Letters from the Front Lines

Mark Foster, DO
8
31

Dear Bob–

I met a new patient today, an African American gentleman in his late 40’s, a successful entrepreneur and innovator (invented and marketed his own garage organizer), who is having devastating health problems related to his heart and weight, problems attributable, at least in part, to side effects of psychotropic medications.  He was tearful today, questioning if he was going to die soon.  His father died of a heart attack when he was his age.

In taking his history, I found out that this patient’s health problems began about twenty four months ago.  He had lived a fairly unhealthy life up to this point, lots of drinking and travel and poor eating, but he had always been active, played in a basketball league, and had never had a major medical crisis.

Eighteen months ago, he began having trouble sleeping.  This was a lifelong problem, really, but it worsened, became debilitating during a time when his business was fending off a major law suit.  He went to see his trusted family doctor, who started him on Ambien, which only helped a little.  Then, for reasons that are unclear, his doctor started him on lithium, perhaps thinking he was hypomanic or bipolar.  The patient does not have insight into why he was started on lithium, but he trusted his doctor.  When the insomnia persisted, he was started on Seroquel, and finally he was able to sleep.  Satisfied that these “brain pills” had calmed him down and fixed his insomnia, he continued this cocktail for a year, and in that year he gained over 120 pounds.  His doctor, seeing him monthly during this time for refills, never raised this issue of weight gain or of stopping the medicine.  Instead, the doctor seemed pleased that the insomnia problem had been solved, and encouraged him to diet and exercise more.

Then the story becomes tragic.  The patient had chest pain one night and wound up in the ER, where it was discovered that at some time previously he had a minor heart attack, and was now going into heart failure.  Over the next few weeks, he developed massive lymphedema, leading to severe, disfiguring swelling of his lower body, including legs and genitalia.  This problem is often called elephantiasis, because it leaves the person’s legs looking absurdly swollen, the skin ridged and discolored.  He developed palm-sized, weeping ulcers on both ankles, wounds that have not closed now in over four months.  He cannot drive or even walk to the mailbox.  He works mostly from home, and pays one of his employees to come change his bandages, because he can’t bend over to change them himself.  His pain and discomfort are chronic and severe.  He is living in misery, becoming hopeless.

About six months ago, his cardiologist stopped the Seroquel and the Ambien, and unfortunately he is now unable to sleep again.  He continues taking the lithium, because this seems to help his pain.  He’s now on six other medications for his various health complications.  He came to see me because he feels like he needs a fresh start with a new primary care doctor.  I found his current health status alarming, though I’m hopeful that we can dramatically reduce his symptoms and suffering with some changes in medication and some new attention to his swelling and wounds.  But no matter what we do, his health status is poor and likely to deteriorate.  I’m also concerned he is developing diabetes, and I’m checking some more labs.

This is a multifactorial problem.  But there can be no doubt that his decline was accelerated, perhaps even provoked, by being placed on potent psychotropics that caused massive weight gain and cardiac problems.  The whole story is a smoking gun.  An otherwise unexplained 120 pound weight gain in the year after starting lithium and Seroquel?  The weight gain led to strain on his heart, which was already at risk due to cardiac effects of these medications.  A heart attack led to heart failure, which led to the swelling and pain and disability.  Tragic.  These medications appeared initially to fix a distressing problem–insomnia–but left so much carnage it their wake.

In retrospect, the patient wishes the medications had never been started.  I can only agree.  How would his life be different?  Reflecting now, he thinks the insomnia wasn’t nearly as bad as he thought at the time.  He would so much rather have sleeping problems and retain his health and longevity.  I’m dismayed that, once the weight gain started, the need for the medications was never again questioned.

The medication on-ramp:  so easy, so enticing for doctor’s and patients alike.  The exit?   So often invisible.

We’ll hope the best for this poor gentleman, whose life is so much worse after the medications than before.

Mark

8 COMMENTS

      • I didn’t miss the point of his blog post. I just wouldn’t like to see Mad in America be taken down by legal efforts because of something like this. It’s safe to assume that if this site ever got popular that Big Pharma would hire professionals to legally attack it and I don’t see the point in making it easy for them. The story he told and the point it made could have just as well been done without telling a true story.

        • Thank you for raising this concern about patient confidentiality. It’s a very important issue.

          On the old https://www.madinamerica.com website, all of my posts were preceded by a confidentiality disclaimer. That disclaimer didn’t make the transfer to the new website, and Robert Whitaker and I are working to get it to appear again.

          Here is the wording of the disclaimer:

          “Editor’s note: These letters are selected from an exchange that Dr. Foster and I have had since he finished reading Anatomy of an Epidemic. They describe his interactions with his patients, and his changing thoughts about the prescribing of psychiatric medications. In all of these letters, the specific patient situations he describes are real, but all identifying characteristics have been altered or obscured, or permission has been sought, in order to protect patient privacy.”

          Now I’d like to add a few more thoughts.

          The “case study” has an important role in the medical literature. I hope my “Letters from the Front Lines” blog fits within that tradition. Randomized controlled trials compile the evidence for what does and doesn’t work, but individual case studies and patient vignettes are what bring those statistics to life and allow physicians, patients and the lay public to access the human implications of the statistics. Nowhere is this more important than in the muddied waters of mental health, where the lines between science and snake oil are so blurred.

          I am aware that as a practicing physician, I sit in a privileged place in being able to interact with and assist patients at their most vulnerable moments. I am also aware that, because what transpires within the exam room must remain protected, there has been little public discussion or awareness of what it is like to be a physician sitting in that room, patients coming relentlessly in various stages of crisis, doctors wanting to help and having so few tools (and so little time) available, trying to make sense of all of the misleading drug propaganda and their own conflicted training, feelings, and biases, and out of that milieu developing a plan that will help the person out of their crisis while also setting them up for long-term wellness. It is rarely a clear-cut situation, and I hope my blog can shed some light into that opacity.

          Over time, a myth has arisen about physician objectivity, as if we were sitting in an ivory tower with a privileged, unbiased perspective of the truth. It’s my strong opinion that, in the arena of mental health, that myth contributes to a power differential between doctors and patients, which leads to patients being mislabeled with confidence-destroying diagnoses and then mistreated with brain-altering medications. This power differential is evident in the last case study I shared, where an intelligent patient was placed on powerful medications for spurious reasons by a well-intentioned and confident doctor. He was maintained on these medications unquestioningly even after serious complications developed, and is now in a fight for his life.

          I take patient confidentiality very seriously. Before I started this blog, I consulted with numerous attorneys as well as executives from medical journals about the ethics and legality of doing a blog like this. I was assured by all that, as long as specific identifying characteristics were altered or eliminated, or patient permission were obtained, that there would be no legal complications, that this sort of writing fits into the long tradition of case studies in the medical literature. I believe I actually do a lot more than is required to protect patient privacy. No reader would be able to identify the patients in question, their true identify remaining known only to me. Yet the essence of their stories, their movement in and out of psychiatric drugging, remains intact. These are stories that I think need to be shared, for the good of society and the integrity of my own profession.

          I hope I answered your concerns, and I welcome any more questions you may have.

          • Dear Dr. Foster,

            I admire your courage to continue to write for Mad in America even though Robert Whitaker announced that you were “fired” by your employer, Littleton Adventist Hospital, on March 15, 2010 after he shared 25 of your letters to him about your patients on his site.

            I think writing as if you were going to submit your post for a peer review rather than story-telling to a friend is a great concept and could help prevent any misunderstandings.

            It is a style that has similar components to legal writing where the author is trying to make a case by staying objective, state the facts, educate the reader on established protocol and gain acceptance for the actions taken/seeking to remedy.

            I know that you state you obsure the detials of your patients but it does not seem necessary to mention certain features such as hair color. For example there is a well-known stigma associated with a woman having blonde hair. It seems unnecessary to mention that feature. If your patient actually did have blonde hair and you said something negative about them without their permission, that is something that would be a concern to any ethical, professional employer.

            Blogging is a lot of fun but we always need to keep in mind that the internet is a new frontier for liablity and law suits.

            A peer-review format holds credibility and would hopefully muster the test if ever challenged.

            Keep your guards up at all times.

  1. This story is tragic. I’m appalled and shocked that his doctor didn’t realize that there was a connection between the psychotropic medication he prescribed and the dramatic weight gain. Why didn’t he try to find the underlying cause of the insomnia and suggest lifestyle changes that could improve the patient’s sleep habits instead? Was this patient evaluated by a psychiatrist? This case is an example of how we need to educate ourselves and advocate for ourselves. The days of being passive and following doctor’s orders without question are over.

  2. Mark-
    I’m wondering to how doctors can prescribe such medication when a person is already in a “risk category” for various metabolic problems. As a Black woman, I’m very mindful of both race and gender risk factors and as such became very vocal about the use of psychotropic medications that were recommended as part of my treatment. I became even more vigilant given what we know now about the detrimental side-effects of neuroleptics and other psychtropic meds.
    Indeed the prescription pad tends to be the first tool of choice for providers when in fact it should be their ears (listening), minds (critical thinking) , mouths (engaging in Dialoque/problem sollving) and hearts (caring about their patients long term health/well-being).
    Clearly, in a 7- minute appointment the Rx pad is quicker and mightier than goold old fashioned and effective engagement. Add the publics over infusion of direct-to-consumer Pharma ads and the result is as you experience a recipe for disaster.
    Education, choice and self advocacy are crucial components to improved lives-
    Keris

  3. I have to wonder why the psychiatrist didn’t have his patient go for medical testing/blood work. I was put on Seroquel (among many other over the years) without having the testing protocol the drugs called for. Unfortunately I got Seroquel Induced Acute Pancreatitis and spent 2 months in the hospital because I was not monitored by the prescribing psychiatrist.I truly sympathize with your patient being on unneeded powerful anti psychotic without any medical intervention till it was almost too late.
    I consider your in depth look into your patients history to be very important as to how they should have been treated initially. Rarely do the physicians go over each medication to check its validation. If there were more caring conservative prescribing physicians the needless poly-drugging would be less.
    Many thanks for your blog.