therapeutic trials…

Posted on Saturday 8 August 2015

My first real medical specialty was Rheumatology. I trained at a place that had a strong section, and they spent a lot of time with the trainees – high standards all around. Rheumatology was [and is] an unusual medical specialty. There are more than the usual number of diseases of unknown etiology; fewer cases with classic presentations [a lot of overlap among syndromes]; a lot of mystery about etiology and pathophysiology [mechanisms]; and biological markers with only statistical specificity [not sure things]. I suppose if I’d thought about it, it wouldn’t have been a half-bad prequel to psychiatry, where all of those things are even more true [like I said in the last post, I must be drawn to mystery and ambiguity].

That same fuzziness surrounded treatments. There was almost no disease specificity, some situation where this diagnosis leads to this drug. In a patient with Rheumatoid Arthritis, developing a "hot joint" might be a call for an anti-inflammatory agent, or physical therapy, or even putting on a plaster cast. "It depends…" introduced the answers to most questions in the Rheumatology Clinic. The attendings made up for the lack of precision by being very careful – taking careful histories, doing careful exams, making careful treatment choices – and the best lesson of all, carefully following up their interventions. Every treatment was considered to be a therapeutic trial.

I’ve tried to follow that lead in psychiatry, making every prescription a clinical trial. It was easy in private practice. I saw people for a long time by usual standards, and there weren’t that many who were on medication. I used to joke that I wrote more prescriptions for antihistamines than psychiatric drugs [you’d have to live in Atlanta to understand why]. But in my stint as a volunteer in a charity clinic, I worried that I wouldn’t be able to do that. I was pleasantly surprised to find that it wasn’t true. I work infrequently, so it’s easy to remember patients visit to visit. And I’m surprised how easy it is to develop a therapeutic alliance even in that setting. When I first started, I was horrified at the polypharmacy and drug regimens the patients were on, and wanted to slash and burn. I quickly learned the error of my ways and backed off. These patients lead hard lives, and they become attached to their medications.

What I found was that down the road, it was much easier to get  people off of unnecessary medications once we got to know each other. I’ve been there for six or seven years now, and there’s no-one in the clinic on antipsychotics anymore who doesn’t carry a bonafide psychotic diagnosis.  I’m kind of proud of that. When I started, almost everyone was taking some flavor of Atypical Antipsychotic – sometimes two. But there’s actually something specific that has me on this airy topic.

There are a reasonable number of patients who have a Generalized Anxiety Disorder. In practice, I never saw them. I just wasn’t the person you would refer such patients to. So it was a new experience for me. They’re a very similar lot. They don’t have "fixed" anxiety – meaning anxiety in certain situations or settings. They’re always anxious. You can see it as they walk into the room, trying to not let it show, eyes darting, jumpy. If you’re a me, you start looking for triggers, or conflicts. What you find is nada, just a lifetime of anxiety as far back as they can remember. Often, they say something like "my Mom had it too." There are invariably somatic complaints and fears of imminent catastrophe, with a history of frequent trips to the ER for suspected heart attacks and the like.

I found that if I tried a medication, they rarely took it for much past the first pill. Feeling any medication effect scared them, and they stopped – even with the minor tranquillizers. I read that SSRIs were supposed to help. But one is rarely helped by a medication you won’t take. I began to start them on homeopathic doses, thinking I could sneak my way up after a time of acclimation. So I would start with 5 mg of Citalopam for example. To my surprise, they returned, saying it helped. In cases where I added a Benzo as a prn for anxious situations, the same thing happened. So I prescribed half of an 0.25mg Aprazolam, and heard the same report. 5mg Citalopam? 0.125mg Aprazolam? Who’d have thought? Over the years, I’ve seen enough of these patients, and written enough of these mini-dose prescriptions, to see that as the way to treat such cases straight away. I still do my "therapeutic trial" thing, but in these patients, it always seems to come out the same. I have no clue about the why? of it.

What brought it to mind was seeing a patient in the clinic who I now only see every three months for refills. She was one of the first I tried on these baby doses. She is now working part time and proudly announced that she hadn’t been to the Emergency Room for over a year. Both things are major accomplishments. She was downright effusive about how much better her life is. I rarely have very much good to say about our medications, so I made a mental note to write about it – I guess to prove I’m no therapeutic nihilist.
  1.  
    berit bryn jensen
    August 9, 2015 | 5:30 AM
     

    Thank you for the excellent lesson on how to proceed and follow up on every carefully considered intervention, making up for lack of precision by being very careful, from start to follow up. Rheumatology appears to have taught valuable lessons of humility and cooperation with patients, faced with the welter of unknown factors, personal and social, shaping our lives, of which the common social factors should be easiest to take into account, depending only on the doctors’ willingness to see and hear what’s right in front of them. But most psychiatrists, many citizens too, are taught the reigning certainties, preparing rampant denial. Mainstream psychiatry is sick, as mainstream political discourse is sick, layer on layer of lies to penetrate – unless we are helped to see bolts of light by honest, intelligent and couragous witnesses to the machinations of power. John Stewart has been effective, I think, I hope, on the larger, louder stage. But as far as I’m concerned 1boringoldman is quietly, persistently mining the same dirty soil for nuggets of golden truth. I’m used to missing Stewart, the screen too often telling me I’m too far away. This blog is at my fingertips every morning. Thank you!!

  2.  
    Johanna
    August 9, 2015 | 3:23 PM
     

    Thanks for a really interesting column. Who knows what we could find out if more doctors would try this? Another useful variation occurs to me: These days most people with an anxiety disorder, even periodic panic attacks, are given benzos and told to take a certain dose every day. David Healy prefers to tell people to take them only when they feel a high-anxiety state coming on, and congratulate themselves for every day when no pills are necessary.

    It leads to far less addiction — and some people feel better just knowing they have these “rescue” pills at hand. Especially those for whom the “fear of the fear” is leading to a vicious cycle. Of course, it’s individual. I’m sure a few people will respond by taking them at every hint of stress and will run out early. That, I guess, is a good early warning sign that this person should not use benzos at all.

    One of our workers comp clients had his first anxiety attack ever, age about 45, after having his medical care and then his benefits check cut off. Went to the ER with his heart hammering, was told there was nothing wrong with his heart. His family doc diagnosed Panic Disorder and handed him a script for Xanax. Take two every day. Five refills. Will he get addicted? Probably. Will he have another psych diagnosis tacked on within a year or so? Pretty good bet.

  3.  
    August 9, 2015 | 3:31 PM
     

    Thanks Johanna,

    My line about Xanax is that the best Xanax is the one that stays in the medicine cabinet. It tells you that there’s help available if you need it. And sometimes, just knowing it’s there is plenty enough…

  4.  
    August 9, 2015 | 6:19 PM
     

    I’ve seen the same thing. Patients who are constantly anxious, somatic almost to the point of obsession, and exquisitely sensitive to side effects. And they tend to take slivers of medication, sometimes just the powder that forms from breaking pills in half.

  5.  
    August 9, 2015 | 7:33 PM
     

    I’ve had a similar response with prescribing tiny doses of a beta-blocker prn.

  6.  
    August 9, 2015 | 8:14 PM
     

    I really appreciate these comments. I first got into the reduced dose in the earliest days of Prozac. While I didn’t prescribe it much, the patients were all people I was seeing weekly. Many/most complained of feeling agitated when they first started taking it [for some, a reason to stop]. Since it takes a while to work anyway, I started prescribing a half dose to start. It did cut down the initial jolt, but to my surprise, many patients were fine with the lower dose. In SSRI virgins [an increasingly rare species], I now routinely start with the half dose for any of the drugs [in my case, usually Citalpram]. I’m glad to hear that others have the same experience. I haven’t tried PsychPractice’s “powder” routine, but I definitely get the point.

  7.  
    August 9, 2015 | 8:58 PM
     

    The “why of it” is this:

    – These drugs are far, far stronger than they have to be.
    – Higher dosages are more likely to have uncomfortable side effects and be activating (very uncomfortable for someone who already on high alert).
    – The action of the drugs tends towards emotional anesthesia.
    – The most effective dosage is individual; the recommended dosages are fictions. These are psychoactives, people, not antibiotics.

    When people come to my site with withdrawal syndrome, they are amazed to find reinstatement of a tiny amount of the drug (such as 1mg-2mg Prozac) often greatly reduces symptoms. (Of course, this is compensating for withdrawal syndrome, not treating “depression” or the like.)

    Generally, they stay on these microdoses for a few months until their nervous systems settle down, then taper off in tenths or hundredths of a milligram. This enables them to finally get off the drug.

    Reinstatement of “normal” dosages often causes symptoms of activation such as akathisia or sleeplessness. (Emergence of these symptoms means the dosage is too high, not that a benzo is called for.)

    It’s pretty obvious that, across the board, “normal” dosages of psychiatric drugs are way too high for many people.

  8.  
    August 9, 2015 | 9:09 PM
     

    If I might add: Going on and off psychiatric drugs sensitizes the nervous system.

    You may well find that patients who are not psychiatric drug virgins seem to do better — meaning, have fewer adverse reactions — with very low doses for this reason.

    This is not an advantage. The iatrogenic sensitivity should be cause for concern. It is a deterioration in nervous system resiliency. Not only does it make psychiatric drug treatment more tricky, it will make the patient’s having anesthesia more difficult.

    Twelve years ago, Giovanni Fava suggested this drug-induced sensitivity might make patients more vulnerable to depression and other psychiatric ailments: Can long-term treatment with antidepressant drugs worsen the course of depression? http://www.ncbi.nlm.nih.gov/pubmed/12633120 This has been followed with similar musings by R. S. El-Mallakh and Paul Andrews, among others.

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