Monday, November 10, 2008

Quote of the Day

I've had a long day and it felt like every one was pretty troubled. I'm trying to decide who to give credit to for the 'quote of the day.' I started by thinking it might go to the person who informed me that I looked good (always nice to hear) and then added that usually I look sick and I've gained some weight. Okay, I'm not sure what to do with that one.

I've decided, instead, that I liked the remark posted by blogging psychiatrist Doug Bremmer in the comment section of my post Tell Your Doctor if You Experience Any of the Following....

He writes:

Doug Bremner (MD) said...

As a "blogging doctor" I am struck by how much anger there is out there about side effects of antidepressant medications, and how much psychiatrists are felt to be to blame for that. Perhaps there has been over-promotion of prescription medications. But there are side effects that we don't know about and only learn about with longer experience. We are not magicians or mind readers.

I do often feel when I read our comments from readers who've had bad experiences with medications or hospitalizations or psychiatrists who say insensitive things, that people feel there is something purposeful about it. It's hard when someone comes in and describes something as a side effect of the medication and I recall that the symptom was there before the medication was even started. With time, we've learned that this can be the case-- if a patient starting an SSRI now says "this medication is making me feel more suicidal," Docs listen. It's still hard when someone says a medicine causes a side effect never described and I don't know what to do with it. Sometimes I try to talk people into staying on their medication if, for example, they complain that a newly added anti-depressant is making them more depressed-- the medicines take time to work, weeks in fact. If a patient continues to complain, eventually I'm left to conclude that this medication either doesn't work or isn't tolerated in this person. Sometimes people complain bitterly about side effects while at the same time they say they feel the medication helps, and then I say: It's up to you. It gets trying when this means that every visit consists of stopping a medication that hasn't been given a fair chance only to begin another medication-- the arsenal of medications available can be run through pretty quickly with this strategy and it doesn't make sense. Okay, I'm rambling.

31 comments:

Doug Bremner (MD) said...

Thanks for the mention. It is a delicate balance between becoming an 'us v them' thing (doctors v patients) and pointing out things that might help people with their own mental journey (e.g. your doctor isn't perfect, your parent wasn't perfect, etc). At the risk of blowing my own horn (still trying to figure out the 'internet etiquette thing; someone should write about THAT) working on a response to this and your facebook post on my web site. Cheers!

Doug Bremner (MD) said...

btw I do not do long term psychotherapy, although I think it is the treatment of choice for mental problems. Therefore I post with my real name. Here is an interesting question. What would be the effect on their patients of psychiatrists doing long term therapy posting on blogs like this with their real name?

David Rochester said...

I think the point the angry people are trying to make, and which you seem to consistently miss, is that there are lots of prescribing docs and therapists out there who do not listen to their clients.

Clearly you don't fall into this category ... although you do seem a little bit defensive about it, so perhaps the topic pushes your buttons for a reason.

Having read quite a few accounts of annoyed psychiatric clients, on and off the web, and having run a support group for people wanting to detox from SSRIs, I've observed a pretty reliable common denominator among clients who are seemingly unreasonably angry. They were not appropriately handled. Their experience was invalidated by the psychiatrist or clinician. They may not have been permanently damaged by the drugs, but they were pretty badly damaged by the uncaring attitudes they encountered.

And yes, that damage does seem "purposeful," insofar as ignorance and lack of ethics are choices caregivers make. Of course some drugs are worth taking despite side effects. And some are not. And we all understand, I believe, that side effects vary wildly from one person to another. That is true of all things, not just psych meds.

But I will say that there is something particularly hurtful and difficult to forgive about people who fail to act appropriately with clients who are already in a highly vulnerable state, and who may have had a lot of trouble asking for help to begin with. This is not an "us vs. them" mentality. This is a simple truth -- when the stakes are highest, the hurtfulness of inappropriate care is greatest. And the fallout of anger is consequently also greater.

Of course people seem disproportionately angry. It's a matter of life or death for many of us. Literally, a matter of life or death. I'm delighted that you, and hopefully most of your colleagues, are not inappropriate caregivers. But you are living in a cotton-wool-shrouded ivory tower if you think there aren't a lot of incompetent and uncaring clinicians out there.

Rather than defending your own standards of practice to your readers, maybe you should be more vocal about those standards amongst your colleagues who fail to live up to your level of care. I guarantee you, there are plenty of them out there.

David Rochester said...

In rereading your post (again), I was struck by your choice of language. According to your post, your clients "complain." They don't "report." I wonder whether they sense the negative affect you perhaps unconsciously attach to their reporting side effects, and perhaps that is why you are a bit defensive on this topic.

Just a thought, which is, I'm sure, grossly presumptuous.

Therapy Patient said...

Right, David! My first psychiatrist, not only did not listen to me, he did not LOOK at me! Somehow he managed to open the door looking down and to the side, then turned his back to me while he went into a walk-in closet to get my file, then he'd sit down and look at his file. I like to make eye-contact with people and found it unnerving, plus I wondered how he'd know if I did not "look" right if he never looked at me. Using courtroom parlance he'd "lead the witness" only to quote back to me at another session words he put in my mouth that did not represent my situation. I am not good at defending my own position and particularly then when I was just released from a hospitalization I was vulnerable to being "run over". This resulted in my feeling misunderstood, misdiagnosed, and in the wrong place.

I also generalized my dislike for him to other "drugs-only" doctors. Certainly the way HE operated was to make an instant diagnosis and prescribe drugs to be taken for life. Return visits were of minuscule length. I think that approach is wrong and expect I will stick to that. I do acknowledge that there may be some more careful, less opinionated, more caring meds-only doctors out there.

My current psychiatrist is completely the opposite, being a psychotherapy specialist with over 40 years experience.

Prynne said...

You write: If a patient starting an SSRI now says "this medication is making me feel more suicidal," Docs listen.

You listen. Some docs listen.

I run into this problem with my own psychiatrist -- an ethical man, and a good doctor. He makes the giant assumption that all doctors are thoughtful and careful, because he is. Uh-uh. And he, too, is prone to statements that begin with, "Doctors don't" and "Doctors are."

There is no single physician overmind. Doctors are just people. Some of them are not all that great at doctoring. I'll try to not confuse you with one of those if you'll not tell me you're all exactly the same.

doug bremner said...

Who said we are all the same? And who said there are not some s**ty psychiatrists out there? I see some of that generalized *rage* coming out here. That said I can understand why people would get pissed when they put their ego/soul out there only to have it abused.

Anonymous said...

David,

I completely agree with what you wrote and am completely stunned that the psychiatrists who have posted don't get it. I realize you can't comment on individual situations but to to deny that there are bad situations or to claim that we want perfection just because you're good doctors is simply insane.

Maybe if psychiatrists put themselves on meds as this doctor did with Wellbutrin, your perspective would change After she suffered horrific side effects and withdrawal symptoms, she is alot more empathetic when her patients complain about side effects:

http://tinyurl.com/5ou35f

Finally, Dr Jay Cohen, who is not antimeds, refers to this story on his website, medsense,

http://tinyurl.com/29pgkv

He talks about one main reason for side effects is that the starting dose is too high.

Well, if you guys listened to the folks who are tapering off of psych meds and have figured out creative ways to slowly lower the dose which result in doses you can't get at your local CVS,, you might learn some things that could be useful in your practices. Instead, you derisively refer to us as amateurs who didn't go to medical school or something similar. I am speaking in general terms as an FYI.

Sadly, you would miss out on information that compound pharmacies are an alternative to mainstream pharmacies for "weird" doses. Also, getting a digital scales and using it to weigh certain drugs helps with those "weird" doses.

I am just very sad and disheartened that this has turned into an either or situation with no dialogue whatsoever.

AA11

Tigermom said...

When a patient reports their not perfect experience with a medication, a pediatrician friend recommended I say, "How important is that to you?"

And sure enough, I realized that my inclination is to fix everything, so when a patient reports a side effect.

Sometimes, they tell me they were just noticing x or y but that it is not important enough for them to change meds mid-trial. Other times, the patine will say, "This is really important to me and I do want to change medications mid-trial.

Lesson learned:
listen first, ask about the importance, then act if appropriate.

doug bremner said...

David,

I am not sure what you are "stunned" about. I am sorry that you had side effects from psychiatric medications and I think it is great that you use a scale to slowly taper your medication. As for doctors not listening to you I am not sure what you mean exactly.

Dinah said...

"Complaints" is routine doctor jargon, it's not meant to have a pejorative edge. All medical notes start with "Patient has no complaints" or "Patient c/o severe headache associated with reading blogs."

It's distressing that people out in cyberspace have had such troubling interactions with their docs and such distressing experiences with hospitalizations.

Note to Doug--somewhere in this mess, I wrote a post about The Blogging Shrink.

doug bremner said...

I guess I was responded to anonymous, sorry.

doug bremner said...

It looks like you have a lot of posts on blogging, Dinah, maybe you could re post the one you are referring to. I liked the one about how you pop up on google with the query about sex with fish. My top hit is 'chiggers' which is a type parasite we have here in the piney woods. I expanded on the topic after a commenter opined about the differences between urban Atlanta and South Georgia.

Anyway sorry to get off topic, but to bring it back to the topic of psychiatry, we could analyze whether my tangential ramblings represent 'flight of ideas', 'loose associations' or 'tangential thinking'.

Might make a nice boards question.

And we could get cme for reading this blog. :)

doug bremner said...

I also liked your post about facebook so I wrote about that today (link provided).

miss mouse said...

these are hard issues, and i don't intend to be fanning the flames....but to me it is about the power differential. you, the prescriber, have the power to give me medication that may ease or erase my pain. you also have the power to "label" me (ie, diagnoses) that may stay with me the rest of my life and become frames that define/limit who I am and how I am perceived and treated by others. You also have the power to have me involuntarily committed to a psychiatric unit, taking away even my civil rights, if I say or do things that you perceive as "crazy", "out of control", "threat to self or others." Do you wonder that I find it difficult to tell you my true experiences? OF COURSE I have issues in interpersonal relationships and in perceiving and responding to others in ways that are outside the usual range of experiences - and I am struggling with my own worth as a person.
When you choose not to shake my hand or to make eye contact with me, what do you think I experience in that moment? If you are honest with me - you don't know for sure this drug or combination will help me, but you think it is worth a try for the reasons you then explain, then I feel we are working together and you are listening and caring. When I tell you what my symptoms are and your response is dismissive, what do you think I experience in that moment?

jcat said...

I seem to be on the other side i.r.o. patient attitudes to this post.

#1. No pdoc that I've heard of actually wants his patient not to get better. They are trying their best to find a solution that works. And if they get constructive feedback, it will happen faster.

#2. As my one pdoc said, if aspirin had been as effective as most psych drugs are today, it would never have reached the market. P-drugs have an incredibly low rate of success, especially when the side effects are taken into account, and that isn't through lack of trying by the meds companies - the first one who comes up with a guaranteed AD with no major side effects would probably become the next world superpower.

#3. I'm not saying there are no bad doctors. Just as there are also bad patients. There is free choice though - if you feel that you and the pdoc you are seeing are not a good match then make a plan. See someone else. If it means going to a different hospital, or increasing your co-pay, or (as most people in this country do) paying it all yourself, then do that. Even if it's hard.

#4. And when you finish telling everyone how bad your doc is and how bad the meds are, look also at whether you actually want to get better. Of the people I know well enough to judge, the ones who complain most about both pdocs and side-effects are the ones who have a vested interest in staying sick.
Not talking about the truly psychotic etc, who seem mostly to be relieved by the s/e's compared to the hell they were going through, but there seem to be quite a few people out there who would rather change meds as soon as there is any improvement and blame it on the doc or the s/e's, just so as they don't have to give up the power they have over their families and friends.

#5. On the other hand, most of the people I know who truly want to get better will put up with most of the s/e's because compared to what life for them has been like, the s/e's (excluding the 1% of patients who really have an adverse reaction) are worth it. So you gain 5kgs or have a tremor or a headache and your sex life goes to hell. Those can be sorted out over time. Being dead can't be....

Dinah said...

I hope everyone is enjoying the lively dialogue.

Doug: I hope I posted a brief comment on your Facebook post!
Here is a link to one of several posts where I've tried to address the blogger psychiatrist/patient issue: http://psychiatrist-blog.blogspot.com/2008/05/its-my-life-ill-blog-if-i-want-to.html

David Rochester: I enjoyed your post and congratulations on the new job. I'm sorry if you didn't want your comment quoted in the body of one of my posts-- I do sort of assume that's okay, please note if I should not.

Prynne said...

Who said we are all the same? And who said there are not some s**ty psychiatrists out there? I see some of that generalized *rage* coming out here.

Since the first two sentences are directed at my comment, I assume the third is also? You read *rage* in my comment? Seriously? Wow. Certainly a bit of frustration, but I assure you, rage looks rather different.

That said I can understand why people would get pissed when they put their ego/soul out there only to have it abused.

Yes. Pissed, and hurt, and further screwed up. And maybe not huge fans of psychiatry. That last doesn't really describe me, however. As I said, the psychiatrist I see is quite good and has been a help to me.

David Rochester said...

Dinah -- It's OK about the comment being used as a post; I was a bit taken aback, as my past experience in bloggerdom has been that people usually ask me before doing that, but I understand (and accept) that anything I post on a blog is out there in public, and the blog owner may do with it as he or she wishes.

jcat -- That's a very interesting observation about psych meds and patients' commitment to getting better. For whatever odd reason, I seem to be in a circle of people who all had bad drug reactions and who therefore decided to get off drugs and pursue serious depth analysis instead, to try to resolve their depression issues, rather than medicating. Thanks for the reminder that there are bad patients, or at least, people who have some attachment to staying stuck.

doug bremner (md) said...

Wow! Lots to comment on here.

First of all, "patients", many shrinks have been in therapy themselves, so don't assume they don't know what it feels like to be a crumb on the carpet of the mighty shrink's office! That said I don't think they should share their therapeutic experiences with you. TRANSFERENCE is a mighty thing, and can be a tool to aid in progression, although it can make you feel like sh*t at times, and sometimes for extended periods of time.

Good shrinks don't act like a door mat, and *say* things and their opinions sometimes. I *don't* think they should talk about their patients and *do* think they should be a repository of confidences. Finding the appropriate balance is the key. Freud never acted like an *analytic screen*, it is only the goofy American shrinks that started acting like that.

What else. Confidential posts. I have been going through an online argument about quoting someone who wrote in a yahoo group. About something totally benign. She has now added a copyright notice to her emails, which makes me not interested in interacting on that site anymore. I think that kills the discussion. Don't post on shrink rap if you don't want people to read it. If you want to be confidential make an appointment with Dinah. Or write anonymously.

I admire Dinah and all for writing about these things. I write under my real name cuz I don't do long term therapy. However everyone gets 'outed' sooner or later in my opinion.

What else. There definitely is an internet subculture of people upset about psychiatric meds. Part of this is based on reality, part is transference.

Fire at will.

doug bremner (md) said...

Oops! I had wanted to leave a link to my relevant post with my name tag but typed it in wrong. Here it is.

http://www.beforeyoutakethatpill.com/2008/11/facebook.html

doug bremner (md) said...

btw could you ask Roy to send me an email, jamesdouglasbremner@yahoo.com, I want to ask him something.

David Rochester said...

Doug -- perhaps you missed the part of my comment in which I said (and I quote myself, here) I understand (and accept) that anything I post on a blog is out there in public, and the blog owner may do with it as he or she wishes.

I was simply surprised at my comment having become a new post topic without running it by me first. I didn't say Dinah had done anything wrong; I simply said I was accustomed to a different etiquette. That is, of course, an issue of my own expectations, and nothing to do with Dinah.

RE: the "Internet subculture" -- I believe we also exist in real life. At least, I am under the impression that I have corporeal and intellectual reality that is not connected with the Internet, and that in this reality, I have the same opinions that I express on the Internet. I suppose it may be convenient to relegate an obnoxious group of folks to an "Internet subculture" -- but it seems unnecessarily dismissive.

I think I missed the parts of the posts here that suggested a psychiatrist should be a doormat who talks about his or her own therapeutic experiences, or talks about other patients. I'm under the impression that those of us who have problems with the system have had problems with psychiatrists who do not listen to us when we try to be honest with them. I am not aware of anyone who wants a psych doctor who is a pushover, or who makes inappropriate self-disclosure.

I don't know at what point you hopped into the loop here, Doug, but this discussion was started on another post by my leaving a comment explaining why I didn't tell my psychiatrist about a disturbing medication side effect. I didn't tell her because all of my previous reports of disturbing side effects had been dismissed by her as having nothing to do with the medication. This was not transference. This was not me resisting therapy. This was me having a side effect of such severity that a neurologist ended up doing an MRI to make sure I didn't have a brain tumor.

Two subsequent meds docs also denied that the meds could be causing the side effects I was having.

So yes, I'm pretty upset about the whole thing, and I think many of us in the Internet subculture are upset for similar reasons. We have reason to hope that the doc is the expert, and when client trust is abused by a psychiatrist or clinician who refuses to take the client seriously, that causes a lot of anger.

Midwife with a Knife said...

I keep debating about this comment, but I decided to go with it....

Through a tragic obstetric misadventure, (the details of which I won't go into because I already did in a comment here once, and they're long) I ended up seeing a psychiatrist (at the insistence of my friends and my primary care doc) soon after starting my fellowship. I was really suffering, and thinking about quitting my fellowship (not the best adjustment to a new job, I suppose) and making other bad decisions.

I have to say, my shrink was never anything but kind, and she actually specifically inquired about side effects (like sexual dysfunction) with the SSRI she started (or suggested?) which I may not have wanted to complain about. By asking, she sent the message that it's ok to complain (?report?) these things. She even realized I was having an episode of depression before I realized that was going on.

Overall, I have nothing but praise for my shrink. She's been a good doctor. I should tell her that sometime, but I don't see her again until Februrary, and chances are, I'll forget.

nardilfan said...

I wonder if perhaps some of the frustration patients experience is caused by feeling that because the doc can't see symptoms, they take them less seriously than they would side-effects that they can objectively measure. Which might mean that they think the doc doesn't believe them or thinks that the symptom is not important.

What I mean is that even though both tachycardia and nausea could either be caused by the medication or be coincidental, doctors seem to be more likely, in my experience, to directly link observable signs like tachycardia to medications than they would reported symptoms like nausea. (Sorry, very long sentence - can't work out how to split it up and have it still make sense).

Also, I personally have felt in the past that some docs are more likely to agree that stopping the drug is a good idea if they can actually see (hear, smell, etc.) the side-effect than if they can't.

I don't know whether the possibility that the patient is lying comes into it, or the feeling that something you can observe is more likely to be a serious side-effect than something you can't.

Maybe I'm wrong, and most docs don't do this (it's just me being weird!) or maybe you do behave like this but there's a good reason for it. I dunno @=-)

Roy said...

So many things here, so I'll just put out random utterances...

Welcome, to Doug and David. Kinda new on our block.

I usually interpret statements that begin "Doctors are..." to mean "Some (or many or most) doctors are..." because, of course, no group is a monolith it should be understood that "always" and "never" words are not intended.

Yeah, there are good and bad doctors just like everything else. And, often, one person's bad doctor is another one's good doctor. I've met pts who complain (and I do mean to say "complain" here) about doctors who tell them too much about possible side effects and others who complain about not hearing enough (hint: read the package insert the pharmacist gives you, circle the things you want to know more about, then bring it to your doc and ask). Some like docs who disclose and others don't. Everyone lies somewhere on a bell curve.

@prynne: I thought it was because someone else mentioned "rage" in their comment.

@mouse: the power differential... we wrote about that before several times... I guess search our blog for "power"... note that this search only finds words in our posts, not in the comments (I think). While I don't disagree, I do take issue with the concept that there must be this great power imbalance in the dr-pt relationship. This is not a power I enjoy, and I do what I can to give it back. "You need to tell me if you experience something unusual or unexpected." Listening... caring... communicating empathy and unconditional acceptance... these things help to balance out the power and control.

I'm really trying to get the three of us together this? weekend to do a podcast (and maybe some Risk?). Lately, one of us (nudge, nudge) has been spending every spare hour dangling from a rock or a hard place. Maybe we should go to doing BlogTalkRadio pieces instead? Then, we could do them without having to be in the same place, and folks could listen and participate live.

doug said...

Nice comments, Roy

Gianna said...

Doug,
you're really starting to be rather humorous in how deeply personally you took my desire to be asked permission to post a private email, on your blog even while telling you it was okay that you posted what you posted....what's the problem? Why is it so hard to understand that it's a courteous thing to do??

Ask your friends Dinah and Roy if they would publish a private email sent to them by one of their readers without permission...because that is what happened to me the first time my privacy was violated.

What you did was MINOR...I didn't even care...I just thought you should know that in general people ask permission...yeah there is and etiquette out here and, so what??...why are you so personally affronted by a simple request that in the future you ask me permission before publishing something I wrote in a private forum??

doug bremner said...

Gianna,

I am not personally affronted. And I don't care that much about it either. I do think it is misleading to describe it as a private email since it was a listserve yahoo group. I have already apologized to you for it not knowing that the group was 'private', although 300 members is not that private.

a psychiatrist who learned from veterans said...

I think the hardest thing in learning medicine is comprehending that there is not a unitary outcome. In pharmacology, the doctor to be learns the mechanism of efficacy. He/she should really learn how to find the side effects as well or even that bad can come with the good.

Case example, I was called, on the medicine service, to consult on a patient with abdominal pain, right upper quadrant. As a 'medical explanation' wasn't found in radiology or endoscopy, the docs concluded that they'd come to a spook problem and a spook drug like Cymbalta was called for for the unknwowable Freudian secret. This turned out to be potentially a tragedy of the possible hypothesis. I reviewed her drugs on Micromedex; Lamictal had a 16% incidence of abdominal pain and the pain went away when I stopped lamictal. some patients get 'the minor statistical effect, a 'side effect,' rather than the main effect which leads to a drug indication.

Anonymous said...

The day the blog ate itself.