ask them about their lives…

Posted on Friday 23 September 2011

    Can my friend call you to talk about her son? They’re wanting to put him on a drug he’s been addicted to.
      He is in his mid twenties. He had always been a sensitive, mopey child – anxious and easily hurt. In high school, he’d gotten into drugs which escalated  in and beyond college and he became addicted to heroin among other things. He’d been through a long drug treatment program and was now clean and in aftercare. His symptoms were chronic depression and anxiety, recently escalating to the point where he didn’t want to go out. He had, however, made friends in his treatment community and was going on hikes with several groups. He can’t date because of his anxiety. He has been diagnosed as Bipolar. He’s on Depakote, Pristiq, and Abilify. Because of his recent anxiety, they’ve added Buspar, but it’s not working.
      He had one manic episode in the past. He was agitated and couldn’t sleep for ten days. It happened when he was put on a new antidepressant and stopped when they stopped it. He wasn’t euphoric, just agitated. Now, his therapist wants to try "anxiety" therapy using Klonopin. That’s one of the drugs he was addicted to. We’ve talked to his psychiatrist about it, but I’m worried.
I find such calls awkward, but have learned how to talk in a way that doesn’t undermine whoever is doing the treating [not easy]. The lady on the phone was pretty smart and seemed genuinely worried about her son and the Klonopin. I agreed with her that I would be worried too. I told her that the manic episode didn’t sound like mania to me, more like akisthisia from that new antidepressant. She said she had thought that herself. I told her that Buspar wasn’t a powerful drug, and that if it helped, it usually only helped some. As we talked, it sounded like the escalation in anxiety was recent to me, acute. So I asked her to tell me some more.
    What did he study in college? What does he do now?
      His degree is in psychology. Since getting out of treatment, he’d worked with us [parents] in our landscaping business, but he’d became depressed about not having any career direction in his life, so he got a job. He tried it full time, but it was too much, so he’s half time now.
      He works in a school for Autistic children. They’ve got two teachers for every kid. He’s the one that holds the kids down when the get out of control. He says they scream all day…
I won’t go on. She told me that he was a wreck when he came home from work. As we talked, she got the wind of where I was heading – that maybe wrestling with Autistic kids had something to do with his increased anxiety. She confirmed that the timing of the recent anxiety burst fit with taking this job. There’s a place in a conversation like this one where you can tell you’ve done what you can do, and we both seemed to know we’d gotten there. She had something she could work with, and that’s all she really wanted. Well, actually, she wanted to hire me. I did my I’m just an old retired man living in the woods routine.

Connecting his current anxiety to his new job isn’t the end of anything – more like a starting place. But I’m sure it’s true, and an essential piece. She thought so too. My point is, that’s not rocket science. It’s interviewing 101. And I hear it all the time. I hear Depakote/Pristiq/Abilify/Buspar/+Klonopin all the time too. Symptom chasing, I call it. Argh! And Bipolar? mania for 10 days? from an antidepressant? Argh! I think it’s that kind of thing that keeps me writing this blog and riled up all the time. I fantasize an article in the American Journal of Psychiatry entitled "Ask them about their lives!" Psychiatrists give drugs. Therapists apply therapies. Who the hell interviews patients beyond logging in a symptom list? I’m being dead serious about that…

I wrote the post above and it made me feel better. It usually does help me clear my mind to write about it when something like that happens. Often, I don’t even publish the post. But I was about to push "publish" with this one, and then I thought of something. So I put the psychiatrist’s name into the ProPublica Dollars for Docs database. Then I didn’t feel better anymore…


    Ga. Eli Lilly 2011 Q1 Speaking $3,000
Ga. Eli Lilly 2010 Q1-Q4 Speaking $18,900
Ga. Eli Lilly 2010 Q1-Q4 Travel $529
Ga. Eli Lilly 2010 Q1-Q4 Consulting $1,500
Ga. Eli Lilly 2009 Q1-Q4 Speaking $23,400
Ga. Novartis 2010 Q4 Speaking $1,500
Ga. Pfizer 2009 Q3-Q4 Speaking $1,000
Ga. Pfizer 2010 Q1-Q4 Travel $820
Ga. Pfizer 2010 Q1-Q4 Meals $742
Ga. Pfizer 2010 Q1-Q4 Speaking $7,500
Ga. Pfizer 2011 Q1 Meals $301
Ga. AstraZeneca 2010 Q1-Q4 Speaking $6,900
Ga. Cephalon 2011 Q1-Q2 Travel $1,766
Ga. Cephalon 2011 Q1-Q2 Consulting $1,875
Ga. Cephalon 2011 Q1-Q2 Speaking $1,300
    September 23, 2011 | 2:12 PM

    $23.4K for speaking???? Looks like I went and stood in the wrong line, Mickey!

    Seriously, why not erase the second half of the post and make like you only wrote the first part? Wouldn’t that make you feel better?

    You should feel good about approaching distressed people as people, not as collections of phenomenologies, or as objects of therapy.

    I’ve suspected for some time that the medicalization of human suffering is made worse by virtue of the fact that people who claim sole ownership of the suffering franchise go to medical school. Thoughts?

    September 23, 2011 | 7:52 PM

    I don’t feel better anymore either. I am so sorry.

    September 24, 2011 | 7:55 AM

    “…why not erase the second half of the post and make like you only wrote the first part? Wouldn’t that make you feel better?”

    I don’t think so. I looked at some of those doctor rating sites on this doctor. Some were scathing. Others were glowing. The latter mostly said he was nice to them. That’s what this woman said too – “nice.” Somehow, being “nice” to a recovering addict while putting him on four psychoactive medication, contemplating adding a fifth drug that he’s been addicted to doesn’t seem “nice” to me. I think the way I’d feel better is if that kind of thing didn’t happen.

    “medicalization of human suffering”

    I think we’ve had our say about the Szasz-ian aspects of that topic. But I do have an opinion about “medicalization” itself. The 1980 revision of psychiatry insisted on “medicalization.” Prior to that, there seemed to me to be “medical suffering” – those dramatic mental illnesses like Schizophrenia and Manic Depressive Illness that did fit the “medical model” like other diseases of unknown etiology – and “human suffering” of the non-medical kind. Since then, “medicalization” has been universal – which borders on the absurd. The case in point in this post is a person unknown to me in person, but from what I heard, I’m not sure I hear “medical” in the mix. While he may be helped a bit with “medicine,” it would be symptomatic at best. To call him “bipolar” implies otherwise and results in Depakote + Abilify. To call him Depressed gets him Pristiq. Anxious calls out Buspar+ Klonopin. Were he to mention being inattentive, I expect he’d get Adderall. If that’s what you mean by the “medicalization of human suffering,” we’re on the same page. This person has already tried “medicalization” of his suffering with Heroin and other drugs to no avail…

    September 24, 2011 | 2:29 PM

    Psychiatrists don’t ask people about their lives because they know there’s nothing they can do about it. Given this young man’s temperament, history, and current circumstances, does psychiatry really have anything to offer him other a controlled version of his previous illicit drug use? No.

    September 24, 2011 | 2:41 PM

    I think it’s high time for the creation of an alternative Board of Psychiatry.

    Seriously. I received my board certification a few years ago and hate to say that the actual exam was a joke. It was rigorous from the perspective of testing whether or not I could think flexibly, thoroughly, and safely on a superficial level, but it did not test or care about Mickey’s Interviewing 101, because, well, that would undermine the tester’s ability to find out if I would remember to ask about family history and screen for a handful of diagnoses, or a couple of dozen other aspects of an interview. Had I had Mickey’s acquaintance’s son as my board interview patient and began taking a bit too much of my allotted 30 minutes asking details about this guy’s job beyond what it is, or spending too much time trying to really determine whether or not this is bipolar disorder or akithisia or a substance-induced mood/anxiety disorder, etc, well I probably would have failed. Had I not done this and “covered all the bases” superficially to show some sort of competence, I would have played the game well and maybe passed, but the truth of the patient’s situation would have been missed and all of us in the room may have been none the wiser — the true clinical situation won’t reveal itself without the right questions being asked.

    Of course, the ABPN is doing away with the patient interview part of the boards. It will all be multiple choice, now. This is just an extension of the problem– increased alienation of the patient from the test, the clinical situation, etc. What the ABPN tests doesn’t require understanding a person at all.

    rob lindeman
    September 24, 2011 | 3:39 PM

    That is indeed what I mean by ‘medicalization of human suffering’.

    In the kid world, where I toil every day, medicalization of normal childhood behavior is the rule. Just when you think it can’t get worse, it does.

    September 25, 2011 | 2:13 PM

    Oh, this is so painful to read, the overmedicalization of a young person with the probability of even more. And unraveling the drug damage when tapering off — he has many years of drug hell ahead of him.

    So many young people are being medicated now — Medco pharmacy-benefit statistics show more than a quarter of U.S. children and teens now take psychiatric drugs regularly — I call this the Med Generation.

    When these people find out how they’ve been betrayed by medicine and their youths sold to pharma, it won’t be a pretty sight. Good psychiatrists as well as bad will be tarred with the same brush. I urge the good doctors out there (you know who you are) to stand up NOW — millions of lives are literally at stake.

    Thank you, as ever, for your posts, Dr. Mickey.

    September 25, 2011 | 2:27 PM

    I’d call her back and give her the heads up on that doctor’s bio and conflict of interest with the assorted drug cos he’s getting income from…which by the way is easy to find him in that database….

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