March 4, 2011

Mark Foster, DO
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Bob–

I’m going to share with you a case from today that did not involve psychotropics, but I think it illustrates an important point about the opportunity cost of reflexive prescribing.

I saw a new patient today, a distinguished fifty-two year-old gentleman who is the CEO of a local engineering firm. He was looking for a new doctor because he was dissatisfied with some communications from his previous doctor’s office. He’d had some blood work done, and a week later had gotten a call from a nurse, who told him that his bad cholesterol was high, and he needed to start a medication. This was the first time in his life his cholesterol had been high, so he asked how high. She answered that she didn’t really know, but she read him a number and told him that the doctor wanted him to start the medication and come back in three months for a recheck. No other recommendations were made. He said okay, and the prescription was phoned in. When he picked up the medicine, he was told this was brand new, and so with his co-pay, it would be $40 a month, and without insurance, it would be $230 a month. He paid for it, but hadn’t started taking it. Something just didn’t feel right. He was frightened to hear he needed medicine, but frustrated with the expense and the lack of explanation, so he came to see me for a second opinion.

I reviewed his labs, and it turns out that his bad cholesterol was borderline high at worst, and that the rest of his parameters were excellent, including a phenomenal good cholesterol. The blood tests had been done the week between Christmas and New Years, and he admitted that he had not been eating well during that time. Also, he had stopped exercising over the winter because of weather and because work was so busy. He wanted desperately to avoid medication, and he asked me what else he could do to get his cholesterol down.

This was a great opportunity. We had a productive conversation about dietary changes, weight loss, exercise, fish oil supplements, etc. He was soaking up all of this information, taking notes, asking questions. Being highly motivated, there is no doubt that he will succeed in getting his cholesterol under control soon without meds. But here’s the kicker: because all of these lifestyle changes have positive effects far beyond the narrow parameters of cholesterol, I think there is an excellent chance that he will be able to get off of his blood pressure medicine, that he will start sleeping better, that he will feel healthier, both physically and mentally, and that if these habits are sustained, that he he will live a longer and more fulfilling life.

There are a lot of disturbing things in this story, but here’s the point I’m trying to make: reflexive prescribing without offering alternatives is almost always bad for the patient. His previous doctor was following a strict parameter, so reflexive that he didn’t even communicate with the patient, but had a sort of perfunctory protocol to just phone in from a nurse. In this doctor’s world-view, I’m certain that he was acting in good faith, doing what he thought was in the patient’s best interest. After all, medical literature and guidelines are very clear: patients who exceed certain cholesterol parameters must be on medication. To do less is not considered standard of care. He has heard this message repeated in seminar after seminar, sees full color ads popping out from every medical journal, has attractive pharmaceutical reps courting him with lunch every week. This is the world in which he lives, and in this world, the cure for high cholesterol is pills.

How harmful this world-view is. While I believe there is a role for cholesterol lowering meds, it wasn’t appropriate for this man at this time. Imagine the cost, the side effects (cholesterol-lowering medications have frequent side effects and require frequent laboratory monitoring). And now imagine the opportunity cost. This highly intelligent man starts taking the pills, thinking he is doing the best thing for his health because that’s what the authority figure in the white coat recommended and what the ads on TV suggest, and he neglects to begin eating healthy, to exercise regularly, to lose weight. His blood pressure stays high, his insomnia worsens, now he is getting muscle aches from the medicines so he starts exercising even less, and above all, he has now constructed a new self-image. He has a disease that is beyond his control, and the cure must come not from within, but from outside, in the form of a pill.

The parallels to reflexive psychotropic prescribing are clear. Patients present with symptoms that seem to fit some authoritative criteria, doctor feel pressure to adhere to guidelines and render therapeutic recommendations, and patients are uncertain and frightened and trusting. Medications are begun, and once that threshold is crossed, their necessity is rarely questioned again.

In the world of mental health, this leads to a dreadful situation that I encountered two months ago: a six year-old girl started on Risperdal by her psychiatrist at age four for the dire symptom of temper tantrums, and then started on Adderall the next year when she couldn’t focus in kindergarten, and now coming to my office for a well-child check looking like a zombie, with the poor mother frightened because her daughter’s behavior seemed to be worsening, and wondering if they needed higher doses of the medicines. And here is what I think should be a crime: the psychiatrist never informed the mother about any potential side effects of Risperdal. Never. In fact, she essentially bullied this mom into starting this powerful brain-altering antipsychotic two years ago, telling her, “If you don’t start this medicine, your daughter’s behavior will only worsen and she will likely end up in jail some day.” As mom told me two months ago, “I was so scared by what she said that I didn’t think I had any choice but to start the medicine.”

I’m happy to report that this young girl is now off of Risperdal, on half her dose of Adderall, and planning to get off everything once school is out this summer. She has a twinkle in her eye and she is doing great in school, though she had to visit with the principal last week when she got in trouble for passing notes in class. But mother’s okay with that. She told me this week, “I feel like I have my daughter back.”

I had a mentor share a quote with me once: “The end result of the movement towards evidence-based medicine will be that hardly anybody takes any medicine.” That may be a little extreme, but wouldn’t that be nice, to use medicines as the very last resort, instead of the first one?

Mark