1 Boring Old Man

I sometimes wonder why all of this business about the Pharmaceutical Industry’s invasion of Academic Psychiatry is such a front burner issue for me now, but wasn’t so much before I retired. Is it that I now have the leisure time to think about such things? Is it because I now realize that the epicenter  of the problem was a couple of miles from my office in Atlanta in a Department I was part of, and I feel guilty about not knowing the extent of things? Am I so grandiose that I think I could’ve done something about it? All of those things get a "maybe," but the simplest explanation is usually right, and these days the problem is in my face – I see it. In Atlanta, I saw the urban educated who were referred by other urban educated. In retirement, I now volunteer at a charity clinic where I see the rural blue collar [or no collar at all] people who have been treated in mental health centers or [mostly] by Primary Care Physicians. An example from yesterday:

After years of chaos, her Schizophrenic father had finally killed her mother and himself in front of her when she was 14. The kids had gone to live with "granny." She grew up being a "people pleaser" because she "knew how hard it was to be told ‘no’" and that intensified in her adolescence as an orphan. Her profession was as a certified aid at nursing homes and she longed to train to be an LPN. She’d found a weekend job at a nursing home here, but was working at Walmart part-time to pay the bills. The central problem in her life was her Walmart schedule. They just kept wanting "eight day weeks."

With some coaching, she said "no" [and then "hell no"] to Walmart, got to feeling some better about herself. They like her at the nursing home. She [uncharacteristically] asked for and was offered a baylor plan – 24 hours/weekend for 32 hours pay. So she quit Walmart altogether and starts nursing training at the Community college in January. She’s still on the Celexa, but off the Depakote and Seroquel, and is beginning to look less rolly polly. Fingers are crossed that the Diabetes will fade. The recent addition of a softer, gentler [employed] Georgia boyfriend [who doesn’t mind hearing ‘no’] hasn’t hurt the picture one bit.

I wish there were more like her. There are plenty on a long list of drugs living marginally, off the grid, a little too far into the "sick role" to make a move. We do what we can. I blame some of what I see on the chronic poverty and torpor of the Appalachian culture. But there are any number of patients on a given clinic day that are victims of our polypharmacy world. These issues we write about on our blogs have a real impact in the real world. It’s not just that SSRIs can cause suicidal thoughts, or that Seroquel can cause weight gain and diabetes, it’s that the whole idea that a mental symptom automatically equals a disease entity, and that automatically equals a bunch of drugs that’s at fault. Street drugs are a huge issue here in the "country." We don’t need to add a second drug problem to the mix.

On the other hand, I see patients who respond to SSRIs, some who do well on Lithium or anticonvulsants for their real "bipolar," people with ADHD whose lives are changed when it’s treated, some psychotic people who can’t function without antipsychotics. But there are way too many whose symptoms have been chased with inappropriate medication to no avail. Way too many. And I often find myself thinking about Adolph Meyer’s old book, "Common Sense Psychiatry." I’m glad I read it way back when – but just the title is good enough…