Last fall, I was filling in at a clinic for a provider who was on vacation, and saw a woman in her late 40s for this complaint: “Anxiety/depression worse, wants to go back on meds.”
Prior to my temporary assignment at this clinic, I had made them aware of my stance on avoiding unnecessary drugs for mental health problems. While not opposed to it, they asked that I tread lightly with their patients who were already on drugs or seeking refills. They didn’t want me to rock the boat too much. These were their patients, after all, and I was just filling in. I told them that I thought it was simply good medicine to be asking questions such as, Do you think the medicines are working? Have you considered coming off? What side effects are you experiencing? What, besides drugs, are you doing to improve your mental wellness? The clinic was fine with those questions. It’s a great clinic. They truly want what’s best for their patients, and those questions all seemed medically appropriate to them. They just assumed that most of their patients would expect to be prescribed a medication anyway, and they felt uncertain about what else to offer them besides drugs. I promised to respect their patients and their practice in that way, while also staying true to my own principles. At any rate, it didn’t portend to be a big problem, as I would be seeing patients for all sorts of ailments, mostly acute care, and it was unlikely I would see too many mental health patients.
So that was the background as I entered the room and encountered a fit middle-aged woman, smiling and serene. There was no air of depression or anxiety around her. We spent a few minutes exchanging pleasantries, talking about Tim Tebow and the Denver Broncos. (This is a surefire way to break the ice with anybody in Denver these days–Tebowmania is epidemic.) Then I proceeded to review some basic information about her health history and asked her what brought her in today.
Her countenance dropped suddenly, and before she could even speak she became emotional. I handed her a tissue box. When she gained her composure, she told me that she had been crying a lot recently, with a sense of constant anxiety that was preventing her from sleeping, causing her to withdraw from social activities. It was taking a toll on her marriage. She didn’t know what was wrong with her, but something needed to change, and so she thought she probably needed to be back on antidepressants.
She told me she had been on prozac ten years previously for depression for about a year. It was the only drug she had ever tried. I asked her why she had been placed on it then, and if it had helped. She said that she couldn’t really remember why, sort of the same thing, being emotional, feeling a high level of stress. She remembered that it hadn’t really helped her much, so she stopped.
I had not divulged any bias I held against medicating, so she answered freely when I asked her some questions. What’s going on in your life right now? What are you doing for these problems besides drugs? If the medicine didn’t help before, do you think it would help now?
With that prompting, she shared several stressful situations occurring in her life that were contributing to her crisis. Financial worries, relationship stress, and mostly the fact that her youngest daughter was now a freshman in college, meaning that she, who had thrown her whole soul into raising her children as a stay-at-home mom, was now a new empty-nester. She wasn’t exercising as much, she wasn’t eating healthily, she was avoiding old friends–she thought these behaviors were symptoms of an underlying disease, not possible contributory factors to her distress. Most telling, she offered this: “I really don’t want to go back on drugs. I don’t think I need them. I’m embarrassed to even ask. But I’m just at a point where I don’t know what else to do.”
By the time she was done sharing–a half tissue box later–there was very little persuading that I needed to do. She had recognized the problems on her own, and decided, for now at least, against drugs. I offered sympathy, tried to normalize her experiences (“I think anyone walking in your shoes would feel the same way”), and told her I thought there were a lot of things she could try prior to going back on drugs, especially if she didn’t want to be on them anyway. Besides, I said, I don’t think you’d like the side effects for whatever minimal benefit they might have. I then told her that I was a family doctor who tried his best to keep his patients off drugs, and I gave her my handout on non-drug remedies for improved mental well-being.
We made a plan, gave her knowledge and support, and scheduled a follow up visit with her regular provider. Then she left smiling, still crying, but now with gratitude.
The truth is that I did little except listen. I offered support, and when I did not offer medications right out of the gate, she intuited her own pathway towards wellness, one that didn’t necessitate drugs.
A few observations from this encounter:
With very little investigation, there were clear social/environmental precipitants for her symptoms. None of her symptoms suggested a physiological problem or remedy.
There is a high likelihood that, without my modest resistance on this day, she would have been prescribed what she thought she wanted coming in: drugs. It is so easy to get onto the train of drugs, and so hard to get off. She was profoundly, unexpectedly grateful to be offered alternatives. In this case, not prescribing took much less effort than I would have anticipated, and was equally rewarding for me.
There is very little financial incentive for a prescriber to do what I did. It does take more time, requires less frequent follow-up, and does not reinforce the patient’s perception that her doctor is essential to her emotional well-being. Who wants to put themselves out of relevance, or out of a paying customer?
In her hour of angst, she turned to her family doctor and to drugs for help. Why? So many factors reinforce the biopsychiatric paradigm: direct-to-consumer marketing, positive media coverage about medications, cultural acceptance of high-tech medical innovation, her previous experiences with mental health care, social pressures from family and friends to “do something” about her “problem.” And most family doctors, who prescribe over 75% of psychiatric drugs in America, have only one tool in their toolbox for mental health issues: drugs.
These are observations you and I have obviously discussed before. No surprises here. But what is stunning to me is that these situations, and all of these esoteric ideas that we bat around, keep happening over and over again: a patient in distress, seeking help, expecting drugs, trusting me, willing to explore alternatives when nudged that way, surprised at their own humanity and resilience.
Sometimes, the prospect of real reform in mental health seems impossible. But sometimes I think we’re not that far away from fundamental change. Doctors, patients, family members, insurers, government agencies–we know what’s not working, and we want something better. We’re sick of the corruption, the cynicism, and the inhumanity of it all. The tide is turning, one patient at a time, a trickle now, but perhaps soon a tsunami? When I’m still, I think I can feel the energy moving in that direction.