1 Boring Old Man

Diane Sawyer’s report on the overuse of medications in the foster care system was long overdue. As those things go, I thought it was a good shot though I fear it will pass and fail to stir the kind of outrage it deserves. I live in a sparsely populated rural community and see those kids in a clinic where I volunteer. I don’t see many kids who are as grossly over-medicated as the ones on that program, but there are enough of them be alarming – peculiar mixes of Atypicals, Antidepressants, Stimulants, Mood Stabilizers. I think of them as irrational cocktails. If there’s a chart or documentation that comes with the kid, the remarkable thing is that there’s no diagnosis attached to explain the bizarre concoction.

When I first started volunteering at that particular clinic, I didn’t exactly know what to do, but now I’ve got it down to a science. Start over. The first order of business is to un-medicate the kid. The problem is that there are withdrawal syndromes for many of the drugs, particularly the Atypicals. So if you just stop the medication, the resultant withdrawl symptoms are interpreted as evidence that the medication was indicated in the first place. So I do a long slow taper routinely, and warn the caregiver about withdrawal symptoms. Oh yeah, I stop one drug at a time. It’s a made up protocol, but it works just fine. In practice, there are some ADD/ADHD kids in that population who end up back on medication, but I’ve gotten them off of antipschotics [except for the psychotic kids and a few autistic kids]. It’s an odd job being a psychiatrist who takes people off medicine instead of the other way around [one of the therapists at the clinic once called me Dr. Backwards, all in fun].

Much of the stuff I write about here is new to me even though it has been going on for years. I really did live in the cocoon of my practice and colleagues, isolated from the goings on in psychiatry at large – something that I had formerly been pretty involved in. A lot of the reason was that I found it uninteresting and unconvincing. But I now realize that I was also avoiding the negativity that blossomed towards psychotherapy or any recognition that the mind even existed after the DSM-III. So now, at times when I get into exploring some aspect of the problems in psychiatry, like the DSM-5 Revision silliness I’ve been looking at for a while, I lose a sense of what psychiatry actually is. I begin to see it like many of the anti-psychiatrists view it – just doctors pushing medications like the ones in Diane Sawyer’s series. Then I have a Clinic Day [yesterday], and I remember what psychiatrists do by doing it, and I get my perspective back. I’m going to give a simple example in a bit, but first another observation from a long time ago.

I did two residencies – Internal Medicine and Psychiatry. When I finished Internal Medicine, I was the smartest guy in the world [I thought]. I could do roundsmanship with the best of them. I was just bristling with facts. When I finished Psychiatry, I wasn’t sure I knew anything at all. I only knew things when I saw a patient, not in the spaces in between. Later, when I was directing a residency, I often advised graduates to take a part-time clinic job while getting a practice going. "Work in a clinic where you know what to do, what you did as a resident" I would tell them, "and ease into practice." "That way, you’ll feel your efficacy at least for part of the day while you build your confidence in your practice." Any number of them later thanked me for the advice.

Yesterday, a mother brought her chubby sixth-grader in, saying that she’s taken him to a nutritionist because he’d gained a lot of weight starting towards the end of the fourth grade. The nutritionist thought he was depressed and overeating because of it.  The mother thought she might be right – hypothesizing that after the boy’s father died from Leukemia when he was five and a half, within a month, she’d taken in three children temporarily [her sister’s kids after the sister died from an unintended drug overdose]. Temporary became permanent for two of them. She thought maybe he hadn’t ever had time to grieve. I knew this woman already. I’d seen one of those kids, a dull boy [IQ around 80] who had given her a fit, and is now permanently placed at a boy’s ranch. The story was even more complex, the mother and the boy’s father had been childhood sweethearts and married right after high school [when she was 8 months pregnant with this boy]. They’d divorced when the boy was two. Her husband wanted to "date other girls." She fought the divorce, but finally gave in. They later became best friends, and were constant companions in the last year of his life as he was dying. He had always been involved as a father to his son.

The boy himself was a cute, kind of shy kid. As we talked, he teared up discussing his dad. He remembered him as a good guy – "fun." His father had "white" [very blond]  hair, and he remembered that vividly. He did not remember his father’s baldness on chemotherapy or his actual death. He said he thought about his dad when he was alone, particularly at night and cried profusely as he talked about it. He dreamed of his father, "just being with him." He had no idea why this thinking of his father started in the fourth grade. As he and I talked, I felt tears in the corners of my eyes too, but his mother was unable to hold back hers and they streamed down her face. Mine were my reaction to seeing the sadness in this boy, but hers were something else. She was crying for his father too, the lost love of her life as it turned out. This boy was the "spitting image" of his father. I had two patients.

She had remarried her long-time fiance right after that older nephew moved to the ranch. You guessed it, it was around the same time her son, the patient, began to think of his father, feel sad, and to gain weight. The new husband was a decent guy who was functioning fine as a husband and father, and the boy sometimes called him "Dad." When I suggested to Mom that her son wasn’t the only person whose grief was interrupted by the coming of her sister’s kids, she confirmed by crying harder – unable to speak. Although she’d never mentioned it to her son, when I asked him if he knew of her grief too, he said "yes" and added meekly, "sometimes we cry together." There was a lot more, about how her persistent attachment to her first husband complicated her new marriage, about the boy’s worry about his mother’s sadness, about how his mother’s marriage brought home the fact that his father was gone forever. They had just met a new therapist at the clinic that they liked, and when I suggested they both go to counseling together for a while, they both readily agreed. They had been sent to me to evaluate the need for antidepressants. It just didn’t come up.