some truths are self-evident…

Posted on Tuesday 27 October 2015

A month ago, I wrote about a woman who had arrived in our clinic on a remarkable regimen if medications [blitzed…]. To repeat:
She was brought to the clinic by her aunt who was taking care of her temporarily. She was a woman in her fifties with a cast on her lower leg from a fall. She was calm, alert, but couldn’t answer many questions. She was blitzed. She told me she’d fallen and broken her hip. But she knew neither the date nor the season. By history, she was obviously the ‘black sheep’ of the family – a failed marriage, no contact with her kids, psych hospitalizations, multiple rehabs for alcohol, benzodiazepine detox, etc. – moving from family member to family member. Her aunt had a piece of paper with her medications written out neatly:
  • Seroquel 600 mg/day
  • Trazadone 450 mg/day
  • Depakote 2.5 Grams/day
  • Neurontin [I forget how much too much]/day
  • Cogentin 4 mg/day
    among other things…
…an outrageous cocktail!
So now I’ve seen her at two week intervals for two months. When I mentioned her last time
Over a couple of months, I got her down to…
  • Seroquel 200 mg/day
  • Depakote 500/day
  • Cogentin 4 mg/day
…without incident. But she was still pretty fuzzy [season "yes" – month "no"]. That was two weeks ago. I had noted her pupils were dilated every visit but  wanted to decrease the Seroquel before taking on the Cogentin. This time they were so widely dilated I could barely tell her eye color [why it wasn’t that dramatic earlier isn’t clear to me] and she complained about her vision being blurred. So I stopped the Cogentin by coming down a mg/every couple of days. Yesterday, I had stepped out to return a phone call. When I got back, the nurse had put she and her Aunt in the office because she was so agitated. She was in the middle of a full scale hyperventilation episode with carpal-pedal-spasm – throwing her glasses across the room breaking them and yelling about…well, about everything.

It took a while to get her breathing slowed. In the barrage of things that followed  [a litany of a lifetime of woes and symptoms], I noticed that her pupils were down to size; that she was fully oriented with intact memory, past and present; and that she was mad as hell about many [if not all] things. As she calmed down, I could see that she had some subtle but none-the-less definite involuntary movements of her tongue. In addition, her legs were never totally still…
Seeing her extrapyramidal symptoms, I put her back on the Cogentin, 2mg at night, and added 0.5 mg Xanax for sleep [she hadn’t slept in four nights]. Today, she appeared, a cognitively functional person, actually kind of happy. The "restless legs" had cleared and her pupils were down to size. She reported normal sleep. Her only complaint was constantly moving her jaw back and forth and the impulse to move her tongue. We decided to take a rest from detox for a while, and take on the Tardive Dyskinesia symptomes next visit. I’ve never taken someone off of that much medication that fast, and I thought a month of re-equilibration might help us decide how to proceed [update: I left out that we lowered the Seroquel from 200 to 150 this time].

How did this woman get on such an outrageous cocktail? I wasn’t able to take as much history as I would’ve liked, but I think I got to the bottom of that question. She was being seen at our local contract mental health center. Every time she went, she left on more medication [both kinds of more – increased dose and/or new meds]. She was never seen by the same person twice. As as matter of fact, she was never seen by a person in the traditional sense. They have telepsychiatrists there, psychiatrists on television sets. She and her aunt had been to the center to complain about the overmedication themselves since our last visit, and the director was mega-apologetic – sheepishly admitting that this wasn’t the first time [duh!]. I’m going to give her a call myself later this week.

I’m not going to wind up on telepsychiatry today. I complain about enough things already. I think it’s a creation of some cost-cutting bean counter and ought to be outlawed as de facto malpractice rather than the subject of glowing articles in the Psychiatric News. I doubt I even have to explain why I think that, so I won’t. This is hardly my first encounter with such a case, and I’m sure it won’t be my last. Some truths are self-evident…
    James O'Brien, M.D.
    October 27, 2015 | 7:06 PM

    That’s restrained compared to what I see….

    She’s not even on Xanax and Soma and Ambien and a boatload of opioids.

    October 27, 2015 | 10:50 PM

    Isn’t it wonderful, there are so many psychiatrist who think better living through chemistry, and yet so many patients being lucky to be living with chemistry.

    I’ve been seeing this for 15 years, and what is so disgusting is so many psychiatrists defend it in the space of a second.

    James O'Brien, M.D.
    October 28, 2015 | 9:47 AM

    Indeed, but to be fair in terms of scale this issue firmly resides in the world of primary care than psychiatry.

    October 28, 2015 | 1:03 PM

    Can you clarify Dr. O’Brien? I realize primary care physicians prescribe most of the psych meds but I have never known them to engage in psych med polypharmacy. I have heard of patients on multiple blood pressure meds but that doesn’t seem to occur as often.


    October 28, 2015 | 2:24 PM

    I might suggest that there is not an adequate history here to support any of the conclusions. In addition, without levels it is hard to say if the patient is benefitting at all from 500 mg Depakote and I have never seen anyone on 200 mg of quetiapine who needed to take 4 mg of cogentin. In my experience cogentin doesn’t do anything for TD except to make it worse.

    I can envision a scenario that results in the patient taking the initial combination of medications – due at least in part due to the fact that complicated problems are inadequately treated these days and follow up is very poor. If we had a functional system of care this woman could be admitted to address this toxicity or not be discharged prematurely to cause it in the first place. Telepsychiatry and telemedicine in general can be viewed as another form of rationing – except in cases where the population is too sparse to support any face-to-face medical services with any regularity.

    October 28, 2015 | 8:38 PM

    I don’t think this patient is benefiting from any of it. I don’t think she has ever been psychotic, know of nothing that suggests Bipolar Disorder, and what little I know of her history, think her psychiatric diagnosis is likely a Personality Disorder and every time she complains, someone throws medicine at her. The reason she’s on that last regimen is just as a stopping place on the way down to getting her brain back so I can take a history and see if the neurological symptoms persist. The one thing I’m sure of is that when I stopped the Cogentin, the akathisia [restless legs] became apparent and they disappeared when I started it back at 2 mg. The bucco-lingual symptoms weren’t apparent when she was on all that Seroquel, but appeared when I came down quickly. So I’m just giving her a break before aiming to see what she’s like when she has the faculties she was born with minus all those drugs [plus a little Xanax for sleep]…

    October 28, 2015 | 8:50 PM

    James et al,
    I got so tired of patients requesting opiods or refills for same that I voluntarily surrendered that part of my DEA license – so I can simply say that to patients and tell them why. I’m not a pain doctor and I know of no reason a psychiatrist needs to prescribe those drugs anyway. To my surprise, the patients seem to understand and have just stopped asking. I guess word travels fast…

    October 28, 2015 | 10:33 PM

    To AA:

    Oh, there are plenty of Non psychiatrists playing polypsychopharmacology mine field applications, I have patients coming to me from the first line PCP who has them on 2 antidepressants simultaneously while on 10 + of Abilify, I have PCPs writing for stimulants along with SNRI antidepressants at dosages that would cause heart damage, and I have recently absorbed a patient on 2 benzos, a stimulant, and Seroquel at 300mg, yet, have no freakin’ clue what I am treating from all the side effects each are causing in, are ya ready, this 55 year old guy!!!

    Nope, non psychiatrists have no problem with polypharmacy. Imagine if these folks went to these PCPs and told them I wrote a script for a first line antibiotic…

    let those hostile calls commence from these well meaning peers. Actually, those calls would be from mean “peers”. Hey, I can’t practice medicine in my office, right, colleagues???

    October 28, 2015 | 10:34 PM

    People regularly show up on my site who are are 5 to 9 psychiatric drugs. Some of their cocktails have been prescribed by non-psychiatrists and some by psychiatrists.

    Often, losing faith in their current doctor, overmedicated people will go to a psychiatrist or hospital psychiatric ward to get sorted out. That they end up on my site demonstrates no such sorting has been accomplished.

    Treatment by a psychiatrist does not guarantee that one will emerge with a carefully composed cocktail or that drugs causing adverse effects have been minimized.

    I think many psychiatrists don’t want to risk taking people off drugs because of potential withdrawal syndrome as well as “relapse” or other behavior necessitating more time-intensive involvement.

    October 29, 2015 | 12:15 AM

    Polypharmacy is alive and well across medicine. I suppose I will write a post about it at some point but just a few combinations that I have worked on over the past 30 years:

    1. Immediate release + sustained release (doesn’t anyone look at the pharmacokinetics?) – opioids and stimulants primarily, but many people on both clonazepam and short-acting BDZ.
    2. Bad ideas: opioids + benzodiazepines + z-drugs
    3. Balancing the sedating and non-sedating: stimulants +/- opioids during the day, z-drugs to sleep, and stimulants to wake up in the AM (beats coffee).
    4. Standard geriatric polypharm: 2-4 cardiac meds + 2-4 diabetes meds + 2-4 pain killers + 2-4 psychiatric medications (usually at least 2 antidepressants). My record was 20 medications. It took me 2 hours to “reconcile” what the patient was really taking from 3 different sources.

    On a statistical basis most of this originates in primary care. There just aren’t enough psychiatrists out there and there are many primary care docs these days who don’t hesitate to make complicated psychiatric misdiagnoses in 20 minutes and initiate polypharmacy. There are certainly not that many psychiatrists prescribing opioids and if I were to hazard a guess the bulk of adult ADHD diagnoses and treatment is done by primary care. There is a strong bias in all of medicine to overdiagnose and overprescribe. Most of that is driven by physicians believing that they are patient centered or patient advocates if they provide the patient with something they are asking for rather than telling them that it is not a good idea to take a medicine. Much of that is fueled by the idea that the patient is incapable of making other changes.

    James O'Brien, M.D.
    October 29, 2015 | 1:10 AM

    Dr. Nardo,

    I too have taken opioids and amphetamines off the table. I simply won’t print the triplicates and haven’t for years. But I’m quite comfortable using TCAs (and to a lesser extent SNRIs) for certain types of pain.

    Psychiatrists (or at least Andrew Kolodny M.D) have actually taken a leadership role against the opioid problem that originated in pain management and spread to primary care and orthopedics.

    The epicenter of the enthusiasm was a study published in NEJM by Porter and Jick in 1980 which stated based on a chart survey that addiction to prescription opioids was almost never a problem. The problem was it wasn’t even a study and it was based only on chart notes without collateral information. Of course someone during a refill visit isn’t going to tell you they have functional impairment from Vicodin. They never bothered to interview collaterals.

    1980 seems to be the year that science started going really in a bad direction…

    October 29, 2015 | 2:16 AM

    I have zero doubt that overprescribing is a serious problem in multiple disciplines, but I do doubt the EMR is blameless in stories like the one that Mickey told at the top of this thread.

    The only way something can ever change in this kind of situation is when someone walks in to a consulting room with a list, on paper, of all the medication someone is taking.

    Because it’s a good bet that the prescribing clinician cannot see anything a sane person would call a coherent prescription history in the EMR. You might see a dozen alarms about medication interactions, many of them false. You’ll see client refills 30 x 2 mg. lorazepam, refill rejected, refill reinstated, rejected again (did it ever get filled? You won’t find out without calling the pharmacy and spending 10 minutes waiting to talk to a human being.) Then you’ll see some anitfungal foot cream, maybe some vitamin B12, blood pressure medication, and then a Seroquel refill, then dozens of entries for electrolyte solutions, maybe some GoLytely for a colonoscopy that got canceled– every irrelevant thing the client is, used to be, or might be taking at some point for the last two ears or so

    On the system I used, which shall go nameless (it was Allscripts) there isn’t some button you can press that says, “Just show me what was actually filled, and the doses and amounts, for the neuroleptics, the benzos, the atypicals, and the Z drugs.”

    My father had a seizure last year because no one figured out that valporic acid and Depakote are the same thing.

    One way I knew clients really wanted to get clean was when they brought in a list from their pharmacist with handwritten notes. Then I know they’re getting serious. The EMR, at least ours, was a joke.

    Matthew Jansky, LMFT

    October 29, 2015 | 3:16 AM

    I sincerely hope that this patient does not end up with yet another dependency – this time to a benzodiazepine. Some patients become physiologically dependent in as little as 2 weeks. I cannot think of anything worse than benzodiazepine withdrawal syndrome that can last for months or years. The British Medical Association has just released an analysis report on prescribed drugs of addiction calling for a consensus on prescribing guidelines,withdrawal protocols and research into the possibility of permanent brain damage.

    The US is in desperate need for the same type of analysis of the problems concerning the prescribing of benzodiazepines, withdrawal protocols and research to help those who became dependent all because they followed their doctor’s orders as prescribed.

    You can download the analysis report titled, “Prescribed Drugs Associated with Dependence and Withdrawal – Building a Consensus for Action” here:

    I am unclear as to why antipsychotics were not included in this report.

    October 29, 2015 | 4:00 AM

    Thanks Dr. Hassman for your response. And obviously, I haven’t been keeping up on SA with the drug histories. I am speechless.

    October 29, 2015 | 11:15 AM

    Andrea, I very much disagree. Benzos have been studied to death over the past 30 years or so, and this seems like a really weak, poorly designed report. I’m not sure it has a design. It’s a “call for evidence in the form of an open ended questionnaire seeking information and views from a range of key stakeholders,” and even that has a pretty clear bias, because it makes the business-as-usual assumptions about which drugs cause dependence and withdrawal.

    Many things are far worse than benzo withdrawal. It’s not always pleasant, and not always easy, but people have been managing it since the ’60s. Many taper successfully on their own. Others have more difficulty, and certainly these folks turn up at 12-step groups; if they have brain damage, they rarely complain of it and show no evidence of it. This group does not seem to be among the chronic relapsers.

    There are patients who have tried stopping low doses of Effexor suddenly, and also tried stopping low doses of benzos suddenly.

    Not a good idea in either case.

    But ask them which was worse.

    Ask them which still gives them nightmares.

    October 29, 2015 | 5:19 PM

    Yes, it’s true, the drug lists in EMRs are a mess.

    There is no doubt whatsoever in my mind that some non-psychiatrists like to play what they think of as psychiatrist and mix up elaborate, nonsensical, and very dangerous multidrug cocktails.

    As we all know, overpromotion of psychiatric drugs and irresponsible studies like STAR*D have convinced many physicians (despite all common sense) that they are so safe they may be mixed and matched at will.

    October 29, 2015 | 5:25 PM

    Recent post from a patient:

    I’m currently taking Pristiq 400mg daily (since 2008), nortryptilline 200mg daily since 2013 and vortioxetine 10mg daily since July 2015. I’m also on lithium, tertroxin, prazosin and lamotrigine.

    She was posting from a hospital in Western Australia. Her doctor, probably a non-psychiatrist, decided to suddenly stop the Pristiq, nortryptiline, and vortioxetine, and sent her to the hospital saying “it might get a bit rough.”

    He was planning to switch her to an MAOI.

    October 29, 2015 | 6:48 PM

    Catalyzt and all,

    Poly pharmacy is, indeed, a mega-problem, whether by psychiatrists or primary care. I’ll have to add the patients into the mix as well. Somehow in all of this, there’s a general feeling that there “should be” some medicine that will make them feel better, so they clammor for meds. “My sister says Klonopin is better than Xanax.” “Is there a new antidepressant out recently?” “What’s with Cymbalta?“etc, etc. Some days, one gets the feeling that people think you actually have the magic bullet and just won’t let it go.

    It takes a while to get people to stop with the symptom list and the medication history and actually talk about who they are and their lives. Once they figure out that’s what you want to hear about, they’re glad for the opportunity. I guess the symptom/med history is what they’re used to being asked about.

    The medication list is indeed important. In this case, the aunt had a knack for this point and had a list [and a sack with all the bottles]. It was a big help because I’m not sure the patient actually knew what all she was taking…

    James O'Brien, M.D.
    October 29, 2015 | 8:01 PM

    Patients are definitely in the mix, especially in the era of Press Ganey and physician service ratings:–35718

    The Onion article isn’t that absurd…hospitals call in doctors who don’t do well in patient satisfaction surveys. How does that work out for the physician who recommends resiliency and sleep hygiene and yoga?

    October 31, 2015 | 1:31 PM

    I still don’t get why, in response to a request from a patient who is already on a number of psychiatric drugs, the doctor cannot simply decline to write a prescription for an additional one.

    From what I’m seeing, doctors are far too willing to add a psychiatric drug to any mix. They probably have faith in them as relatively harmless “shut up” pills. (Or maybe there’s a passive-aggressive wish to get rid of the patient by any means necessary: “Hey, you want this drug so much, you’re gonna get it. And go away.”)

    At any rate, it seems that psychiatric drugs are prescribed far more liberally than any other type, except possibly PPIs, also overprescribed.

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