All this recent digging around about the PHARMA invasion of psychiatry weighs on my mind at times. I get a creepy feeling about a profession I found fascinating and rewarding. Phrases in the articles like monotherapy, treatment resistant depression, comorbid this-and-that, the neurobiology of … begin to grate on my nerves. It’s not that I don’t understand the terms, or even that I object to what such an approach might teach us. It’s that I begin to hear it as a mechanistic, simplistic view of human experience and I start feeling righteously indignant and grumpy. It’s a bad feeling. Then I have a day as a volunteer at a clinic and…
A fifteen year old attractive girl in a seemingly functional family has been "cutting" and trying to learn to be bulemic increasingly over the last year. Last month, she took an overdose of benadryl and nitroglycerin from the medicine chest and was hospitalized for a week. She was discharged on Celexa 20mg and Trazadone 50mg, both at bedtime. In her visits with her counselor, she’s been flighty and kind of silly – not engaging with her therapist or seeing the impact of her behavior.
Twenty years ago, this patient wouldn’t have shown up taking two antidepressants. And I expect the FDA would be wondering if anyone treating her had been reading much about the drugs she was taking, the part about akisthisia and suicidality in adolescents on SSRIs [though they are used to treat bulemia]. As we talked, she was kind of flighty, almost "flip." But when she was pushed about what she was feeling when she cut herself, or tried to purge, all she could come up with was that she was "stressed out." Her history was of being the oldest of three with brothers one and five years younger. She had been picked on in Elementary school, but with the coming of puberty, she blossomed into being one of the "pretty ones" – an ugly duckling to swan story. Her response was to become a bully and mercilessly tease her former tormentors for their acne and misfortune in the looks department. A friend, also a "looker," had helped her see the error of her ways, though she secretly continued to enjoy the other girl’s envy of her "smooth complexion" and good looks.
I asked her how she understood that she was pretty, popular, smart, yet she was going out to be a mental case. She seemed interested in that question and got more engaged with the interview. At one point, she mentioned her recurrent dream – her one year younger brother and she were being pursued by rapists. She was trying to protect him. When I asked "why are you protecting him instead of yourself?" She immediately answered that he was the "important one" – thin, smart, athletic. They had always been both "close" and "at each other’s throats." She mentioned that
she had once asked her Dad which one of them would be the most popular. Her father had answered quickly, "Your brother."
I’ll not go on and on here – just summarize. She’d grown up envying her brother – as far back as she could remember. No matter what she did, he was the chosen one. When she reached puberty, her envy jumped over to the "pretty girls" and was consciously responsible for the bulemia. She didn’t feel "pretty" because others were "prettier." When I told the Snow White story, about what the mirror said, she pointed at herself and said "that’s me!" Looking into why she wasn’t engaging with her therapist, after a bit of exploring the answer was simple – envy [her therapist is an attractive, confident woman].
I visit this Clinic a couple times a month to help out with diagnosis and medications. The clients all have counselors – pretty good ones. It’s mostly routine kinds of things – ADHD kids, conduct problems, fractured rural families. Almost everyone comes in on some kind of medication prescribed by their "PCP" [Primary Care Provider] – often an antidepressant [in the designer class as seen on television] or Seroquel. I do a lot of switching around and stopping medications. Some are cases like this girl where I get to do the kind of nosing around that makes me feel like a real Psychiatrist instead of simply a "more informed" PCP. She’s got a good therapist who she saw after I saw her. I was told later that she marched in and said, "I envy everybody, including you. I need to talk about that!" I really liked hearing that.
At the end of our interview. She spontaneously said, "Do I have to take this medicine?" She was taking both at bedtime. She thought the Celexa "hyped her up" and that’s why they started the other one [Trazadone]. "I think that’s why I have so many bad dreams." I asked if they helped. Both she and her mother shook their heads no. So we stopped the Trazadone and moved the Celexa to the mornings. Because she had stopped both the vomiting and the cutting, I thought we’d wait a bit before either decreasing or stopping the SSRI. We agreed to rethink the medications next time I’m in the clinic.
Obviously, this whole business of the current directions of Psychiatry are in the front of my mind these days, and particularly after a "clinic day." I might come across in this blog as "anti-meds." It’s not true. I expect I might have thought about an SSRI [at a lower dose] in a case like this if her symptoms persisted because, empirically, both girls with Bulemia and "cutters" seem to be able to give up those symptom more easily when they’re on the medications – at least early on. What bothers me is the almost universal reflex use of medications these days, without really knowing what’s being treated. This girl was in a mental hospital for a week and nobody apparently asked her about her life.
Oh yeah, the overdose was about a boyfriend she thought was attracted to one of her friends – one of the "prettier" ones. As it turned out, she had it backwards.
When I was in the business of training psychiatrists, I saw the task as teaching them how to listen, how to hear the music behind the words. It was fun, watching them slowly begin to "get it." We taught them about diagnosis and the various treatments, sure enough. But I always thought that the learning how to listen was the most important part. Some couldn’t learn how to do it very well and there were plenty of places for them in the specialty, but I’ll admit to being proudest of the ones who were able to develop [or were born with] that third ear.
I think it would be wrong to look at this girl [who came in reporting that she still felt depressed] as a case of treatment resistant depression, failing SSRI monotherapy, and starting her on an Atypical Antipsychotic. And when I read all of these articles, I don’t hear in the background that they’re written by people that have their fingers on the pulse of the human experience in the right way. That’s the part that bothers me the most. Color me old fashioned, but I just don’t believe that this young woman’s end-plate serotonin levels had much to do with her envy problems. Anyway, when I came home from the clinic day, I didn’t feel grumpy anymore…
You are a good doctor, Mickey. I wish there were more like you and that you were still teaching the young docs how to listen before reaching for the Rx pad. I agree that is the most important thing we analysts can contribute to medical education.
I’m guessing you were born with enough parts of the “third” ear that the organ flourished in the various developmental experiences to which you subjected it – and I love reading your case studies. In this general connection, I recall that well before you embarked on the psychoanalytic path, you were well known to diagnose Rocky Mountain Spotted Fever in rural East Anglia and other exotics such as dyspaerunia – all because you were disposed to listen to what your patients were saying about their lives.
I note that the role of “managed care” seems not to have attracted much of your focus in the recent discussion….their spreadsheet-driven insistence on n (much much) >1 at the least cost to their ROI, salaries, bonuses etc..
The skin that PHARMA has in the game is plain enough and, as you’ve noted, nothing especially new – nostrums, traveling medicine shows, a long and colorful history of “successful” quackery in medicine, and a vehemently naive public desperately wanting to believe that they can obtain attach of a miracle cure (for pennies!) that will cure whatever ails them- these phenomena are not limited to the 19th and early 20th-c.
Nor are characters like “Dr. Rolls-Royce” Nemeroff restricted to the practice of Psychiatry, (Cf. Plastic Surgery!) though I recognize you would be more strongly identified with the usurpation of your own specialty by those who promised less work, more money and greater profits for everybody with a stake (not necessarily including the sufferers who create the market in the first place).
Fascinating and absorbing stuff this and I, one of many I’m rather sure, commend your eloquent, fact-based, revelatory, junkyard-dog emphasis in general and especially on these subjects which you are uniquely qualified to address. That you have identified, developed and burnished this very contemporary technology in a way that reaches who-knows-how-far beyond your immediate circles is the very stuff of Leadership (in the purest sense of the term).
There was a song I listened to on FM radio in the mid-60s, never been able to resurrect a reference to it but the main lyric was “Don’t let the bastards get you down, don’t get hassled to a frown” – I wish I could convey the fetching musicality in words. You could call me on the phone next time you are feeling grumpy on clinic day – it is permanently etched in my memory and I will sing it for you. (NB. I’m unable to accept 3rd party payments)