November 4, 2010

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Bob–

Today, I saw a healthy, strapping young man, 28 years old and an avid recreational softball player. He is a former college athlete and plays in a couple leagues at once right now. He is fit and cheerful, has a master’s in social work and works in public schools counseling children. He got married two years ago. Previously, I have seen him only for some softball related injuries and dealing with mild asthma. Yesterday, he came to see me to discuss adult ADHD. He was very pensive and subdued, and said, “I’ve been talking to my wife and a friend who’s a counselor, and I have all the symptoms of it. It’s affecting my job and my marriage, and I’m at the point where I need to see if medicine can help me. It’s taken me years to admit that I have a problem, and I’ve always been skeptical about medicines for something like this. But I’ve got to do something different.”

First, I felt he needed to know my new perspective on psychiatric meds, so I offered this: “I need to tell you where I’m coming from here. My only goal is help you be healthy and happy, both in the short term and the long term, and you need to know your doctor’s perspective so you can get the care you are seeking. Adult ADHD is a very nebulous diagnosis, and the criteria has been expanded so much that nearly everybody can place themselves within the diagnostic criteria somewhere. Now, if the medications weren’t necessary but were simply benign, then no big deal. But there is an increasing body of evidence to suggest that these medications are not only ineffective in the long-term, but actually very harmful to your emotional and physical health. Short term, yes, there is no doubt that they will help you focus and give you more attentiveness and energy. But long term, they can lead to weight loss, headaches, insomnia, not to mention causing violent mood swings, obsessive compulsive tics, even creating depressive and bipolar states.”

He listened graciously, and then I asked him to elaborate on how his symptoms were affecting his job. He said that he had trouble finishing projects, that he had lots of great ideas but could never follow through, that by the end of the day his head was so full of noise and chatter that he couldn’t focus on what students or coworkers were telling him. He said that if he looks back, he sees this pattern extending throughout his life.

Yes, I challenged, but yet you still managed to get a college degree and a master’s degree. He said, “Well, yeah, but even then, it was a daily challenge to make it through homework and studies.”

I then asked how it was affecting his marriage, and he said, “You know, I love my wife, and before we got married, I just couldn’t get enough of her, and when I was with her it was so easy to focus on everything about her, whatever she was saying. But now, it’s like no matter what I do, I just tune her out when she’s talking to me. I want to pay attention, but I can’t, and it really hurts her feelings. She thinks I don’t find her interesting any more or care about what’s important to her. That’s why she’s started doing research and has helped me see that I have a problem here, and that maybe medicine can help.”

At this point, I said, “I’m speaking to you here as a husband myself, and I think what you just said could probably apply to every married man in America. I don’t know why it is, but we tune our wives out. I do, more than I’d like to admit. I love my wife, and it bugs her, but thankfully she’s learned some strategies about when and how to approach me so that I’m ready to listen. But that doesn’t mean I have a disease. We need to be very careful that we are not diagnosing a relationship problem as a biological disease state requiring a drug fix.”

So far, so good. But he pushed back. He had done a lot of research, and he really just needed to find out if things would get better with medicine, as a sort of experiment.

At this point, I had a decision to make: he was determined to seek medicine one way or another. I could refer him to a psychiatrist, or he could seek another family physician on his own. Either of these pathways, I was 95% certain, would lead him down the pathway of one or more psychotropics, but without the restraints that I was willing to place on it, and I didn’t want to set him down that path by being inflexible. So I tepidly offered a referral, and then struck a bargain with him: “If you and I agree to a one month trial of Ritalin, so that you can see how you are affected, then will you agree to read a book that will give you a different outlook on psychiatric medications?” He earnestly agreed, and so I told him about your book, and gave him a script for one month of Ritalin. I told him that I didn’t doubt that he would notice a short term improvement in his symptoms, but that we can’t mistake that short term success as an indication for long term treatment. He also agreed to continue counseling, promised to read the book and see me in one month.

Thus are the negotiations and compromises of my daily clinic. Here was a intelligent man, a school counselor who sees kids every day that are “controlled” on ADHD meds, who is getting messages from his friends and his wife that he has a pathological disease that can be fixed with a systemic, psychoactive medication, and he comes to see his trusted doctor to ask his opinion. By any measure, his life is a success as it stands, though not without struggles, as he described. But yet he has convinced himself that he has a disease and needs a drug. I resisted, challenged, and eventually compromised in such a way that allows my message, and your book, to convince him intellectually of the problems with chronic med treatment, yet while also satisfying his preconceived expectations of our visit, and give him some potential short-term help with a vexing problem.

And we live to fight another day . . .

Mark

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.