worthy of respect…

Posted on Tuesday 28 February 2012

8:00 AM 
    I was getting ready to leave for the clinic and my wife was playing the phone messages from the day before. One was from one of my oldest friends, a psychiatrist/analyst, returning a call, "Sorry I missed your call. I’m in my office catching up on my pharmacy calls. I don’t practice medicine anymore, I practice pharmacy! The back number is …"
8:15 AM 
    On the way to the clinic I recalled something this same friend quipped last year, "People don’t want psychotherapy anymore. They just want meds"…
10:00 AM
    "My Lexapro isn’t working any more…I was on Lexapro 30mg, Xanax 1 mg four times a day, Seroquel 250mg at bedtime…I’m Bipolar and Anxiety Disorder… When lost my insurance I had to stop the Seroquel and the Xanax…"

    "What happened when you stopped?" I asked…
I expect you know the answer she gave about withdrawing from those two particular medications at the same time. It wasn’t pretty. The way it actually worked – the insurance she lost was coverage from her ex-husband… which is why the Xanax and Seroquel ran out and the withdrawal symptoms [I think from the Seroquel] kept her home for a few days… which is how she lost her job… which is why she and her two kids moved back in with her parents… which put her back in close proximity with her mother… which is what was wrong in the first place – not Lexapro running out of juice.

I doubt my blogging about all this medication madness has done much about the fate of American psychiatry, but it has certainly made me a more informed clinic doctor. I would never have known to ask about Seroquel withdrawal [having never prescribed it or been told about that particular symptom]. As long as I’m on this specific case, the diagnosis of "Bipolar" was made around the time of her divorce when she felt "down." I thought maybe that might have been a mistaking of grief for depression, but that wasn’t actually it – she was glad to get out of the marriage. But when she divorced, she and her kids had moved back in with her parents. You guessed it, home again with mother was probably the reason for the "down" that lead to the Bipolar diagnosis in the first place, and then the medications. As a matter of fact, home with mother may well have had to do with a premature not-so-hot marriage in the first place to get away from home.

I guess I think of such cases as "circle of life" cases – where a problem leads to a solution, which itself sooner or later becomes the next problem needing a solution, et cetera, et cetera, and go round and round and round the circle again. This lady was not Manic Depressive by any measure. She was actually resourceful and pretty quick-minded. She "got it" as we made these connections. She left with a prescription for Vistaril – an ancient little-bit-of-an-anti-anxiety drug. She’s got a new job and I’d bet she’ll be leaving her parent’s house pretty soon. She is also [wouldn’t you know it] having some sexual side effects from the Lexapro and that’s a problem she didn’t know was probably medication related. We agreed to think about tapering it as soon as she gets her living situation squared away – "Now’s not the time," she said with an if-you-met-my-mother-you’d-understand look.

I also see cases in the clinic where the medications actually help people – where the anti-depressants work, where the undiagnosed childhood ADHD responds to medication. But I see way too many cases like this one where medications actually interfere, or complicate, or do nothing. And I see some where they are a disaster. Today, it was about 50-50 in the morning. In the afternoon, it’s a child-adolescent clinic, and things are more optimistic. I see cases followed by good clinicians. A lot are collaborative diagnosis consults. The rest are people I’ve seen from the start, so if there’s a medication tangle, it was something I did and so far, knock-on-wood, there aren’t many. But the comment from my old partner and friend on the answering machine haunted me throughout the day. Actually, it wasn’t the taped message itself ["I don’t practice medicine anymore, I practice pharmacy!"], it was the reminder of what she had said before, "People don’t want psychotherapy anymore. They just want meds."

I think many would hear that in a different way than I did. They might hear something like "See, that psychotherapy stuff doesn’t work … was a waste of time…" or maybe  "wasn’t cost effective…" That’s not the way I heard it, at least not the way it replayed in my mind today. Patients usually present because they feel "bad," some kind of "bad." And of course they want to feel "good," or at least not "bad" or maybe less "bad." There’s nothing wrong with that. Who wouldn’t? But there are plenty of situations where the bad feeling is a signal that something is very not right, something in life, something in a relationship, something in the mind. Using medications to feel "less bad" – even if it works – can lead to people staying in some really dreadful situations either external or internal. The thing that haunted me today is that I think my friend is right. I think the modern milieu of psychopharmacology and managed care has created a population of patients that expects or feels entitled to "feel better." And medications and faux diagnoses ["Bipolar" in the case above] actually deflect the whole point of emotional life – guidance, emotional guidance.

When the system is working right, emotions are the gyroscope, the compass, that keeps us on course – including many of the dysphoric ones. There are plenty of diseases that throw the system out of whack – the traditional psychiatric disorders – things like Melancholia and Schizophrenia. There are acquired problems, things like personality disorders, PTSD, etc. that themselves disrupt the system in global ways. But, in my experience, the majority of people who wandered into my office are people where the system isn’t the problem. The signals from the system are right, they’re just not being heard, or are misunderstood, or are ignored. I’ve always seen my job as figuring out about that. Is it the message from the system that’s haywire or is the problem in the receiver?

I think that my partner was correct. The focus on medications for bad feelings that’s in the clinical trials, the DSM-whichever, the ads on television, the way insurance has directed mental health care, the articles in our journals has had a culturally damaging effect – not so much the "feel good" generation eg drug culture [though that may be part of this], but more the automatic focus on how-one-feels as the central problem. Patients these days seem more in the "what do you have to make me feel better?" mode than the "I feel bad can you help me?" mode. I don’t like thinking that because it feels a bit like blaming the victim, but it’s what I feel none the less.

So back to that 10:00 lady I started with. The case has been changed around some to disguise her identity, but the essence of things is accurate. The reason she stood out in my mind is because of how she wasn’t. She came in talking like a disease that needed a tune up. But she was easily engaged in looking at things differently and quickly joined in the process of parsing out the story [the "I feel bad can you help me?" mode]. The pieces about her relationship with her mother seemed like little light bulbs. I don’t think she had really ever connected jumping into a marriage to get free, the "down" when she moved back in after her divorce, and the recent "lexapro isn’t working" down having moved back home as all related with each other as part of her narrative. I don’t know what the problems are between she and her mom, only that they are significant – and I’d bet money she’ll have something to say about that later.

We talk a lot in these blogs about the problems psychoactive medications can cause, and rarely discuss when they can help [which really is "sometimes"]. What we don’t talk about is how this hyper-chemical viewpoint might be interfering with how people see the most basic "compass-like" functions of emotional life. In this case, "I’m Bipolar and Anxiety Disorder" would never ever help her. There’s a lot more mileage in "Whenever I’m with my mother, I get down" followed by "I wonder what that‘s about?" The larger point, obviously, is that the pathologizing of negative emotions seems to me to have had a negative effect culture-wide, independent of any down-side of medications themselves. We didn’t spend all the eons evolving or getting created to have a system as complex as the capacity to feel "bad" only to see it as something to shut down. It has a central and important function – worthy of respect…
When you’re lost at sea in a submarine, you don’t turn off the sonar…
    February 29, 2012 | 8:27 AM

    “how this hyper-chemical viewpoint might be interfering with how people see the most basic “compass-like” functions of emotional life”
    Absolutely so. Great point, well made. Huge iatrogenic effect of DSM-related depression as disease assumptions. Struggling with mood worsening life problems.
    I strongly recommend you check out truly excellent “The Mindfulness and Acceptance Workbook for Depression” from which comes… “an important feature of depression behaviors: They’re mainly short-term strategies that lead you to avoid or escape from emotionally charged situations that, for any number of reasons, you’ve decided are too hot to handle. Th e numbness and sense of detachment from life that characterize depression double as a protective shield. When you’re depressed, your emotional world shrinks in scope, allowing you to avoid potentially painful life situations. Th is isn’t something you’re doing on purpose; it’s the result of falling into a trap in which you trade dealing with your issues for keeping your mood in check. Unfortunately, this robs you of the will to address challenging situations, and those situations can and do worsen over time.”
    Btw the first chapters in this opened my eyes to the “different” aspect of “melancholia” in a way you might find really interesting. Book available via Amazon in kindle or New Harbinger in pdf / epub. I have no vested interest, just reckon it’s great in helping really understand the function of depression and also in debunking many current mythologies about causations and treatments.

    February 29, 2012 | 11:28 AM

    “sometimes drugs help”…I’m quite sure that in those few & rare extreme cases; when drugs are prescribed for a short duration or as an emergency intervention; that this statement can be considered a truism…but when a person walks into a medical professionals office with life problems….do we tell them that the drugs are like playing Russian roulette…They might help…Maybe…or they may cause many more problems than they treat…in fact, they may actually cause serious life threatening problems physically & psychologically…and do we tell them the truth; That doctors don’t have crystal balls & that most likely the life problems they are wrestling with will pass in time without any chemical intervention at all…as with these drug interventions or making major constructive changes to one’s life…it’s about what hard informed and wise choices to act upon…not hiding, covering them up, or running from them…

    I really believe we are doing patients a disservice by chemically masking the discomfort and pain that is a natural and important part of life…it really comes down to the social-ital brain washing machine regulating what emotions are acceptable and what ones are not….pain, sadness, anger, discomfort many times are the very basic catalyst for change…if we continue to chemically mask and devalue humane emotions….we are not treating people or their life situations with compassion, rationally, with professionalism, or acting in their best interest…

    medicine has some how taken on the role of social police & corporate propaganda marketing machine which acts as a non-beneficial crutch that neither serves the patients best long term outcome or their overall health. It certainly isn’t doing our society and culture as a whole any good.

    Mind Medicine has to stop making excuses while using half baked defenses of “Sometimes it works” or “in this situation it’s appropriate” while continuing to muddle around in the grey zone of dangerous innuendo that keeps this grotesque failing & atrocious paradigm on life support; while continuing as the dominant force & accepted norm in medicine.

    Please ask this simple question…if these myriad of psychotropic drugs & the untold billions that have been vested in them had never been introduced into the market place & as a medical option….would patients and society be healthier & better off?

    I believe the answer to that question is undeniably YES!

    Medicine & doctors really need to ask themselves if they are living up to even the most basic standards of their professional and ethical oath…”First Do No Harm”.

    No one is forcing any doctors hand when they are writing a script for this or that…but those dark forces of influence exerts control still with “this is the accepted norm & expected” or “patients are asking for them” or “there are no other viable or affordable options available” or “what will my peers think” or “I don’t want to cause a ruckus”.

    That to me doesn’t sound like real medicine; it’s more like playing a role in a scheme…so what does it matter?….for all the training, education & experience!…first, do no WHAT?

    February 29, 2012 | 2:20 PM

    Withdrawing from 4 mg/day Xanax has really got to hurt, plus Seroquel withdrawal!? This lady is lucky she only missed “a few days of work”: typically, she’d have ended up on a psych. ward diagnosed with “agitated depression” or “mixed mania”.

    Joel Hassman, MD
    February 29, 2012 | 3:25 PM

    Cue the ballpark announcer: “high fly ball, deep centerfield, and, it’s gone!!!”

    Yet, the damage is done. Check out Dr Pies’ most recent piece at http://www.psychcentral.com/blog re his latest defense of grief in the depression category. So lame and lost to me. Yet these guys are the KOLs to the public defending this bs PR agenda.

    Joel Hassman, MD
    February 29, 2012 | 3:31 PM

    By the way, to give my opinion to Stan’s above comment re would things be better without meds, I say no for two reasons: the Internet and the fact that medications do help people who are truly ill.

    February 29, 2012 | 4:44 PM

    I love this blog. As a psychiatric social worker, I saw all kinds of drug cocktails given to patients in a state hospital and a community clinic which basically just quieted them down.

    However, when we moved to San Antonio, TX, I became a research associate in a project through the UTSA med school which involved testing Zoloft on old folks. This was in the 1990s. I won’t make any comments on the purity of the research effort, but I will say that, some of the subjects really responded positively to the medication. As a life-long depression and anxiety sufferer, I was truly impressed. I had in the past been hospitalized where I was, put on Mellaril and one of the old tricyclics. I felt terrible. First I stopped the Mellaril and managed to wake up, then after about six months, the tricyclic. The depression returned. I don’t think anyone would challenge that I suffered from long periods of really major depression and anxiety. I had a wonderful an extremely patient therapist who worked very hard with me so I couldo understand environmental stuff (family background, etc.) and to learn the techniques of cognitive and then cognitive-behavioral therapy and live without meication. However, depression lurked and often enough invaded my being so completely that I could not find the wherewithall to use what I had been taught except to get myself through the very basic tasks I had to do as a single workin mom.

    I went to my internist and told him this story. He put me on Zoloft. It worked well after a period of adjustment. I ended up on 75 mgm daily after a high of, if I remember, 250 mgm. I kept reading horror stories about SSRIs etc and tried by myself to cut back and cut it off and eventually it stopped working. After an environmentally challenging year, major depression attacked and became unremitting. I now take Effexor, 150 mgm daily. I really think it has saved my life.

    I think we have to stop with the black and white approach. The crimes lie in doctoring research and in way overselling the product, but not in the notion that medicines can and do also save lives. The issue should not be medicine bad therapy good or vice versa. I have benefitted a great deal from both. There are horror stories about therapy as well as about medicines and certainly there are a gazillion lousy therapists, whatever their field (I definitely would include some psychiatrists I’ve come in contact with an would definitely say it isn’t necessarily the degree that makes for an effective therapist) but rather how we can get pharmaceuticial comanies and those who earn money from them to clean up their act and how we can truly evaluate therapists and therapy. And how can we do research which will allow for the use of both medicine and therapy on an individualized basis.

    February 29, 2012 | 5:16 PM

    Dear Joel:

    NO? 1. you may want to explain & justify the “Internet” part of your response for everyone …and 2. the supposed “FACT” that medications help/treat some patients is really hilarious; since we don’t even know with any definitive or accurate scientific measurement that can fulfill the burden of proof to exactly what is being treating in those labeled truly mentally ill.

    We do know that now is that we get poor long term outcome, decreased remission, & decreased life span for those given these drugs. In Fact; in the cultures than do not use chemical interventions, people recover at a much higher rate and for longer duration.

    In Fact, with the explosion in the use of psychiatric labeling & psychotropic drug use among the general population, there is absolutely zero doubt that far more harm than good has been done since the introduction of these drugs to medicine.

    What we have in FACT; is a modality that is using a dangerous chemical straight jacket shot gun approach to treat mere behavioral symptoms: and for something that cannot be categorized or proved to be of biological origin or physiological in nature.

    Of course I can understand a Psychiatrist stepping up to defend the so called modern day false profession; being as the vast majority of your colleagues and yourself have become nothing more than prescription writers that would be left obsolete and unemployed if or when the public and society ever wakes up to this colossal con job that has been propagated against them.

    Heck, as it stands now…one could realistically train the average monkey to do pretty much what most psychiatrist actually do in practice each day….just print up a bunch of scripts, place them in a hat, and have the monkey pull out one of those one size fits all drugs when the patient drops in.

    Have nice day 🙂

    February 29, 2012 | 6:37 PM

    Dear Esther Klein Buddenhagen:

    You stated: “After an environmentally challenging year, major depression attacked and became unremitting. I now take Effexor, 150 mgm daily. I really think it has saved my life.”

    or did it…? you seem to believe it did…maybe a placebo effect…who knows..

    Though you have stated that you have delved into the root causes of this unsettled state through talk therapy; and now have turned to a chemical black & white solution.

    Have you asked or investigated into how the drugs actually work, what it’s going to do to create a fix, and what the risk are related to it’s use going forward…

    Do you or your doctor believe that you have some kind of chemical imbalance that needs repair…an ongoing brain disease…that some kind of depression virus attacked you…or that you have some form of genetic predisposition that these drugs can some how fix…?

    I would be very interested in you showing everyone exactly what these drugs are supposedly fixing with this unspecified externally derived malady: and maybe exactly how the process works and how it is to be measured.

    If your choosing to take a drug…wouldn’t you want to know exactly what it’s supposedly to be fixing…have you asked why the Zoloft doesn’t work now…and magically the Effexor is working…are they targeting your neuro-pathway using a different mechanism to stimulate and control your serotonin levels…?

    From what you have shared…you have had some had some burdensome outside influences…or environmental challenges that effected you negatively & emotionally…as in feeling depressed!

    So instead of confronting the root causes…it appears you are looking for this emotional & situational fix through internal chemical alteration…which quite honestly doesn’t make a whole lot of common sense or does it seem a rational solution to me personally…way…way..to black or white or hocus-pocus for my taste; especially without the real verifiable science to back up those highly touted claims?

    Heck, a bottle of good scotch, a cigar, a laugh with some friends, or even a baseball bat to the head will alter your brain chemistry and probably bring temporary relieve to a myriad of emotional states…….but then we don’t call them medicine or write prescriptions for their use… 🙂

    Joel Hassman, MD
    February 29, 2012 | 6:43 PM

    I’m sorry you feel your opinion trumps mine. I have my experiences, you have yours, and others have the right to pursue their own. Rigid extreme views do not help those looking for dialogue. Thank you for illustrating one example of how the Internet does not consistently aid mental health matters.

    Joel Hassman, MD
    February 29, 2012 | 6:51 PM

    By the way, I credit you for using your name. Anonymous at mental health sites is now synonymous for antipsychiatry bashing without boundaries.

    Exhibit A for readers, google Shrink Rap for the psychiatry blog, archive to about 3-4 weeks ago, jan 30 I think to Dinah Miller’s post per being harassed mercilessly by commenters, and you the readers judge my interpretation.

    You going to attack that opinion too, Stan?

    February 29, 2012 | 6:59 PM

    Dear Esther:

    Where are all these “saved lives” you speak of?
    There has certainly been no reduction in suicide rates in spite of the massive drugging of the population in this country.
    Or did you mean to imply that the quality of life of a person on drugs is improved to such a level…
    If so, where are those numbers?


    February 29, 2012 | 7:00 PM

    This reminds me of the old days, Dr. Hassman, where your comments begin to respond to particular commenter names. I was hoping that wouldn’t re-visit itself.

    February 29, 2012 | 7:03 PM

    PS- I recall Dr Hassman declaring a self-banning from Furious Seasons comment section as a self-imposed silencing of his admitted internet addiction, it became quite interesting to see Dr Hassman go after people with certain names (the ‘S’ crowd he called them) and yet would leave them alone if they came in under a different alias.

    February 29, 2012 | 7:07 PM

    Jeol aka “therapy first”…who hid, bashed, and attacked as a Dr. anonymously; while being an admitted unraveling internet addict has those true colors revealed once again…That huge ego is a beautiful thing to behold by the way….who’s the extremest here by the way Mr. prescribing psychiatrist…lol

    Joel Hassman, MD
    February 29, 2012 | 8:47 PM

    Again, thanks for validating my opinion. Per your logic with psych meds, with 10% of the population allergic to penicillin, let’s ban it! I’m sorry people have had negative experiences with psychiatry, but bashing the whole profession as some commenters have repeatedly in my travels is just lame. I openly am unhappy with my profession, but what some of your “peers” have written at mental health blogs over the years, my above reference of exhibit A as recent example, is validation I hope readers read and learn. Hey, that is my opinion, but attacking someone for not agreeing with others is not dialogue, but just extremist rhetoric.

    And where is Furious Seasons today?

    Joel Hassman, MD
    February 29, 2012 | 8:51 PM

    And by the way Stephany, really disappointing as soon as I don’t echo your position, thank yous become basically F— yous

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