Saturday, September 13, 2008

I Have A Friend....

ClinkShrink is looking for something to climb. Roy is collecting links to Mental Health Blogs: Thanks for all your contributions and if you'd like to add another mental health blog to the list, please visit Roy's post and comment.

I titled this post "I have a friend..." because it's not an unusual way for someone to start a conversation with a psychiatrist about a mental health problem in a social setting-- maybe it's about a friend, maybe it's about themselves, I never ask, I take it at face value. Sometimes I later hear, "actually it's my problem."

So I have a friend (--really) ....

We're together in a public place, there are people around that we know, probably not within earshot, but who knows? The friend is, well, more of an acquaintance-- we don't know each other so well.

"I know you don't like Xanax, but it's the only thing that helps when my thoughts race."

I'm caught off guard. It was a statement, not a question, and I should have listened.
I mumble something. Whatever it was, it was probably the wrong thing to say.

"Why don't you like Xanax?" Friend asks.

Oy: if you haven't read Roy's post on Why Docs Don't Like Xanax (some of us), then by all means,

Issues with addiction, I say.

"I don't take it every day, just when I can't sleep and my thoughts are racing. What else could I take?"

Okay, at this point I retrospectively cringe at my response. What was I thinking? Roy and ClinkShrink would crawl under a rock and pretend they don't know me. I mumble something about Ativan and Valium being less addictive. I mumbled something about perhaps the Xanax wasn't a problem. Oh, I recommend these medications rarely, really rarely, and only to patients I've carefully evaluated. What was I thinking to suggest the names of other meds? Or what
wasn't I thinking?

The subject changed, we didn't discuss it any farther, but I was left obsessing about the weirdness of my response, the irresponsibility of it, the cavalierness of even hinting that certain medications (addictive ones at that) might be better than something already prescribed for a condition I didn't explore, by another physician, for a person I didn't know terribly well.

So this post will now have two themes:
1) When personal friends asks a psychiatrist (this psychiatrist in particular) for advice.
2) What I did wrong, which is basically everything.

Friends ask me for suggestions from time to time. ClinkShrink and Roy might (I'm not sure, I'm surmising this) say one shouldn't give any suggestions and that by listening, engaging, offering advice, that one essentially establishes a doctor-patient relationship and becomes responsible for them and becomes open to all the obligations inherent in any doctor-patient relationship, including the right to be sued for malpractice. Again, I'm putting words in their mouths, so Clink and Roy: do feel free to add to the bottom of this post.

I don't tend to worry about being sued. And when a friend wants to talk about a problem, knowing I am a psychiatrist, I listen and I don't usually immediately say, "Ask your Doctor" --because, well, it feels dismissive and I feel like the voice-over in one of the pharmaceutical commercials. I usually listen, answer what's asked to the extent that I can, and if the situation warrants, I gently suggest it might be worthwhile to have at least a one-time psychiatric evaluation. I never, ever, tell my friends they need long-term intensive psychotherapy or specific meds: that would be the job of the evaluating psychiatrist and I like having friends! I will refer friends to shrinks I think they'd like, if they want, though, hey, it's my best guess as to interpersonal/professional chemistry. I try to figure out an appropriate boundary -- somewhere that's caring but not opening myself up to to hearing all sorts of overly personal details-- and I try not to upset my friends or leave them feeling uncomfortable. Finally, I try to be of help.

Here's what I did wrong with my Xanax-for-racing-thoughts friend:

  • I didn't listen to the issue. Was there even a question or was it just a request that I hear that Xanax is helpful to this particular person? I never found that out.
  • If there was a question as to the appropriateness of this particular medication for this particular person, I really was in no position to comment or second-guess the doc who prescribed the med.
  • I jumped to a conclusion that, in the moment, I didn't even realize I was jumping to: The friend mentioned that Xanax helped with racing thoughts. I know this friend has trouble sleeping when there is a lot going on. "Racing thoughts" are a symptom of Bipolar Disorder-- it's a term used to describe the symptom of having one's thoughts go so fast that the patient can't keep up with them. They don't generally happen with conditions other than mania, and I assumed the friend wasn't really having "racing thoughts" but anxious ruminations associated with insomnia-- in other words, dwelling on daytime events and worrying which were interfering with sleep. I don't know any details, it was a quick assumption. It wouldn't have been appropriate ( nor would I have wanted) to ask all that I'd need to ask to figure out the precise phenomena, diagnosis, or if Xanax or something else was the appropriate treatment. I also assumed this friend doesn't have a substance abuse history and I'd have no way of knowing that....perhaps any addictive drug, be it Xanax, Valium, Ativan...might be the wrong choice. I should have kept quiet.

The subject changed, it took me a little bit to process what I'd said and what I hadn't said, and somewhere in there, we followed it up with a second, briefer conversation in which I said much of what I've said here.

Hoping my friend is now sleeping bette