September 21, 2010

Dear Bob:

Today, fittingly, was a very psych heavy day at my clinic. I saw the whole gamut of patient situations, patients (and their conflicted young doctor) who are swept up and away in this psychotropic-intensive paradigm of care. When you’re in the thick of it, on a busy clinic day with 15 or 20 minute appointments, with very few effective alternative treatment resources available, it is difficult to see an exit from this fray.

Briefly, I’ll share some snapshots with you, because I think these cases illuminate different facets of this tangled mess:

(1) A muscular, friendly 27 year old man whom I saw for the first time. He has an obvious low level of intellectual functioning. Six months ago, he had a brush with the law and was temporarily incarcerated, and while in jail was diagnosed as bipolar and started first on Geodon, and is now on Depakote and Abilify. Currently, he is on parole, and he came to see me today because he thinks he has ADHD and wants to go back on Concerta, which he was on as a child. He states (somewhat contradictorily) that he doesn’t want to see a psychiatrist anymore because “all they want to do is put me on more drugs”–when, of course, he’s asking me for more drugs.

I told him that I felt Concerta was an unsafe drug to be on in his current state, and (reluctantly) I advised that he should follow up with his psychiatrist to discuss his psych med management. (I punted this one back, because although I am very wary of this man being over-medicated by the psychiatric establishment, I don’t have any better resources to offer him, and I’m not anxious to take on the medical legal aspects of withdrawing a violent criminal from his psych meds.)

(2) A 42 year old man whose wife recently separated from him, taking his young son and moving to California. He is distraught, has lost his appetite and nearly 20 lbs, hasn’t slept in weeks and appears gaunt and haggard. Years ago he was on Celexa briefly, and now needs something to help him sleep and to help him cope emotionally as he struggles to save his marriage and his job.

I gave him some Ambien for sleep, and started him on a three month trial of Paxil. I strongly encouraged daily exercise, continued counseling, and a healthy balanced diet. He is at his wit’s end, desperate for any outside intervention, and therapy and counseling are not getting him anywhere yet, and his typical support system has disintegrated. Today, I felt I had to intervene in some way, even if it is placebo in nature, because he is on the verge of total decompensation. He needs someone else to take some of this burden from his shoulders, and I feel that I did that by handing him a prescription, though with the clear understanding that this was a stop-gap measure.

(3) A 31 year old blond woman with a history of traumatic brain injury and partial hemiplegia. She also has Hep C and a history of severe polysubstance abuse. She states “I don’t want any more drugs” and then promptly asks to be switched from Effexor to something else because it doesn’t help anymore, and by the way could I give her something for pain and for anxiety and for sleep? She tells me she’s taking 6-8 tylenol PMs twice a day to help her sleep. She says she’s “addicted to sleep” because that’s the only way she can avoid the impulse to go back to illicit drugs. And by the way, she’s trying to get pregnant. (Gulp)

I switched her from Effexor to Trazodone. She is a difficult patient, a bottomless pit of needs with no coping mechanisms, and I don’t have a clue how to help her. She is truly a “broken brain”–literally–and will always be disabled. In her case, keeping her semi-sedated makes some sense–to spare herself and society the legal and criminal consequences of her mind unleashed. It seems to be what she wants. In her case, I made a med change that may address one aspect of her problems (sleep) and hopefully spare her the liver damage from the Tylenol, and then we live to fight another day.

(4) A 35 year old Spanish speaking woman who I saw for follow up today. Six months ago, she broke up with her boyfriend and over the next three months lost weight and became passively suicidal and socially withdrawn. She requested to be put on a medicine, and we agreed to start Paxil for a 6 month trial. We also discovered at that time that she was over-medicated on her thyroid pills, and we have subsequently stopped that medicine. We also started her on birth control pills for irregular periods. Now, three months later, she is feeling much better, but there are many variables in play (antidepressants, birth control, thyroid, relationship healing) that may have contributed to that, and it’s difficult to know what effect the Paxil itself has had.

We agreed to continue the Paxil for two more months and then consider a careful withdrawal.

And there were several more, but I will spare you . . .

That is not an unusual day for me, interspersed with my usual blood pressure checks and sore throats and back pain, and it’s easy to see how that can become overwhelming, and how the temptation for both doctors and patients is to reach for the quick fix, especially when cultural expectations are so skewed in that direction and when so few other effective alternatives are available for these patients with limited mental, emotional, financial and social resources. I wish there was a system in place, similar to the Lapland mental health system in Finland that you describe in your book, that had the time, resources, and expertise, to where I could with confidence direct some of these difficult patients, knowing they would receive a comprehensive evaluation and personalized, multi-dimensional treatment plan. But alas, such a system doesn’t exist, and we primary care providers, the front-line warriors, just do the best we can, which admittedly is not very good sometimes.

But honestly, I think that is a fundamental part of the problem: the belief that there is some cure out there for whatever ails you. In our Western medical ethic, we have set up the expectation that, if there is something wrong with you, then some smarty-pants doctor out there will have a fix for it, usually through some impressive sounding drug or technology. Every patient interaction, every diagnosis rendered or prescription written, serves to reinforce that misguided and ultimately harmful notion.

The body can heal itself. So can the mind. Often, the best we can do is get out of the way and be patient. “Don’t just do something, sit there.” Unfortunately, there is no money or glory to be had in that sort of approach.

If you ever had the inclination, there would be a very interesting book to be written about the corrosive influence of the magic bullet delusion, the pharmaceutical industry, and the rise of a for-profit health care industry on the whole of American health care.

Have you read much of Andrew Weil’s work? The perspective he outlines in his book Spontaneous Healing, and his prescription for health care reform in Why Our Health Matters, would be excellent companions for your book.

Again, thanks for your response. This is a valuable opportunity for me to interpret the concepts of your book through the pragmatic context of my daily clinic life.

Take care,

Mark