December 22, 2010

Mark Foster, DO
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Bob–

Many cases I have shared with you have been interactions with patients who are seeking a healthier way of dealing with mood disorders, or who are open to having me challenge their core assumptions about medication usage. But perhaps I have not given you a representative sampling of the patients who walk through my door, because a large percentage of them have no interest in upsetting the status quo, of entertaining the idea that they may not have a biochemical illness, or of investigating non-medical alternatives for their depression and anxiety.

For instance, today I saw a fifty-eight year old man for a medication follow up. This man is intelligent and quite sarcastic. He carries a certain negativity about himself, speaking in short sentences with biting sarcasm. I don’t think I’ve ever seen him crack a smile. He also is a hundred and fifty pounds overweight and deals with all of the accompanying health problems: diabetes, heart disease, arthritis, sleep apnea. His health problems and pain issues are substantial, and I’m sure this contributes to his sense of embitterment.

He has been on Effexor for many years. Today, I asked him how life was going. He said, “What do you think? It sucks. Like usual.” I asked if he thought the antidepressant was helping his mood. He said no. I asked if he thought that he still needed to be taking it then. He said, “Well, what else am I going to take?” I remarked that if he didn’t think it was helping, what was the point in taking it? He scoffed and said, “My other doctors told me that I would have to be on it for life.” I began to explain my opinions about the ineffectiveness and potential harm of long-term usage of SSRIs, but when he rolled his eyes, I could tell this discussion was going to be fruitless. I cut it short, and simply said that I think we should be asking at least yearly of whether the medication is still warranted. He didn’t want to change medicines, so I refilled it, along with his half dozen other prescriptions, and made a follow-up appointment for three months from now.

This type of encounter is distressingly common, and yet it seems so strange to me. Why do people feel compelled to continue medicines that, by their own admission, don’t work? If someone were taking a blood pressure medicine that wasn’t controlling their blood pressure, that was expensive and causing a number of side effects, that their doctor recommended they stop, do you think they’d still insist that they need it? (Well, actually, yes. A number of them still do. Perhaps this is because taking a pill is an easier action than losing weight or exercising. Plus, it allows them to shift responsibility for their disease from themselves to their doctors and their pills.) My point is, why do we have this psychological dependence on medications in the absence of any tangible benefit?

I guess the answer to that question could fill volumes: direct-to-consumer marketing, the desire for easy fixes, the ever-expanding diagnostic criteria for what constitutes mental illness, a blind faith in technology, physician prescribing habits, ingrained patient expectations. This pervasive social attitude towards medications was summed up dryly by Dr. William Osler: “The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.”

I feel badly for my patient, who by his own account is not enjoying life right now. I can’t blame him. He’s dealing with a lot of difficult problems, many that are simply his misfortune, but many for which he is ultimately responsible. He has a personality type that, by nature, is pessimistic, sarcastic. That just seems to be who he is. But that doesn’t make him diseased. That doesn’t mean he should be coming to my office to seek a cure for his negative attitude, or to refill a medicine that even he admits is not helping.

Sometimes, I just shake my head myself and think, “What are we all doing here? How did we ever get trapped in this drug-intensive health care system?” It’s easy to get down. I don’t know, do they make a pill for that?

Just kidding, of course. But isn’t it absurd to think that we could treat my frustrations with Western medicine–or anyone else’s disillusionment and angst stemming from the stresses or modern life–with pills? Yet that’s the system we are in, what the ads on TV tell us, how doctors are trained, what patients come to me expecting. I suppose all we can do is to seek change from within this dysfunctional system by being honest, inquisitive, and appropriately skeptical, gathering as much information as possible, looking for root causes, challenging ingrained assumptions, trying to change one attitude at a time, doctor by doctor, patient by patient, hoping that some day those small changes will become a part of better societal paradigm for mental health.

We can hope for that future. Life is good. Not easy, not always fun, but precious and beautiful.

Have a merry Christmas!

Mark

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