Medications: The Easy Way to Avoid Real Change

Are we taking the easy way out?
Are we ignoring the real problem as long as we can shift the burden or consequence to someone else, or a later date?

I'm thinking of all the medications out there used to treat symptoms of poor life choices.
If the problems are due to smoking, drinking, unhealthy diet, lack of exercise, infidelity, overworking, etc... and a drug makes the symptoms better - are we just removing the pressure needed to make difficult personal changes?


Instead of using the fundamental solution: Changing our lifestyle; are we settling for the symptomatic solution of medication?

I understand the healthcare costs.  I know how much needle exchange has decreased disease and it's treatment in IV drug users.  I've seen people who work 80 hours a week function for years with the help of stimulants.  I have seen obese people saved from the catastrophic results of high blood pressure and diabetes.

These are good things.  But is good the enemy of great?  Are we sacrificing the crucible, the pressure needed to make us change our lifestyles?

Psychiatrist, not Psychic

The horror just keeps growing.

Some of my friends think I'm paranoid because the new gun law scares me.

Yes there are gun issues, gun rights, second amendment, self protection and other issues.

This is about my role as a psychiatrist.  This is about the state and federal government asking me to be a psychic.

The newly passed New York gun law states:

"Section 9.46 of the Mental Hygiene Law will require mental health professionals, in the exercise of reasonable professional judgment, to report if an individual they are treating is likely to engage in conduct that will cause serious harm to him- or herself or others."

THAT SCARES ME TO DEATH!

Why?  We already have a requirement to report anyone who is am imminent danger to themselves or others.  It's called a 72 hour legal hold.  If someone is an immediate threat to themselves I can call security or the police and have that person held against their will for up to 72 hours.

There is also the Tarasoff Law which requires me to warn a potential victim.  If a patient of mine makes a threat against a specific person - I have duty to warn that person or get the police to protect them or something to better ensure their safety.

This new law is different.  It doesn't ask a psychiatrist to look at an immediate threat (which is all we can do).  This asks us to predict if a patient is "likely" to be violent.

Do you have any idea how horrific psychiatrists are at predicting suicide or violent acts?

In the very short term - we're pretty good.  When psychiatrists were asked to predict which patients would be violent WHILE INSIDE the psych hospital - they were right 82% of the time.

Predicting OUTPATIENT violence in the next 3 days we get it right about 65% of the time.

After 1 week our predictions are no better than a flip of the coin in fact we're worse.  Psychiatrists trying to predict violent behavior more than a month out were wrong more than 50% of the time.

SO - how liable are we as psychiatrists for our patients behavior?  How long are we liable?  Does this new gun law change that?

Suing of a psychiatrist for failure to intervene has already happened.  The Aurora Theater shooting in July 2012 has led one victim's spouse to sue the shooter's Psychiatrist.

The shooter was making violent threats in June

OVER 30 DAYS LATER he shot those people in the theater.  The wife of one of the victims state's that the psychiatrist should have put him on a 72 hour legal hold when he made violent threats to her in June.

I wasn't there, I don't know what happened.   I know I have patients threaten me all the time because they don't get the treatment they had expected. I rarely put patients on a legal hold because unless I believe they are an immediate danger to themselves or others, I'm not going to revoke their civil liberties.

I doubt the case will be decided against the doctor - but that's because it's in Colorado.  What if this case were brought forth in New York?

Can we sue the shooter's mom?  After all - she likely knows him much better than the psychiatrist.  What about school teachers, friends, counselors, etc? 

What else am I supposed to be able to predict?  Robbery, Suicide, Infidelity, going AWOL???

This is a scary slippery slope.  I understand the need for mental health treatment, and for reducing gun violence - but calling a medical doctor a mind reader is, well, insane.

Defensive Medicine - What Makes Psychiatry Even Harder

When most people think of "Defensive Medicine" they envision what physicians do to cover their backsides rather than really help patients.

I think of being a medical student working in the ER when a drunk patient comes in complaining of chest pain.  My attending physician asks - "what does that patient need?" I answer - "He needs a rally bag, some food and a place to sleep for about 12-18 hours."
She then says - "but you know what we're going to do right?  He's going to get a CBC, CMP, UA, BAL, Chest X-ray and an EKG - and that's just for starters."

And that's how it goes.  We know what's wrong - or least we're pretty sure.  But we have to cover ourselves legally - because what if???

Can a drunk guy with chest pain be having a heart attack?  YES

It's like they say: "Every Hypochondriac eventually dies from something."

My residency director often said: "A man with diseases can have as many as he pleases."

Just because someone uses drugs and has a personality disorder doesn't mean they can't have epilepsy.  Yep - just because someone has pseudoseizures doesn't mean they can't have real seizures too.

And that's why we do it.  Yeah - we don't want to get sued - it's true. 

We would probably be correct and save thousands and millions of dollars if we treated people how we REALLY think they need to be treated.  But we don't get to make that call.

Psychiatrists have it even worse.  I wish I could just look at a depressed patient, or an anxious patient, and give them what they need.  I could give them the medications that are most likely to help them and get them the therapy that is most likely to have a lasting effect - but I have to do more than that.

Every patient I see - I have to look at their medication list and ask myself - "If they took every pill in their medicine cabinet - would they survive?" "If they tried to kill themselves - have I given them the tools to do it?"

I always have to worry about suicide.  Always.

I can't just treat symptoms, or even diseases.  I have to practice defensive medicine - meaning I have to defend the patient from themselves.

It's an impossible task.  I don't control their free will.  I am not their parent or their conscience.  I am merely their psychiatrist.

Yet somehow - when I get that call - the one where some ER doctor tells me that my patient just attempted suicide by overdosing on the pills I gave them - I'll feel responsible.

Maybe I can get used to it.  Is that what makes a good shrink?  Being able to handle things like that?

Maybe that sinking pit of guilt, despair, and regret at having facilitated a patient's suicide goes away?

Maybe it should.

Maybe it shouldn't.

Natural Supplements for Mental Health

Many supplements are nothing more than expensive additives to your urine - but there are some that have real value.  Some work very well and have good solid evidence to back them up.  

Here are some supplements that work for mental health problems.

Folic Acid (Vitamin B9):

What for: Depression

Dose: 400 micrograms daily (up to 800 if pregnancy is possible)

     - Rx dose: L-methylfolate 15 mg

Warning: Don't take more than 1000 mcg per day

SAMe (S-Adenosyl methionine):

What for: Depression

Dose: 400 - 1600 mg daily, can go up to 3000 mg per day if needed.

Warning: If taken with antidepressants like Prozac (SSRI, SNRI) it has a very small chance of causing a very dangerous reaction - Serotinin Syndrome.  It can also trigger mania in patients with Bipolar disorder

Ginkgo Biloba

What for: Alzheimers disease and sexual dysfunction from taking antidepressants.

Dose: 120-240 mg daily

Extra info: It takes 8 weeks to start working, so be patient.  It does no good for people who just have stressful lives, it helps people with alzheimers.

Valerian

What for: Anxiety or Insomnia

Dose: 450 - 600 mg daily

Warning: It can cause headaches and an upset stomache.  No one knows if it's safe in pregnancy

Extra info: It takes a while to work.

Omega 3 Fatty Acids

What for: Depression

Dose: 1-2 grams daily (MUST contain both EPA and DHA)

Warning: Don't go over 3 g daily, it can cause stomach ulcers and bleeding

St. John's Wort

What for: Depression

Dose: 900 - 1800 mg daily (usually spread out over the course of the day)

Warning: It can reduce the effectiveness of TONS of prescribed medications, like birth control, blood pressure and cholesterol meds, blood thinners, immunosupressants.  So check with ALL your doctor's before taking this.

Melatonin

What for: Insomnia

Dose: Good luck (literature disagrees).  Start as low as 0.25 mg, go as high as 9 mg daily.

Warning: High doses could cause you to sleep too long.  So again - start low.

Psychiatrist Meme - What others think I do