Bob–
Yet another challenging day. I had two more patients today whose trajectories would relate perfectly to Anatomy of an Epidemic.
The first was an 61 year old man on three antidepressants (Wellbutrin, Remeron and Zoloft), as well as daily Xanax for anxiety, who came in complaining of cloudy thoughts, just not feeling himself. I asked him when this started, and he said, “Ever since I started those meds . . . ten years ago.” Why did you start the meds? “I had a panic attack when I developed some serious health problems and my father died unexpectedly.” And so they started you on all these meds at once? “No, they started me on Wellbutrin, and I couldn’t sleep, so they started me on Remeron, but then I got more depressed, so they started me on Zoloft. Now I need the Xanax, too, or I’m crawling out of my skin.” Are you worse now than you were ten years ago? “Hell, yeah. I can’t even think straight, and now I’ve got this tremor.” Do you think the meds could be part of the problem? “I’d love to get off these pills.” Well, long term use of psychiatric meds has been shown to make the problem worse, not better. Why don’t we try weaning you off the Zoloft first? “You got it, doc.”
Potentially a success story. So fascinating (and sad) that in this man’s experience over the last ten years, every time a medication caused a known side effect, instead of stopping the med, yet another one was added to combat it. It appears that his other physicians never even considered the possibility that his initial panic attack was a situational problem that could be expected to resolve on its own, or at least they never offered this option to him. I don’t really blame the other doctors, because I’m certain I’ve been guilty of the same narrow-minded thinking. Treat side effects with more meds. The momentum is always towards adding more meds, not stopping them. Just stepping back to glance at the big picture, and it’s so easy to see the sad irony of this man’s all-too-common scenario: a transient mental state is diagnosed as a pathological, biological disease, and the patient is started on a chronic psychoactive medication that has side effects and whose efficacy wanes with time, only to lead to further medication, more side effects, more meds. Really, it seems ludicrous. But patients accept it, and doctors, when we’re in the thick of it, don’t recognize the futility and hazard of it all. In this guy’s case, he’s actually anxious to stop the meds, but it appears no one has ever proposed it. I probably wouldn’t have if my eyes hadn’t been opened by your book.
Of course, I’m saying this all with an air of confidence that we will be able to successfully wean him and have a happy ending. We’ll hope for the best. I’ll be seeing him back in two weeks.
My next patient is a fascinating case, a 32 year old man who is wired tight and addicted to Ativan . . . but I’ll have to save that for another day. It’s a good one, one of the two patients that I constantly thought about while reading Anatomy.
This sort of thing–your book, the personalized root cause analyses of the inefficiencies of our healthcare system–these things get me fired up. Writing is a good outlet for me, and so participating, on a broader scale, in this conversation, through a blog on your website, seems like a good opportunity, and I appreciate the offer. I have learned that I often have to put the brakes on my native tendency towards zealotry when something gets me animated. (I’ll have to tell you about my anti-cagefighting crusade sometime.) But I want to stay grounded in reality, which at least means acknowledging that there are no easy answers to this mental health epidemic, and that most doctors and patients are simply doing the best they can in the system that they’re conditioned to accept. For the most part, patients just want help, and doctors just want to solve problems. The problem is that our short-sighted pharmaceutical solutions have created a long-term problem all its own, a devastating epidemic of iatrogenic mental disability.
Part of me just wants to jump right into this fray head first, but I’m aware that my greatest value to this project may be in being an active front-line warrior with a voice, a field reporter sitting in the trenches and describing the battle for the folks back home. I guess I need a bit of time to think about the ramifications of taking this step.
I’ll look forward to hearing from you again.
Mark
