{"id":58879,"date":"2015-08-08T20:11:59","date_gmt":"2015-08-09T00:11:59","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=58879"},"modified":"2015-08-08T20:13:07","modified_gmt":"2015-08-09T00:13:07","slug":"therapeutic-trials","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2015\/08\/08\/therapeutic-trials\/","title":{"rendered":"therapeutic trials…"},"content":{"rendered":"\n

My first real medical specialty was Rheumatology. I trained at a place that had a strong section, and they spent a lot of time with the trainees – high standards all around. Rheumatology was [and is] an unusual medical specialty. There are more than the usual number of diseases of unknown etiology<\/font><\/em>; fewer cases with classic presentations<\/font><\/em> [a lot of overlap among syndromes]; a lot of mystery about etiology and pathophysiology<\/font> [mechanisms]; and biological markers with only statistical specificity [not sure things]. I suppose if I’d thought about it, it wouldn’t have been a half-bad prequel to psychiatry, where all of those things are even more true [like I said in the last post, I must be drawn to mystery and ambiguity].<\/p>\n

That same fuzziness surrounded treatments. There was almost no disease specificity, some situation where this diagnosis leads to this drug. In a patient with Rheumatoid Arthritis, developing a "hot joint" might be a call for an anti-inflammatory agent, or physical therapy, or even putting on a plaster cast. "It depends…" introduced the answers to most questions in the Rheumatology Clinic. The attendings made up for the lack of precision by being very careful – taking careful histories, doing careful exams, making careful treatment choices – and the best lesson of all, carefully following up their interventions. Every treatment was considered to be a therapeutic trial.<\/p>\n

I’ve tried to follow that lead in psychiatry, making every prescription a clinical trial. It was easy in private practice. I saw people for a long time by usual standards, and there weren’t that many who were on medication. I used to joke that I wrote more prescriptions for antihistamines than psychiatric drugs [you’d have to live in Atlanta to understand why]. But in my stint as a volunteer in a charity clinic, I worried that I wouldn’t be able to do that. I was pleasantly surprised to find that it wasn’t true. I work infrequently, so it’s easy to remember patients visit to visit. And I’m surprised how easy it is to develop a therapeutic alliance even in that setting. When I first started, I was horrified at the polypharmacy and drug regimens the patients were on, and wanted to slash and burn. I quickly learned the error of my ways and backed off. These patients lead hard lives, and they become attached to their medications.<\/p>\n

What I found was that down the road, it was much easier to get  people off of unnecessary medications once we got to know each other. I’ve been there for six or seven years now, and there’s no-one in the clinic on antipsychotics anymore who doesn’t carry a bonafide psychotic diagnosis.  I’m kind of proud of that. When I started, almost everyone was taking some flavor of Atypical Antipsychotic – sometimes two. But there’s actually something specific that has me on this airy topic.<\/p>\n

There are a reasonable number of patients who have a Generalized Anxiety Disorder. In practice, I never saw them. I just wasn’t the person you would refer such patients to. So it was a new experience for me. They’re a very similar lot. They don’t have "fixed" anxiety – meaning anxiety in certain situations or settings. They’re always anxious. You can see it as they walk into the room, trying to not let it show, eyes darting, jumpy. If you’re a me, you start looking for triggers, or conflicts. What you find is nada, just a lifetime of anxiety as far back as they can remember. Often, they say something like "my Mom had it too." There are invariably somatic complaints and fears of imminent catastrophe, with a history of frequent trips to the ER for suspected heart attacks and the like. <\/p>\n

I found that if I tried a medication, they rarely took it for much past the first pill. Feeling any medication effect scared them, and they stopped – even with the minor tranquillizers. I read that SSRIs were supposed to help. But one is rarely helped by a medication you won’t take. I began to start them on homeopathic doses, thinking I could sneak my way up after a time of acclimation. So I would start with 5 mg of Citalopam for example. To my surprise, they returned, saying it helped. In cases where I added a Benzo as a prn for anxious situations, the same thing happened. So I prescribed half of an 0.25mg Aprazolam, and heard the same report. 5mg Citalopam? 0.125mg Aprazolam? Who’d have thought? Over the years, I’ve seen enough of these patients, and written enough of these mini-dose prescriptions, to see that as the way to treat such cases straight away. I still do my "therapeutic trial" thing, but in these patients, it always seems to come out the same. I have no clue about the why?<\/font><\/em> of it. <\/p>\n

What brought it to mind was seeing a patient in the clinic who I now only see every three months for refills. She was one of the first I tried on these baby doses. She is now working part time and proudly announced that she hadn’t been to the Emergency Room for over a year. Both things are major accomplishments. She was downright effusive about how much better her life is. I rarely have very much good to say about our medications, so I made a mental note to write about it – I guess to prove I’m no therapeutic nihilist.<\/div>\n","protected":false},"excerpt":{"rendered":"

My first real medical specialty was Rheumatology. I trained at a place that had a strong section, and they spent a lot of time with the trainees – high standards all around. Rheumatology was [and is] an unusual medical specialty. There are more than the usual number of diseases of unknown etiology; fewer cases with […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[5],"tags":[],"class_list":["post-58879","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/58879","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=58879"}],"version-history":[{"count":6,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/58879\/revisions"}],"predecessor-version":[{"id":58892,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/58879\/revisions\/58892"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=58879"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=58879"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=58879"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}