else thinks is. I know this is one area where the subjective nature of our profession comes in to play, but this is where I think stigma also gets fueled - If I think a kid or adult has symptoms of something that warrants a diagnosis and medication, like ADHD, then I'm gonna diagnose and treat. The whole point is to improve functioning, but like someone said earlier - if they only need it for tests, then they don't have it. THAT, I think, would truly be "cosmetic" psychopharmacology. That case is completely different than an anxiolytic/benzo used intermittently and for only certain situations. This is where our clinical judgment kicks in (or at least, its supposed to)- that's why we get paid to see them and make a clinical decision based on our assessment of their specific and individual case, not just a bunch of check boxes for meeting diagnostic criteria. Hell, that's why we have so many people being diagnosed with PTSD at the VA, getting benefits for life, despite their ability to hold down a job or go to college. That's some significant social and occupational functioning, right there ;) ...and a topic for another day.

David said...

All medicines have side effects and physicians should be responsible enough to prescribe these meds to their patients. They must assess the condition of the patient and see to it that the person really needs to take a certain medication and only prescribe the right amount of it. There are a lot of factors that must be considered before giving a person any medications.

Joel Hassman, MD said...

I am not writing checks, the rulers you vote for to stay in office and take your money give it to people who don't need are the ones to ask.

Really, how many incumbents in office for more than 10 years have you voted for in the past 20 years? I know I haven't. Incumbency = incompetency.

My point if it wasn't clear is that too many people are coming into mental health care to treat their socioeconomic crises. Some will never figure a way out, but some could with a little help. But not from polypharmacy.

Yeah, well, truth doesn't pay the bills these days, does it!?

Anonymous said...

Two hypothetical situations for all the medical folks on this blog:

1. Person with insomnia wants xrem due finding out that it provides deep sleep unlike the other sleep meds. Not concerned about cost.

Would you prescribe it? Asking because many physicians wouldn't due to it being the date rape drug.

2. Person is having a horrific time getting off of Xanax and would like to cross taper to valium because he/she feels due to its longer half life, it would easier to get off of? Do you prescribe the med? Many psychiatrists would not.

Joel Hassman, MD said...

Xyrem I assume you mean, sodium oxybate? You need to have a special license to write for it. Isn't that making a loud statement why NOT to consider it unless you work in a tertiary care facility?

Gee, exchange valium for xanax, not my best recommendation, especially if the reason to taper is abuse/misuse in the first place. Librium is still out there, although not one of my favorites either. Here's an idea that I sense over 75% of prescribing practitioners read as chinese hyroglythics: maybe NOT write for xanax in the first place, consider as a last option for anxiolytic management, especially anyone with a prior substance abuse history irregardless if not alcohol as one substance, write for ativan or klonopin.

I plan on writing a post at my blog tonight about the growing disruptions that benzo users create at least at my CMHC. I guess my colleagues left their consciences at home when they write for benzos like pez.

Hey, here's a marketing idea, make a pez dispenser for XANAX!

Call it the XAN-I-DO !!!

Anonymous said...

Dr. Hassman, didn't know it took a special license to prescribe Xrem. What a shame.

I am curious why you would be concerned about someone wanting to abuse valium who wanted to cross taper from Xanax so they could get off of it? Doesn't Xanax have just as much abuse potential if not more due to its short half life?

Also, it seems if someone wanted to abuse valium, cross tapering from Xanax wouldn't be exactly an easy to way to do it.

You're right though about not prescribing it in the first place. Unfortunately, many of your colleagues aren't heeding your advice and putting people on it in horrific situations regarding getting it off.

Joel Hassman, MD said...

My last comment for this thread:

don't understand why it is a shame to closely regulate a drug of serious ramifications like Xyrem--umm, you noted it was the date rape drug, and I'm not sure why people would gravitate to a med that just acts like an anesthetic and knocks you out for 8 hours without any recall; that said, if the prescription dosages minimize that response, well that is good, I guess.

People in recovery will tell you the two worst benzos due to the euphoric effects often felt by abusers are, in order, valium and then xanax, so why risk trading one drug of abuse for another, and then further the consequences with long acting metabolite build up that valium can cause? Quite frankly, I am curious why so many colleagues just ignore or rationalize away the frank addiction behaviors that go on with benzo addicts in the office. I ask people to close their eyes and listen to the patient in front of them when they present with their benzo seeking behaviors and tell me they don't envision an alcoholic sitting there. Oh yeah, you're writing the script, that might color the interpretation a bit.

You know what, as harsh and unsympathetic this next comment will be, anybody doing honest and consistent recovery work would agree with me: go through benzo withdrawal just once and then think if you want to go back on it again once free of the acute symptoms.

That is why this class is such a terrible medication to give to naive, unsuspecting people with a risk for addiction: eventually, EVERYONE will have a moment of withdrawal, and that could be lethal for some. And really, tell me there is no ceiling dose for xanax or klonopin, colleagues, how completely disingenuous a comment/attitude is this!?!?

Anonymous said...

Dr. Hassman,

Many people have found Xrem helpful for insomnia. And apparently it provides deep sleep unlike the other insomnia meds.

It is also used for narcolepsy

So we're going to penalize people from getting treatment that might be beneficial because it has been misused ? That doesn't seem right.

Sorry I wasn't clear with the xanax example. The person does not have a history of abuse.

Anonymous said...

The same doctor that prescribed my son Suboxone, also prescribed him xanax. Although I'm sure my son gave the doctor a very convincing "anxiety" story, he had a history of opiate abuse...hence the suboxone! Of course, my son quickly developed a benzo addiction, and died Feb 6, 2013 of a lethal overdose of xanax and heroin.

I guess when my son told the doctor "nothing else worked" or that he was feeling "hopeless and suicidal" or he couldn't articulate why it made him feel "calmer", the doctor decided if was OK.

Thank you Dr Hassman for taking a stand.

Eas said...

Dinah -- Thank you for commenting on the Seroquel question. I sometimes wonder why more people don't prescribe Benadryl for sleep instead of Seroquel. The Seroquel has the metabolic risks, and it's incredibly expensive.

I saw a sleep specialist for what turned out to be sleep hypopnea. The fellow I saw before the attending mentioned to me that there were actual data in support of valerian root.

A lot of people don't bring up alternative treatments with their MDs, because they think they'll look nutty, but some have more validity than others. Could be worth discussing when Seroquel is the alternative.

EastCoaster said...

The last one was from EastCoaster