Some of the more important learning in medicine doesn’t come from medical school, or residency, or even sitting at the feet of the masters. It comes from reflecting on the long days seeing patients – what kind of things keep coming up over and over? Early on, it hadn’t occurred to me that my own experience was such an important source of information. I recall how I first began to realize otherwise.
Most people seeing physicians don’t have an illness in need of treatment. They have symptoms, and have often fallen prey to a universal phenomenon – once you notice a symptom that there’s something wrong, you lose your intuition for the aches and pains of living – every bodily sensation becomes suspect as part of the unknown disease. So on arriving in the doctor’s office, the story is laced with extraneous reports, and the task is to sort through and find the things that matter. The average expectable patient wants three things:
In a modern world where the television ads are blaring and patients have friends that are taking antidepressants, the patients come in with the idea that they may have a depression disease, and want to try some depression medicine. Even if they know that their life situation is deplorable and they can’t change it
– but they can take a depression medicine. If it doesn’t have the desired effect, they’re understandably disappointed and want to try something else. They know that it’s out there as seen on television, but they think they just haven’t found it yet. So like in the above example, one is well advised to develop a similar pre-emptive line.
– but they can take a depression medicine. If it doesn’t have the desired effect, they’re understandably disappointed and want to try something else. They know that it’s out there as seen on television, but they think they just haven’t found it yet. So like in the above example, one is well advised to develop a similar pre-emptive line.Sometimes adages help. In this case, Honesty is the best policy is the one I have in mind. So there are several things I say up front:
I started with the "finger thing" not as a ploy to lower expectations [though that’s not a bad idea]. I did it because I had a number of patients who would stop after a short time without giving the medication a chance, or who were looking for more than these drugs ever offer. I reasoned that if they’re going to take them, they need to have a realistic idea of what to expect and take them in a way to optimize their chances. To my surprise, patients would often walk in to a follow-up visit holding up their fingers in a some way to communicate how much. It actually helped.
| But the point of this post is really a sermon about the patients who are on some gaggle of medications already and/or who have tried a bunch of different antidepressants and who come in saying My antidepressant has stopped working. They talk as if they have a depression disease, and it’s one of those diseases that medications wear out on – so they need another medicine [I know of no such depression disease]. Sometimes, they’re pissed, like I’ve let them down because I haven’t created the drug they’d like to take. |
| Although they’re often changed to a different medication or [gulp] some new medication is added to an already overflowing pharmacopoeia, I think we owe them more than that. They’re doing the only thing they know how to do, even if they’re hostile or defeatist about saying it. I think it’s time to take a real history instead of pretending patients are chemistry sets, even if the waiting room is full. The yield of things one finds out is well worth the journey. It’s a much more productive use of time than chasing symptoms with medication [when that has already proven itself to be something of a dead end]. This is the situation where clinicians think about augmenting or combining or sequencing which often only adds to the risk and side effect burden. End of sermon… |
One final idiosyncratic comment. I live in a rural and beautiful area of Appalachia – the area where the moonshiners and revenuers played Thunder Road in a more colorful era – where the legacy of NASCAR and Hot Rods from the white lightening drivers of yore is still with us. Drug use has replaced the white lightening, particularly Methamphetamine and Opiods. A new Sheriff helped, but it’s still endemic. I always ask [even if they’ve said no before]. And I frequently find this coming out of my mouth…
We don’t have any medicine that comes close to whatever-you-were-taking on the streets. Good for you that you stopped, but the only thing on your side is time and the help from others who have been through it. No antidepressant is going to stop the craving or replace learning to live drug free. We can give antidepressants a try, but your best bet by far is…
… and I launch into my NA speech [I’m surprised and pleased by how many of them end up going!]…
Great post… hope you give us some highlights from your NA speech someday, because I’m still beta-testing my AA pitch.
Also like your third point about what patients are looking for– the symptom to go away. Had an intake recently where I was so busy with releases and forms and risk assessment that I almost missed that. I suddenly hit 55 minutes and realized this guy (or woman, or couple) had forked over their hard-earned copay, and I hadn’t even come across with an intervention.
So sue me, I left some of the checkboxes for next week, ran a few minutes late, and gave him/her/zher/them a few things to try over the weekend.
It just felt like a better way to end the intake than going over the damn list again. The list is never done anyway.
I would also add the need to address head on that when we say “these medications may not help” the person hears ” nothing will help.” It can be a tricky discussion when people have become convinced that the only help is in a pill.
Lord I’m blue,
But I won’t be blue always.
‘Cause the sun’s gonna shine,
In my back door,
One of these days…
Thank you. Mickey.
The tone and diction even echoes the style of the Big Book itself. Silkworth couldn’t have said it any better!
As those Old Testament dudes used to say: SELAH. If only more folks could hear such wisdom from their doctor!
As for the patients who’ve been buying “something on the street”? The street may not have anything to offer them, either — at least, nothing that can match how that “something on the street” made them feel for the first year or so, when their relationship with it was new. Now they’re just running in circles staving off withdrawal … and chasing a romanticized memory of those first few times.
So just let’em know: the very best they can expect from an antidepressant is a lift for the first year or so. Or maybe just 30% of a lift. After that, they may find themselves in much the same jam they are in with the street stuff. But there’s a good chance they can find something in AA or NA that does not “poop out” …