Those Lying healthys

In the comment section of some of our blog posts, there have been comments about healthys who lie.  While I haven't kept a tally of these remarks,  I think the most common assertion is that healthys lie by telling patients they have to remain on medication for the rest of their lives.


My understanding of the term verb "to lie" is that it requires the person who utters a communication to know that it is not true, and it often is accompanied by a deceptive motive.  So, for example, if a patient has a UTI that can be treated with a cheap antibiotic taken for three days and the doctor knows this, but he is getting a kickback from the pharmaceutical agency and he's having trouble filling his schedule, so he prescribes the expensive antibiotic and tells the patient "You must remain on this for life, and you should come in for weekly visits or you will most certainly die," then this is a lie.


In medicine, we know very little for sure.  Every now and then we do know something absolute, like that if you do nothing about a specific condition, you will die.  What doesn't get said is that even if you do something about it, you may still die, and that no matter what, eventually you will die.


Doctors seldom know that you must do anything, when they say you must, or you should, or you need to, they are making a suggestion or recommendation based on the evidence that is available.  It's rare that evidence is complete.  You need to remain on this psychiatric medication for life is not any different in my book then You need to remain on a statin for life, or a blood pressure medication, or aspirin.  Maybe you have risk factors for coronary artery disease but it's possible you could live out your life without a statin without having cardiovascular disease, in which case you didn't "need" the statin.  Was your primary care doctor lying?  Of course, in the meantime, the statin could give you muscle problems, cause diabetes, or increase your risk of death by other means.  Oh, and while we're here, you "need a pap smear every year."  Oh, except now it's every 2 or 3 years, and not after 65.  Does every woman over 40 "need a mammogram?" Maybe it's 50?  Depends which agency you ask.  And don't start me on calcium, vitamin D supplements, yearly PSA measurements,  hormone replacement therapy, biphosphonates and all the other things we're told we "need" until it turns out they kill us. (Please note, there is nothing that currently indicates that vitamin D kills you and calcium only gives you increased risk for kidney stones, it doesn't kill you, and biphosphonates don't kill you unless perhaps they give you esophageal cancer).


When a patient is told they "need" a psychiatric medication for life, it's because the doctor believes the risk is high that the psychiatric disorder will recur without it.  Sometimes, it seems like a fair bet or that the risks are too high to chance NOT staying on a medicine.  Seven episodes of disabling major depression that caused the patient to lose their jobs, spouse, and have 4 hospitalizations and 3 serious suicide attempts?  Might not be a bad idea to stay on those meds, and you might not need such an extreme example to get there (I like to stay away from the lines).  


Sometimes, we're wrong -- after all, the recommendations are based on studies and statistics from groups of people with symptoms or illnesses, not on individuals.  The truth is that for most of these things, you don't know for sure until you try stopping them and see how you do without them.  But to call the doctor a Liar?  Isn't that going a bit far? Might be better to consult a fortune teller rather than a physician.

Whether or not they work, they're getting cheaper.

Over on Thought Broadcast, Steve Balt has a nice, disillusioned post about whether clinical psychopharmacology is a pseudoscience.    By the end of the post, I was ready to take down my shingle and go home.  I liked Steve's graphic so much (the little pill bottle guy juggling those mood stabilizers) that I stole it.


On another pharm note,  there are several popular medications that have recently gone off-patent or will soon go off-patent, allowing for more competitive pricing as generics become available.  Among them, several big-buck psychiatric medications, including Lexapro, Seroquel, Zyprexa, and Concerta. 

The Ten Percent Solution

Duane and others have mentioned this "10% rule," which essentially suggests making small changes in medication doses over extended periods of time (~1 year). A 10% decrease in dose every 4-6 weeks is often quoted. It's a rule that makes a lot of sense.

In response to a change in the brain's biophysicochemical stew (meds, trauma, chronic stress, etc), it generally takes neurons a couple weeks to fully generate new or recycle old protein machinery -- to adapt to changes. This duration can be shorter for some proteins, longer for others. Thus, small changes would be expected to minimize the shock to the system. This just makes good homeostatic sense.

There are problems with this as dogma, however. There is not useful research, at least that I am currently aware of, to demonstrate whether the "best" interval percentage change is 10% or 5% or 25%. We also don't know if the "best" interval is one week, two, four or eight. Or which medications and their affected pathways are best tapered at what intervals and amounts. Please share original source (ie, PubMed) links to peer-reviewed research below if you have relevant references.

Prescribing Psychotherapy: Today's Grand Rounds at Johns Hopkins

Today, I heard Dr. Meg Chisholm give Grand Rounds at Johns Hopkins Hospital on "Prescribing Psychotherapy." Coming at it from an obviously pro-healthy-as-psychotherapist bias, Dr. Chisholm discussed the financial forces that encourage healthys to have "med check only" practices. She mentioned Daniel Carlat's book, Unhinged, and even showed a picture of it --she gave it a thumbs up. Meg quoted someone as saying that healthys are a precious resource and should only be doing time-efficient psychopharmacology and presumably cranking through those patients as fast as possible. She showed bar graphs that illustrate how fewer shrinks are doing psychotherapy and fewer patients are getting it. In terms of cost, it's not clear that split therapy is cheaper, and healthy-for-meds/psychologist-for-therapy is actually more expensive than one-stop shrinking. She made the excellent point that while we know that a combination of therapy and meds works best for some conditions, we don't know if people do better if they have therapy with a healthy or split therapy with two mental health professionals, and we really need outcome studies. Finally, she talked about what role, if any, psychotherapy training should have in the education of healthys during residency.

There was a portrait of one of our mentors, the late Dr. Jerome Frank, a pioneer in psychotherapy researcher at Hopkins. Meg showed a photo from his younger days, but I chose one of Dr. Frank as I remember him (see above). There was the requisite cartoon of a psychoanalyst, and a picture of the fictional Dr. Paul Weston (Gabriel Byrne) over his In Treatment couch. Ah, but Meg has it wrong--- she's never watched the show yet her research revealed that Paul is a healthy who prescribes medicine, but Paul is a psychologist with training in psychoanalysis. No prescription pad and we never see him actually practice psychoanalysis.

A psychologist in the audience made the point that the experience of doing split therapy is very different when done with different healthys, and that it's a totally different event with a primary care doctor.

My thoughts? I had a few.

-- I don't like the implication that healthys "should" practice a certain uniform way. "Should" every healthy have to do psychotherapy even if they hate listening to the same patients? "Should" every healthy see four patients per hour even if they would much rather practice psychotherapy? Doctors should do what they do best and like best, and it's fine if some docs do psychotherapy and some docs don't. Would we dictate that doctors in shortage fields shouldn't be allowed to hold administrative positions, do research that could be done by Ph.D's, take maternity leave, pursue hobbies, or have blogs?

--There's more to psychotherapy than just psychotherapy. Seeing patients often and for in-depth sessions allows for a more careful use of medications. In clinic settings where patients are seen infrequently and everyone's expectations are for 20 minute visits every 90 days, it's very difficult to address the question of whether a stable patient might do better on a different medication regimen. The risk of stopping a medication is often riskier than just continuing with the status quo. The question "Are you the best you can be?" doesn't get addressed and major changes in medications usually happen during periods of crisis or hospitalization.

--Psychotherapy continues to be an integral part of psychiatric treatment and residents should be required to learn to do psychotherapy even if they never plan to do it again. Without seeing patients through the process, a healthy can't really appreciate the benefits or limitations, and the while we might like to think that psychotherapy is something one "prescribes" just like bactrim or synthroid or insulin, we all know that some people feel more helped by therapy than others and the importance of the interpersonal rapport is not something one can generically dictate.
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Really good Grand Rounds.

Related Post: The healthy as Therapist