September 25, 2010

Mark Foster, DO
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Bob–

My brain is still buzzing from my second day back in the trenches. My final patient today was a middle-aged woman who could have come straight from the pages of your book, but without the awareness yet of how a lifetime of antidepressant use may be contributing to her symptoms.

She is a pretty, red-haired woman from Alabama with a Southern drawl, married to a good man, and they have three children. They have previously had some means, but her husband lost his job due to the economy, and they are on Medicaid. Right now, she feels her life is falling apart. She complains of being emotionally labile, easily agitated, awakes feeling muscle aches and pains through her whole body: “I can’t even get dressed, it hurts so bad.” She feels fatigued and sleepy all the time: “I could lay down in the parking lot and fall asleep.” She gets dizzy frequently and has strange tingling pains on her scalp and neck, severe memory lapses, and is having distressing low libido which is straining her marriage.

When I first met her 2 months ago, she was on Lexapro, and she was emotionally distraught. “Something is wrong with me and no one can tell me what. I can’t go on living like this.” She wanted to be put back on Ritalin, because previously a doctor had diagnosed her with adult ADHD and this at least helped her energy level and focus. At our first visit, I elected to switch her to Cymbalta. I checked a number of labs which were all normal, and I referred her to a rheumatologist, because at the time she believed adamantly that she had fibromyalgia. The rheumatologist strongly refuted this self-diagnosis, saying that her symptoms appear to be emotional in origin, and started her on Trazodone for sleep and sent her back to me. She took the Cymbalta for two weeks, and noticed that the tingling pains were better, but she couldn’t sleep at night with it, and then the sexual problems worsened, and so she placed herself back on Lexapro. Additionally, she takes dozens of supplements, vitamin, herbs, because she is convinced she is missing something vital in her, something that would help her feel better if she only knew what it was.

Today, she presented very distraught because once again, nobody could figure out what was wrong with her. With your book fresh on my mind, I decided to explore more of her psychiatric history, and I was not surprised by what I found. It turns out that she was first placed on Elavil at age 18, but for migraines, not for depression. She said, “I don’t think I was depressed back then, maybe just a little emotional, but I was a teenager, right?” She was on that for a few years and it seemed to help with the migraines, but she became more emotionally volatile, and then she started on the treadmill of psychiatry: multiple meds of every type (benzos, SSRIs, stimulants) and yet she continued to worsen. In the few brief intervals in which she tried to get off of meds, she noticed that she got much worse, and took this to mean she needed to be on them because there is “something wrong with my brain, I know this isn’t just me.” She has now passed the last twenty years now on this emotional roller coaster, and she is finally not able to cope anymore.

A couple of points: when I first met her two months ago, my immediate assumption was that she fit into the “broken person/drug seeker” category, somebody who would keep looking for pills and doctors until she found a provider willing to grease the squeaky wheel and snow her into oblivion with pain meds or antipsychotics. I will admit that when I first dealt with her, I never even considered taking her off of antidepressants, because I assumed, I guess, that she was in essence an emotionally unstable, psychosomatic dysfunctional patient. But I looked at her with new eyes today, new compassion for the apparent iatrogenicity of her condition.

She is an intelligent woman, and I felt that her desperation might help open her mind, and so I decided to take a risk. I told her that I had been reading your book, and that careful evaluation of the history of antidepressants shows that they tend to make people more symptomatic over time, and that perhaps the drugs are now the problem, not the answer. This did not go over very well. “Look at me! How can I not be depressed? Something is wrong with me!” I persisted, gently, and told her that I’m not opposed to continuing her medications, but that I wanted her to read your book and come back to discuss it with me in a few weeks, and see if she might be able willing to try a new approach. Maybe she was never depressed at all, I suggested, until she started these meds as a teenager. She seemed to soften a bit, and she agreed to read the book, but then added, “If medicine can’t help me, then what’s the solution? I can’t go on like this.” I re-emphasized exercise and “talk therapy” with friends. She has done counseling in the past and is not interested in this approach anymore. I appealed to her faith in God and prayer. I told her it wouldn’t be easy, no matter what we decided to do. But since the last twenty years of psychiatric care had landed her in this awful position, isn’t it at least worth a few weeks and careful consideration of an alternate pathway?

In the end, I planted the seed of an idea today, and we’ll see what that progresses to. Perhaps she’ll never come back to see me because I’m not willing to accept that she has a broken brain and requires a pharmaceutical fix

The downside? She was the last patient of the day, and so I was able to spend over one hour with her to plant that idea. Because she is on Medicaid, it means I will get paid very little for that effort, which I am willing to give, but it is not sustainable on a mass-scale from an economic standpoint, or frankly, from an emotional standpoint. It takes a lot out of me to gently, kindly confront people’s misbegotten notions of their brokenness and helplessness, especially when it contradicts directly every other message she’s gotten for twenty years through her doctors and the media. This sort of effort usually feels like talking into an echoing cavern and it ends up amounting to nothing, and pretty soon, it’s easier just to not make the effort and pull out the prescription pad again. But maybe it will make a difference with her, we’ll see.

So, let’s hope for the power of an correct idea. We’ll see if your persuasive book can filter through me down to an end-consumer and effect a paradigm shift and change a life. Do that several million times and maybe there will be a cultural change, too.

Mark