1 Boring Old Man

My practice as a long term psychotherapist in a cosmopolitan city hardly prepared me for a rural charity clinic in Appalachia. It wasn’t an unfamiliar place, but it was an alien practice environment. More than that, I’d been a Rip Van Winkle to the Age of Psychopharmacology, and it was a shock to meet patients who grew up in this new world where the usual opening line was "my antidepressant has stopped working/doesn’t work." Polypharmacy; multiple classes of drugs; multiple drugs in a given class; little mention of life; lots of substance abuse, particularly methamphetamine; the most peculiar of living situations; on and on. I was a stranger in a strange land – one I knew as a person, but not as a psychiatrist.

I had several reactions: buying pharmacology books to see what strange things had happened in my absence; thinking that this wasn’t for me; feeling dumb; feeling smart; feeling confused.

I decided that the place was better off with me than without me, even if all I did was decrease the medicine count and arrive at something rational.

There were enough people I could help in ways I knew to sustain getting to know the medication world I found myself living in [a world I frankly didn’t much care for].

I had to make some decisions. I was going to only prescribe Benzodiazepines short term except in certain circumstances. I was never going to prescribe or refill narcotics, and actually gave up that part of my DEA License. I was going to be careful about ADD drugs, but prescribe them if they were clinically warranted. Antipsychotics are for psychotic people – no one else. But mainly, I wasn’t going to blame the patients for the world they grew up in, the world of too much chemistry. Like people everywhere, they just wanted to feel better, and didn’t expect much from people. And I spent a lot of time getting to know the community resources [which were much broader than I had imagined, though good things are often found in odd places].

That was five years ago. I’ve learned a lot about how to work there, and actually a lot from writing this blog.

I worked Friday, and realized I haven’t see a single patient taking Seroquel® in months! And I almost never see someone who I would consider "drug seeking" in the sense of addicting drugs. The medication counts are higher than I’d like, but so much lower than before. And polypharmacy is rare. I’ve had more success in that regard than I knew.

I have a feeling that I’ve developed a new lingo of things I find myself saying over and over again, but I can’t recall exactly what they are. Maybe I’d be embarrassed by my new patter.

I’ve had to adjust my thinking about diagnosis. As always, medical illness comes first. Next, the classic psychiatric syndromes or diseases depending on how you think, What used to come next was a dynamic formulation, more narrative than diagnosis driven, but there’s not time for that usually, so I’m in the world of symptoms – and that’s a place where one has to be careful not to become the medication hack I decry.

One thing for sure. I don’t think about the DSM-anything very often. I wonder if others do. A lot of patients actually seem to want that, or are used to that. There’s something I often say but, again, I can’t recall what it is.

I really do warn every patient I put on antidepressants about akathisia, and tell them to stop the medication and call if… And an increasing number of people are willing to leave without being disappointed not to be holding a prescription, even though, for me, I do a lot of prescribing.

The most rewarding thing is that over time, even though I see the patients infrequently, the kind of relationship I’m used to having with patients has slowly developed. The thing that seems to matter most is that I have an elephantine memory, and being remembered is apparently a new experience for many of these patients. And so they start to bring up the things that are the real problems in their lives after a while, and frequently come in talking about resolving something we discussed long before where all I really did was listen. Human beings thrive in an environment where there’s a listening, neutral audience. It’s a major tool in being a country doctor. I guess it always has been. All of this is an introduction to the latest piece from Dr. Allen Frances with Dr. Christopher Dowrick:

Well framed and dead on target. I would just add that there’s a lot that can be done for unhappy people besides not giving them medications. In an appalachian charity clinic, unhappiness is the main order of business. And if there are principles guiding treatment – they are listening, remembering, and a heavy dose of Adolf Meyer’s Common·Sense Psychiatry…