Tuesday, May 16, 2006

Change is Good

I've been in corrections long enough now that my name has become inextricably associated with prisoners. Free society clinicians occasionally call me and the call goes something like this:

"I was supposed to see Joe Blow** and he didn't show up for his appointment. Could you check and see if he's been locked up?"


"Joe Blow's sister called and said the police picked him up last night. Could you make sure he gets his medicine?"

For all practical purposes, I've become the local lost-and-found for psychiatric patients. That's OK. I like talking to free society clinicians, particularly the part where I tell them: "Yeah, he's already been seen. I saw him the day after he got locked up and his meds have been ordered."

There's always a bit of a silence at the other end of the line, or a general expression of surprise. People are so used to hearing stereotypes about correctional mental health care---universally negative---that they can't believe a system could ever possibly work well.

On my end of this process, I have a wish list.

I wish that clinicians who call me about their patients' medications would actually know the medications that the patient is on. As in, the name, dose and frequency.

I wish the free society medication regimen would make sense. Granted, psychiatry is as much of an art as it is a science so psychopharmacological approaches can vary reasonably between reasonable clinicians, but I see some med combos that don't come close to reasonable. I get patients from free society who come in on subtherapeutic doses of two or three medications from the same medication class, or on meds with no proven efficacy for the diagnosis the patient has been given. And I am responsible for making treatment decisions given this history.

Sometimes I change medications from what a patient was given in free society. I know this is heresy, and it tends to engender suspicion from my patients and/or concern from outside parties, but I do it. I do it when I want to give treatment that is consistent with current practice guidelines and research. I do it when there are known contraindications or potential complications (like addiction) associated with the free society regimen. I do it because sometimes the patient actually may require less--or no--medication once he/she is abstinent from drugs and alcohol. I do it because I am responsible for doing what's best for the patient, even when the patient demands care that is outmoded or even inappropriate.

Yes, I change things. But sometimes things need to change.


**Not his real name. Duh.


Anonymous said...

For the record, I work for a medical school whose Dept. of Psychiatry contracts with the state prison system to provide inmates with a "mental health" designation pre-parole assessment in preparation for parole- mandated out-patient care. I preface my comment by saying that this state's corrections medical system has been placed in conservatorship because it was ranked the worst in the country.

I find that state prison is the only place I have found where a man can be diagnosed with adjustment disorder for 11 years, where NOS reigns, and psychiatrists place lists on their doors of otherwise appropriate medications which they will not prescribe. Why? Basically rumor: e.g. inmates believe that can get "high" on Bupropion and "low" on Quetiapine. Therefore, Dr. Whomever no longer prescribes these meds, "Don't even ask." Patients who have had an otherwise successful response on a "banned" medication are suddenly discontinued by virtue of being transfered to another prison; certainly not because of a change in diagnosis or response. Then, upon release, the parole out-patient doc (who wants to know from me the history and which medications the patient feels were most helpful) may restore them to the banned medication because there is more "latitude" in prescribing on the outside.

I have worked in a forensic environment for a considerable period of time, and I am certainly aware of abuses and attempts to abuse the psychiatric system ("I have a seizure disorder and depression. Do you think it's right I'm on the top bunk? Can you help me out?"). But I find no rhyme or reason for most of what I observe. Attempts to discuss evidence-based rationale with a provider will generally (at best) result in a "Who the hell are you?" look, or (at worst) a complaint to their union. Regardless, either seem preferable to the flat out indifference I often encounter: "You've given me something to think about." Right.

The point is, knuckleheads are inside and outside the fence. I wholeheartedly agree, do the right thing 'cause it's the only sensible thing to do.

ClinkShrink said...

The challenge is to find people who are willing to do the work. There are lots of people willing to stand outside the walls and point fingers, but relatively few like yourself who are willing to come in and help out.

Fortunately forensic psychiatry fellowships require that students get at least six months of correctional experience, and child psychiatry fellowships are also requiring forensic exposure. More people are getting a taste of "life inside the walls", are at least willing to consider it as a possibility.

Dinah said...

From today's Wall Street Journal:

and if that's not enough:

And yes, Clink, you may fix my links. Hope you like the pic.

ClinkShrink said...

Alas, I am not a Wall Street Journal subscriber. I am left with only a tantalizing paragraph of the full article. Unfortunatetly, I'm afraid I can imagine the rest.

I like the picture--feel free to accessorize my posts anytime.

Sarebear said...

My husband has a shirt that has Dilbert on it, his hands up facing outward, and it says, Change is Good, You Go First.

I'm gonna have to wear that to therapy . . . . hee! Especially when I see my difficult iatrist next.