Patient Times

The other day a patient sent me an e-mail explaining that after consulting with her spouse and parents she had changed her mind about taking the medication we discussed during her appointment. She had reviewed the DSM Criteria and was confident that she had bipolar disorder, despite my conclusion that her symptoms were not consistent with that diagnosis. This situation— a patient using the DSM to trump her psychiatrist and diagnose her own disorder– happens often in psychiatry. I would guess it happens more often in psychiatry that in other specialties. I can’t imagine a patient moving his sore knee around while reading about the examination for a torn ACL. Likewise a person who is told that he has coronary disease discusses the diagnosis with family members and concludes that he instead is experiencing esophageal spasm. I suppose there are those patients who are angered when told they have viral infections and who demand antibiotics. But there is little harm done in such cases when the doctor gives in and writes the prescription, unless one has a strong moral compass about preventing resistant bacteria in the community.

It is ironic that self-diagnosis is so specific to the field of psychiatry, given that psychiatry is an area of medicine that is probably among the most complex and least understood. Given that psychiatric experts have trouble making consistent diagnoses, what are the chances that people with no psychiatric training are going to get the diagnosis right?

I understand a counter-argument: that knowing a person for a lifetime provides a more ‘complete picture’ than the short-time view of an outsider. The history of a patient over time can be valuable information, but only if seen through a perfect lens—as opposed to the distorted view of family members.  In reality, lifetime observations of a relative or a close friend’s personality are too distorted to be of much historic value. The medical records over time would be far better sources of information for a diagnosis that requires remote history—especially if the records contain observations by impartial experts.  The distortion caused by ‘closeness’ is not only because of the distorted perspective of the close observer, but also because the person being observed will act—and FEEL—different depending on who is watching.  Psychiatric symptoms themselves are strongly influenced by the nature of the relationship between the observed and the observer.

It is considered unprofessional for a psychiatrist to diagnose and treat a close family member, and no court would consider testimony valid that comes from a psychiatrist who had a personal relationship with his/her patient. Yet laypersons cling to the idea that the closer one is to a person, the better one knows that person. This leads to the sometimes-incorrect notion that a spouse, mother, or child of a patient is in a better position to make a diagnosis that a psychiatric expert who has only known the patient for a short time.

It is difficult to address this situation with patients without arousing anger. A patient who is told to trust his doctor over his family is likely to see the doctor as arrogant, or even insulting to his family. Likewise family members in such a situation are going to do all they can to get their beloved patient away from “that crazy psychiatrist” who is making a diagnosis without knowing their sister the way that only they know her. 

Part of the problem may come from easy access to the DSM criteria on the internet.  There is an impression among psychiatry hobbyists that diagnosing psychiatric conditions is simply a matter of checking off symptoms from section A and a few more from section B.  But as any experienced psychiatrist knows, making a correct diagnosis requires much more consideration and wisdom than can be found in the DSM alone. The DSM criteria, when read by a layperson, take on the nature of horoscopes or fortune cookies. Any person can pick up the DSM and self-identify with a number of disorders. And of course I have done the same thing myself, as have most medical students at some point. We all looked through the criteria for personality disorders for example, wondering if we were cluster A, cluster C, or (oh no!) cluster B. I now know that the mind provides a veil of repression thick enough so that any self-diagnosis is guaranteed to be profoundly incorrect.

I remember an incident from my teen years when my dad went to a retreat– one of those California-style retreats that were popular back in the 1970’s when people tried to better understand themselves by going through humiliating, overly-personal experiences with strangers. I remember my dad talking about an exercise where people first ranked themselves on qualities like empathy, happiness, cooperation, optimism, and friendliness. Then they were ranked on those same qualities by people who spent the course of a week getting to know them. I remember my dad’s anger that everyone at the retreat had him all wrong. I don’t mean to pick on my dad, as I give him credit for going through a number of similar self-exploratory activities throughout his life. But his angry reaction to the impartial observations by outsiders was a universal reaction. We see ourselves as we want to see ourselves, or even more, as we have been told to see ourselves over many years by those close to us. This misperception is why diagnosis by family committee is pure folly. Families have their white knights and their black sheep. Families see a family member as they want to see him—and as they need to see him. On the other hand, an impartial, practiced observer can see the patient/family member as he truly is, making such an observer a threat to the tightly held opinions of those who care about their brother or husband.

I often write about the deficiencies of modern psychiatry that result from the insufficient length of time for encounters between psychiatrists with their patients—a length of time that is shortened by the scheduling practices of health systems and the reimbursement schedules of insurers. The effectiveness of psychiatric care would be greater if patients understood the phenomenon that I just painstakingly described, but discussing this phenomenon with a patient takes at least an hour.  It is more efficient—not to mention easier– to go with the flow of the family diagnosis. And the bottom line is that if a family is convinced that one of their own has bipolar disorder, it will take a great deal of time to convince them and the patient otherwise.

But on the other hand, we all went into medicine to do the right thing.  We take an oath to first do no harm, and the medications used to treat bipolar disorder affect multiple organ systems, so it is important that we get the diagnosis right.  One of my favorite phrases in when it comes to helping a person change his/her mindset on a major issue is that “Insight maketh a bloody entrance.”  This topic is one of several that make the practice of ‘good psychiatry’ one of the most challenging fields of medicine!

I’m sorry for the hiatus in posting; I have another blog (related to addiction) plus there always seems to be tons of paperwork this time of year– not to mention getting things together for the tax season.  With taxes in mind, perhaps it is appropriate to write a post that has to do with the FDA. 

I am going to share an e-mail exchange with a patient about a medication that is part of the changing landscape for treating depression.  Since the replacement of ‘tricyclic antidepressants’ like amitriptyline and desipramine by SSRIs (serotonin reuptake inhibitors), the general approach to medication for depression has been SSRI, second SSRI, SNRI, then augmenting the SNRI, then augment with something else, and finally consideration of ECT.  There are other treatment choices in the algorhythm such as psychotherapy, bupropion, or mirtazepine, but the general pattern of SSRI— second SSRI—- SNRI has been the backbone of treatment in the modern era of psychiatry.

At the same time there have been other medications that are thought of as ‘mood stabilizers,’ including a group of medications known as the atypical antipsychotics.  To use their trade names, the medications include Zyprexa, Risperdal, Seroquel, Geodon, and Abilify. Recently two of these medications have received FDA indication for uses other than for bipolar mania or for schizophrenia, and there are indications that the lines between medications thought of as ‘antidepressants’ and medications considered ‘mood stabilizers’ will become more blurred going forward.  This should be a good thing, as we are gaining additional options to treat mood disorders– a group of illnesses that cause considerable suffering in the country and world.  But the new medications have powerful effects, and so like most medications have potential side effects– in this case the risk of increasing blood glucose, cholesterol, and triglyceride levels, and increasing the risk of weight gain and diabetes. 

The e-mail exchange relates to the issue of medication side effects, and when should a person disregard the scary print at the bottom of the advertisement (or the ridiculously-fast-spoken list of side effects at the end of a TV commercial).  The patient has struggled with depressive symptoms for a number of years, and has been treating the symptoms with the ’safest’ medications– i.e. SSRIs– avoiding medications with greater risks and side effects.  I have been her psychiatrist for a short period of time, and we are not yet certain whether her symptoms are part of Major Depressive Disorder or are instead the depressive side of Bipolar Disorder.   I recently suggested to the patient that we look at the big picture– that the depression is taking a toll on her life, that the depression has affected her relationships and career path, and that the depression has even put her at risk for suicide.  I think I will let the exchange finish the point I tried to make.  She is a bright patient who reads up on whatever we discuss, something that sometimes makes my work easier, and other times makes my work more challenging– albeit in way that medicine SHOULD be challenging.

I suggested considering a more potent medication, such as Seroquel.  She sent a message that included the following comment:  

I looked up Seroquel…and get freaked out by things like this:  http://www.usatoday.com/news/health/2009-04-08-fda-seroquel_N.htm  I will let interested readers go to the link on their own, but the link is to an article questioning the wisdom of the FDA in giving Seroquel the new indications.  As I mentioned earlier, I think that more choices are a good thing– providing we have bright doctors who take the time to educate their patients, who take the time to learn enough about their patients, and who make reasoned decisions based on ‘risk to benefit ratios’– assumptions that may or may not be valid.  I have written about my disdain for psychiatric practices that do ‘7-minute med checks’, and I believe that those practices may serve their patients more safely by sticking to the SSRI’s!

My long-winded response to the patient:

I am not pushing Seroquel- only suggesting that when you look objectively, there may be a case for more aggressive treatment of your depression.  I want to point out a couple things in the USA Today article, an article that is clearly written by someone with certain preconceptions.

First, the article correctly reports that the FDA found that the risk/benefit ratio of Seroquel does not favor using the medication as a  first-line agent.  But it is important to note that after reviewing all of the data, the FDA DOES favor approving the use of the medication for treating depression in people who (like you) do not achieve remission of mood symptoms from first-line treatments like Prozac. 

There are a couple comments in the article that I find misleading; for example, the quote of lawyers who said ‘the company knew Seroquel caused diabetes.’  Seroquel doesn’t ‘cause diabetes’.    There is an increased risk of diabetes in people taking Seroquel, but the risk varies with dose and length of time taking the medication.  The drug is used at 600-800 mg for mania or schizophrenia but only 300 mg for depression, and people who take it for a short period of time at a lower dose are at lower risk.  The risk of diabetes in patients taking Seroquel goes from around 3% to around 6%.  For an individual, the risk of NOT getting diabetes goes from 97% to 94%.    The effect can be worded in a scary way—‘the risk of diabetes doubles’- but going from 97% to 94% odds of NO diabetes is less frightening—especially when the odds ratio takes into account the risk and pain of experiencing years of depression.  The risk if diabetes can be greatly reduced, by the way, by monitoring blood sugars and stopping the medication if glucose tolerance changes.

It is important to distinguish between the risk to an individual vs. the risk to a population.  The FDA looks at the latter, but the individual should look at the former.  For example, much has been made of the risk of suicidal ideation in children and adolescents taking antidepressants.  The result of the FDA black-box warning of this issue has been a significant drop in antidepressant prescriptions for children and adolescents, and at the same time (coincidentally?) a significant increase in suicides in the same age group.  The warning came because retrospective evaluation of pooled research data showed that ‘suicidal ideation and behavior almost doubled’ in depressed patients starting antidepressants compared to depressed patients starting placebo tablets.  A ‘doubling’ sounds bad… but there was no increase in actual suicides, and the data may reflect something benign.  For example, perhaps kids on antidepressants talk about their thoughts more.  Looking at the data beyond the ‘doubling’ headline, in the placebo group about 2% of the depressed patients had increased suicidal thoughts.  In the treatment group the number was around 4%.  This is in fact a ‘doubling’ of suicidal thoughts, but we can look at the exact same data in a different way.  In the placebo group, 98% of the patients did not report increased thoughts of self-harm, and in the treatment group 96% had no increased thoughts of self-harm.  This way of looking at the data is much less likely to scare a mother into dumping her child’s Prozac down the drain… but is also less likely to catch your eye in the check-out aisle where the papers are sold! 

I will again point out that no suicides were attributed to antidepressants.  But meanwhile, suicide IS one of the leading causes of death in that age group, and most of those suicides occur in adolescents with untreated depression.  There has been less dramatic reporting of similar increases in suicidal ideation in patients taking virtually any of the anti-seizure medications, and in similar effects from other medications—like Singulair, a medication for asthma. 

Government health agencies look at fractional risk multiplied times 200 million people.  A 5% risk of diabetes means an additional ONE MILLION people with diabetes!  But an individual still has a 95% chance of NOT having the illness.  I remember going through a similar calculation back in med school, when I contemplated giving up the bacon that I loved to lower my risk of heart disease.  For now, I am still eating bacon!

I want to leave this discussion making two primary points.  First, it is important that patients know the true balance of risk to benefit for any treatment or medication, and that they try to learn the truth behind the headlines.  This point is a perfect segue for a plug for my practice.  I see at most two patients per hour for follow-up visits, and find that even the 30 minutes that I set aside at minimum is a short period of time to adequately explain all that the patient should know– particularly when most of the appointment must be used to collect information from the patient, not the other way around.  I have no idea how people gain anything from the typical 7-minute appointment.  If you are a dissatisfied patient, give me a call through my telepsychiatry practice!

Second, at some point it may become time to treat a mood or anxiety disorder or some other psychiatric condition with more potent medication, including medication that has temporary side effects.  When a person develops gallstones, he/she usually ends up with either a number of small scars from laparoscopy or one big scar under the right ribcage from an open procedure.  In either case, the person experiences significant pain for a number of days.  I sometimes think about the different tolerances people have for the treatment of different conditions, from the financial perspective and from the perspective of tolerable side effects.  People think little of spending thousands of dollars for anything involving a scalpel or anesthesia… my teenage daughter’s broken arm took 10 minutes to cast and the orthopedist charge was almost $1000, but I will get nowhere asking an insurer to pay $140 for an hour of my time with a patient!  Likewise, mild nausea from Effexor will keep a patient from taking the medication, even when the illness is so severe that the person is home-bound from panic attacks. After several days of at most mild dysphoria, the medication has a good chance of eliminating the anxiety entirely! 

What are the reasons for the differences?  I have a few guesses, including the stigma of mental illness, the difficult nature of change, and the powerful effects of denial.  In all cases I don’t see significant changes in ‘how things are’ on the horizon… so noncompliance and unwillingness to accept proper treatment will likely remain an issue for psychiatrists to understand and to consider as part of the entire illness.

Thanks, as always, for reading this far.  I wish you all the best.

JJ

Another Shrink Zone psychiatry radio show from the archives, this one from 6.08.2009.

Click here to get the mp3 file

Or use our player to listen now:  

Send questions for the show to drj@fdlpsychiatry.com

Click here to get the mp3 file

Or use our player to listen now:  

Send questions for the show to drj@fdlpsychiatry.com