I first heard the term "Med Checks" when I started working at my current job in a community mental health center 17 years ago. There was even an office with a sign on its door, "Med Checks". This term has never had meaning for me and the title of this blog is one I used for an essay I wrote many years ago for an in-house newsletter explaining how I conceptualized psychiatry and the role that psychiatrists play in a community mental health center. This essay comes to mind as I read on this website the various opinions about what psychiatrists should be doing. I have been fortunate to have worked at an agency that has allowed me - perhaps out of desperation over loosing yet one more psychiatrist - to shape the role that psychiatrists have within our agency and I will describe that role in this blog.
We are a large - at least by Vermont standards - community mental health agency - and we employ hundreds of people of whom only a handful are psychiatrists. That says something - psychiatrists play a small part in the services we offer to our clients.
Psychiatry remains a subspecialty of medicine. Within that tradition, the psychiatrist's main role initially is one of evaluation. Whatever one thinks of psychiatric diagnosis, the role of evaluation is nevertheless important. When someone comes in complaining of hearing voices, the list of possible diagnoses is enormous, ranging from brain tumor to endocrine dysfunction to what Corinna West and others call emotional distress to what Michael Cornwall calls madness. I have written elsewhere about how I conceptualize psychiatric diagnosis. Whether one likes these labels or not, the process that precedes it - listening to someone's story, hearing how his life has been, learning of important relationships, asking about head injury, substance abuse, and medical problems, learning of his family, how he was raised, what problems or challenges other members of the family had, hearing what has meaning and value for him as well as where he feels he has been successful - is valuable. The label that we give to the symptoms is not the most important outcome of this process but rather it is understanding what brought the person to my office in the context of this person's life that is most valuable. It is only after this process is completed that one might make a recommendation about treatment.
The outcome of this evaluation may lead to recommendations that have nothing to do with medications. We help people to get housing and work. We offer different types of non-drug treatments - groups and individual counseling of various types. We might offer help achieving sobriety. If the recommendation includes pharmacotherapy, the psychiatrist is the one who prescribes since she is the only one who can do that. But when someone for whom I am prescribing medications returns to my office, this visit is not a "med check"; I am not checking on the medications, I am checking on the person. I do review ongoing symptoms but more importantly, I talk to a person about her life, how she is spending her time, what is important to her.
It is true, that on a practical level, our psychiatrists are often in our offices talking to patients about medications. We are expensive and by limiting our roles to the things that only we can do, we are trying to free up resources within the agency to offer our clients the many other important services they need and request. I guess I do not mind this role although I try to prescribe in a deliberative, careful manner. However, it is not all we do. Our psychiatrists also spend a good amount of time in collaboration with others; we consider that critical to good quality care. We do not ask doctors to see people every 15 minutes and do nothing else. We schedule in time to talk to patients, family members, and collaborating colleagues outside of office visits. We have insisted on this because we believe that this is what is required for us to provide good care.
It is funny that this term "med check" may have arisen within my profession. I believe it was coined to distinguish what I do in contrast to what a colleague offering psychotherapy does. There was a notion that I just handed out medications while my colleagues actually talked to patients. However, I have never known how to work with someone who is, let’s say, hearing voices -without talking to the person about his experience and trying to understand what this feels like, what it means to him, and how it might be disrupting his life. If I am not talking to my patients, what else am I doing?
So if I talk to my patients, what do I actually say? I have tried to listen carefully to what is written here and elsewhere and to incorporate that into what I have learned on my own and from my own patients. I believe that the conversation should include a full assessment of the short and long term risks and benefits of drug treatment. This has manifested itself in my having serious discussions repeatedly about the long term use of medications and making changes to insure that a person is on no more medications than necessary. I believe it is critical to be extremely cautious at the outset and to try and avoid the introduction of medications. Given our current cultural climate, this sometimes requires much explanation. I am in the process of tracking my experience with systematic tapers of neuroleptic drugs and I hope to be able to report on this soon. This is often a values ladden discussion and some people choose to remain on medications despite the risks while others are extremely eager to stop.
Corinna West, Dan Fisher and others have articulated how language matters and there is nothing in what I have described here that is inconsistent with talking to people in a respectful way that promotes hope and recovery. I try to be careful in asking people what certain words mean to them; for instance, it was not apparent to me that talking about the brain would translate into someone thinking she has a fixed problem not amenable to recovery because that is not what it means to me. I am spending much of my spare time lately reading about stories of recovery so that when I talk to people about this, I am talking with genuine conviction rather than parroting words so that I am politically correct. It is the nature of clinical work that we tend to see people who are doing less well since the ones who are recovered have no reason to come to our offices; I have come to believe that we have an obligation to actively fight against the distorted perceptions that can develop over time.
Although we try to be cost effective, we do not limit our psychiatrists to office visits. These are some other things that psychiatrists have initiated at our agency in the past few years:
-Cognitive Behavior Treatment for insomnia - One of our psychiatrists was dismayed at the long term use of hypnotic agents (sleeping pills) to treat insomnia. He has given lectures to our staff about sleep and he has explained why drugs are often the last choice for treatment of poor sleep. He emphasizes the role of differential diagnosis of this condition - i.e., does the person have sleep apnea or some other condition that would be best treated with non-drug interventions. For several years now, he has offered a group for CBT for insomnia, an effective, evidenced based approach to this disorder.
-Food Education group - I have written about this elsewhere.
-Education- Every year, my colleagues and I lecture to our staff about drugs. In these lectures, we talk not only about the drugs we prescribe but also about their limitations. I have talked in the past about the impact on advertising on prescribing practices and this year I discussed Anatomy of an Epidemic.
-Book and movie group-I just started a reading group open to any one who works or uses services at our agency. In the spirit of Open Dialogue, this is meant to be an inclusive discussion. We read I Never Promised You a Rose Garden by Joanne Greenberg and next month we will begin watching Daniel Mackler's documentary, Take These Broken Wings. If you are interested, stay tuned! Our first group was a huge success and I may blog about this in the future.
Anatomy of a Psychiatrist: Dr. Steingard chronicles how she is integrating information from Anatomy of an Epidemic into her community mental health practice. She also discusses changes in Vermont's mental health system and the influence of pharmaceutical advertising on clinical practice.