Recently, I saw a thirty-six year-old Bulgarian man for a follow-up visit. He is my age, with three children almost exactly the same ages as mine, so I felt an easy connection with him. He immigrated to the United States fifteen years ago, and owns his own picture-framing business. He is thin, with long swept back hair, a salt-and-peppered goatee and wire-rim glasses. He has a thick accent, and is self-conscious of his English, though he actually speaks it quite well. He first came to see me two weeks ago. At that visit, his chief complaint was a racing heartbeat and insomnia. We did an initial medical evaluation that suggested no primary physiological problems.
I asked him why he couldn’t sleep, and he said that he has been very worried recently. He lays in bed all night ruminating on his life, and this is when his heart starts racing. It turns out that his business is struggling in the poor economy, and there has been a lot of fallout from that, especially in regards to his marriage. As he shared these things with me, it was obvious that he was feeling the stress of a provider who was not certain how he would feed his children next week, which must be a heavy burden, indeed.
He had come to see me at the behest of his wife. He was nervous and reserved. I asked him what he thought the problem was, and he said with resignation in his thick accent, “I don’t know, I think I probably need a pill to help me out.” As I was a medical doctor, it seemed his only expectation was that I would prescribe him a medicine. When I divulged my concerns about turning to pills as a first resort, he seemed initially suspicious. This was not what he had expected to hear. But as our conversation continued, he began to brighten. I told him that I did not believe the symptoms he had described were part of an organic brain disease, but rather a very understandable human response to the difficult circumstances he was facing. I reassured him that with time, this could be expected to get better on its own, and then I provided him a handout that detailed specific strategies to improve mood and mental wellness, such as exercise, healthy diet, meditation, supportive friendships, etc. I told him that undoubtedly an improved economy would help things, too.
Two weeks later, I saw him back for a follow up. He was smiling. There was energy in his step, and he could hardly refrain from expressing his gratitude. He shook my hands several times as he told me that he had been exercising everyday, sleeping better, and hadn’t had a single episode of racing heartbeat. I congratulated him on his efforts and the obviously good results. He said, “Doctor, I am so glad you didn’t put me on a pill. I really didn’t want to take it. And now I feel so much better. I am telling all my friends about you. Dr. Foster is now famous with my family in Bulgaria!”
Of course, his recovery had virtually nothing to do with me, Bulgarian notoriety notwithstanding. I simple resisted offering a short-term fix, shared some perspective, and provided general recommendations to promote mental and physical well-being, all of this with the intention of helping him understand and take accountability for his moods. The biggest thing for him was the paradigm shift, and it took surprisingly little persuasion for that message to find its resonance. In his case, with his enthusiastic temperament, I feel very good about his potential for a sustained resolution of symptoms and long-term improvement.
For a moment here, I’d like to peer into a parallel universe, to speculate what may have happened had I resorted immediately to medications at the first visit. After all, this was his stated expectation, and for much of my medical career, I’m embarrassed to say, that would have been my knee-jerk reaction. I shared this story recently at a conference, and an attendee stated with some exasperation, “Yes, but that man was not mentally ill. It was clear that he didn’t need a medication.” Agreed. If only that attitude were prevalent among prescribing providers today. I can tell you that from my experience in modern psychiatric and primary care, this attitude of “prescribing restraint” remains virtually silent, if present at all. Instead, mood and thought disturbances are presented and understood as biological in origin, with effective and even necessary drugs available to treat them, safe magic bullets best taken chronically. When you have only the hammer of drugs at your disposal, then suddenly everything–and everybody–starts to look like a nail. Somebody presents with anxiety or sadness? They are requesting a pill? I’m running thirty minutes behind? Here’s your script.
(Sidenote: Isn’t it interesting how we shorten “prescription” to “script”? It’s as though when we hand them the prescription, we have helped to write their new script for life, their new role to play out. At the top of the playbill of their mind, instead of reading “Human Suffering Transient Distress,” it now reads “Victim Of A Broken Brain.” A person with a white coat, a title, and the authority invested by society has said so. Here’s your script. Curtain down.)
For this Bulgarian man, he was feeling broken, and he didn’t know where else to turn. His body and mind were relenting under the cumulative stresses of life, and thus he was in a very vulnerable state. Had I given him a script for a pill, I’m certain he would have taken it. After giving a cursory review of the medication’s administration and side effects, I may have shared my lifestyle recommendations, too. But these would have been forgotten as background noise. The decisive and searing intervention of our visit would have been the pill, which, per my prescribing habits, most likely would have been Paxil.
Here’s what I think would have happened next: After a few weeks, he may well have noticed a difference in his moods. He probably would have noticed a lessening of anxiety, but also a sensation that many patients describe as a “numbness,” a sort of apathy to their problems. He may have started sleeping better, but also would have felt concurrent daytime somnolence, a general fatigue and dulling of his senses. He might have developed a chronically dry mouth and upset stomach, as well as intermittent dizzy spells. He almost certainly would have noticed a big decrease in his libido. These are all very common side effects of antidepressants, but generally accepted by patients who believe they have a disease that requires medical treatment, and who have felt a difference in their mood, even if they have a hard time describing it as an improvement, just a dampening. To them, something just seems different, and they feel less anxious or depressed, which is perceived as a remission of a disease that had been causing them so much distress. Therefore, they continue taking the pill in spite of significant side effects.
Next, I would have seen this patient back in three months for a follow-up, and if his anxiety symptoms still seemed improved, I would have provided him a year’s worth of refills and told him to see me again when they ran out. I would have given him a cursory reminder about lifestyle interventions, and then handed him the script with refills.
A year later, I would have seen him back, where he would have expressed to me that the medicine just didn’t seem to be working as well, that he was having trouble sleeping again and occasional panic attacks, and maybe he needed a higher dose. It is possible that, at this point, I would have recommended trying to stop the medicine, to taper off of it slowly, but after three weeks of this strategy, he would have seen me back in misery, with worsening symptoms of panic and restlessness, and so we would have decided to resume the medicine, but at a higher dose. I would have given him a benzodiazepine for the panic attacks, and told him to see me back in three months.
Another year later, when he was now taking the benzos daily and maxed out on the Paxil dose, I probably would have suggested a change in anti-depressants, most likely to Lexapro, to see if this helped matters. I would have recommended that he go easy on the benzos, warned him of addiction, but, yielding to his desperation, I would have refilled them anyway. Additionally, he probably would have gained at least ten pounds from our initial visit, and it is unlikely that he would be exercising, due in part to the fatigue and weight gain.
At our next visit, most disturbingly, there is a decent chance that he would have reported to me some episodes of what appeared to be mania: worsening insomnia, spending sprees, violent outbursts at his wife and kids, reckless driving. I would have reviewed his medication list, given him some more benzos, perhaps changed his dose of medications again, and given consideration to adding an atypical antipsychotic, most likely Seroquel, thinking that he was showing signs of bipolar illness, and this could be a useful adjunctive therapy. This thought would have entered my mind in part because Seroquel has a large ad that jumps out at me every time I thumb through one of my mainstream medical journals: sad, disheveled, miserable patients languishing in depressive muted colors, but look! By the next page, they are brimming with vitality and color, smiling ear to ear, the only apparent difference being that somewhere between those two pages, they started taking Seroquel. At this point, I also may have re-referred my patient to counseling, but he would have refused, because this far into our relationship, the pattern had been set: he had such severe, biological mental illness that no other interventions would be worthwhile. He needed pills, and I was the one who would, after prattling on a bit about alternatives, provide his fix.
If I had started him on Seroquel, then at his next visit, I might have noticed a glassy look to his eyes, but would have been pleased to hear that he did not report any further manic episodes, and thus would have noted this as a therapeutic success. I would have noticed that his weight had increased by another ten pounds. A year later, his weight may have increased by fifty pounds. I would express alarm about this, checking some labs to see if his thyroid was okay, only to find that he had developed Type 2 Diabetes. In addition, his blood pressure would probably now be elevated, which I would have attributed as secondary to the weight gain. It is likely that I would have started him on new medications for both his blood pressure and blood sugar. These new prescriptions would have consumed the bulk of our fifteen minute visit, and at its conclusion, through his glassy stare, he might have reported to me that he and his wife were getting divorced, and could I help him apply for mental disability? Because there was really no way he could work anymore, not with his condition and all of these new medications. He couldn’t afford any of it unless he could qualify for Medicaid, and the only way to do that would be to be deemed disabled.
This worst-case scenario may seem extreme, but I fear that it, or lesser versions of it, are all too common. It pains me greatly to write this alternate destiny because for too many of my past patients, this became their destiny, and I helped to lead them to it, down that path–always with the best of intentions, mostly oblivious to the ironies and to my own complicity in their downward spiral–down down down from mild mood disturbances and cries for help until we reached the final tragedy of full blown mental disability. My labeling helped engender a devaluation of their self-concept, a smothering of the potential lessons to be learned from their transient emotional distress, and my prescribing helped to iatrogenically create a new form of mental and physical suffering.
No more. Although I still maintain the pragmatic approach that there is a limited role for psychotropic medications in mental health care, I use these now as a last resort, not a first one, and it is for short-term benefit with the clearly stated goal to get off of them within six to twelve months, and with the predominant emphasis placed on the therapies of exercise, counseling, meditation, and other lifestyle interventions. Medicine is usually, at most, a short-term adjunct to these.
The past is the past now, and I have to choose to not live my life filled with regret for my prior practice habits. I want to press forward with optimism, with a deepened appreciation for how my patient’s mood disturbances are woven into the fabric of their lives, not symptoms of disease, but common, sometimes heavy, and generally transient burdens of having been born human.
For now, I can choose to enjoy my Bulgarian patient’s contagious, reborn positivism. Because of our similar ages and family situations, my feeling is that, if we ever met outside of the clinic, we might well become friends. Maybe someday we will be. Maybe five years from now, instead of being divorced, depressed, and disabled, he will be thriving at home and at work in an invigorated, globalized economy. Maybe my family, together with his, will take a trip, our kids playing together on the plane and train rides, as we visit his native Bulgaria, where it appears that we might be greeted, perhaps, by a few misguided admirers. I have no doubt they will be disappointed.
But I like that version of the future better. I think he would as well.