Bob–
Today was full of psych stuff from the first patient to the last. Yes, these clinic days are representative of my typical practice. Just counted, and 9 of my 15 patients today had a significant psych component to their visit. Yesterday it was 5 of 16. I’m not seeking this profile of patients. I think they are a representative cross-section of our society, and I guess that is emblematic of how extensive this epidemic is.
An interesting follow-up to your book would be to look the role that Family Medicine (as a specialty) has in prescribing these drugs. My guess? It would be upwards of 50% of psych drugs (at least of SSRIs and benzos) are initially prescribed by FM doctors and an even higher percentage are renewed by us, simply because there are so many more of us and we are more accessible to most patients.
Truthfully, I’ve had my eyes opened the last week as to just how often I deal with these psych issues. One disturbing observation: I often deal with psych issues and drugs as background noise. “Oh, you need a refill of your Prozac? Is it helping? OK, now let’s talk about your blood pressure.” My default position has too often been, if someone is stable on their psych meds, then don’t rock the boat. And this is from a guy who has been a skeptic for years.
Perhaps, though, Family Medicine’s complicity in this epidemic can lead to an initial point of attack to curb it. We are separate from psychiatry, thus not as beholden to their pharmaceutical-intensive paradigm, and affecting powerful change through the FM ranks could substantially turn the tide in prescribing and maintaining these meds. I think we FM docs, generally speaking, keep a much broader view of patient health, and also a sizable percentage of us are holistically minded, skeptical of the drugs companies, etc. Of course, we also have comparatively little time to spend with patients on their psych issues . . .
1) My first patient today was a 24 year old man who is going back to school to be a radiology tech, and I was seeing him in order to update his immunizations for school. Incidentally, he asked how I felt about giving him Adderall to help him focus in class. Sadly, one of his professors, who is a retired physician, had a discussion with him in which my patient divulged that he had a history of ADHD as a teen and had previously been on stimulants. This doctor recommended that he talk to his doctor about getting back on the drug. Mind you, he is doing well in class, not having any problems. The doctor’s point of view was that if he had this disease as a child, then he still had it now, and the only fix for it was a drug. The patient and I had a brief discussion of your book, which was enough for him to be convinced. “Good,” he said, “I really don’t want to start the medicine again, but this doctor made me feel like I needed to be on it.” A success, and a sad commentary, too.
2) My last patient of the day was a pretty, blond 20 year-old college sophomore who just moved here from North Carolina to live with her mother, because she was getting into a lot of trouble and failing out of a community college back home, where she had been living with her biological father. Her father, apparently, is very unstable, moves around all the time, and let his daughter run wild through her teen years. (This is of course from the ex-wife’s point of view.) Regardless, the mother seems newly devoted to her daughter and determined to provide a stable life, and she came to the visit with her daughter. In the past, the patient has been involved in drugs (meth, mostly) and has been promiscuous, also running afoul of the law several times. She was started on Effexor for depression at age 12, which she was on continuously until last year when she was switched to Paxil. It’s not hard to imagine that a lot of her erratic behaviors were created, or at least worsened, by her SSRI usage. She is enjoying this move to Colorado as a fresh start in life. She is taking school seriously, and wants to go to law school, or maybe become a photographer. Of her own accord, she asked if we could decrease her Paxil dose, because “I don’t like the way it makes my brain feel, like a zombie.” That opened a door for a brief discussion of your book, and I suggested that as her life stabilizes, and as she becomes more removed from the illicit drugs, the instability of her father, and the chaos of her teenage years, that she will one day be able to come off of these meds completely. She had a very positive response to this, and it was rewarding for me to see her eyes light up. I could almost see her giving herself permission to entertain this new thought: “Maybe I’m not broken. Maybe I can be okay without medicine.” Priceless. We cut her Paxil dose, and I will see her back in one month. I probably will keep her on the lower dose through this school year, but the goal is definitely set now: get off meds completely.
3) In the interest of fairness: I have had several encounters with patients over the last few weeks who have had dramatically positive responses to SSRIs. Today, I had a 31 year old young woman who a month ago saw me at the end of her rope. Her countenance was darkened, she exuded despair, a true lost soul. She has a long prior history of substance abuse, and then had a terrible accident two years ago, sustaining major trauma to her back , and now she requires heavy duty pain meds until she can afford a surgery, but she can’t afford a surgery until she gets a job and insurance, and yet she can’t work due to pain. She can’t afford counseling, has very little social support. We started her on citalopram, and now today, a month later, she was following up with me. Her response was very positive. She has started connecting with friends again, she feels motivated to look for a job, she isn’t crying spontaneously anymore. Indeed, she smiled and laughed easily throughout our visit. The only real variable here is the citalopram, and though it may be in part placebo, it has provided the kick start she needed to dig herself out of this pit. Another case is fairly similar, a young woman with a history of a terrible back injury and on heavy duty pain meds. When she first came to see me two months ago, she was deeply depressed, no appetite, no volition, intense anger. We started her on Remeron, and she is sleeping better, has gained back ten pounds (she was emaciated before) and has some twinkle in her eyes again.
I have seen these positive short term responses countless times. But as you so clearly pointed out in your book, we doctors have incorrectly concluded that short term success necessitates long term therapy. I’ve been careful to paint the picture, even to these success stories, that the medicines are for 6-12 month trials and their necessity must be regularly re-evaluated, that we have to pursue non-medical alternatives, and that the time will come that they will no longer need the meds. That feels like a healthy, balanced approach to this dilemma.
Finally, my wife (a non-medical person) is reading your book and loving it. I think you balanced the personal vignettes and the scientific reviews very nicely, and made the book convincing to medical persons like me and accessible to non-medical persons like her. Strong work.
Mark
