Sunday, September 24, 2006

A Taste of Our Own Medicine?

I'm prone to rumination and a number of years ago, a shrink friend (but not a shrink rapper) told me I should take Zoloft. No one before or since has ever suggested I should take a psychotropic medication and I dismissed my friend's suggestion with the thought that it was motivated by something along the line of misery loves company. You see, my friend had an anxiety disorder for which she was taking Zoloft, and she found it helpful; while I don't imagine she told everyone she met to take Zoloft, I did think it predisposed her to see whatever my issue of the moment was as psychopathology, not just any old psychopathology, but pathology just like hers that would be helped by Zoloft, just like hers.

So we worry that our practice of medicine will be influenced if we're given pens by the pharmaceutical companies. If we're talking about how that free lunch influences us, might we talk about how the doctor's personal response to medication effects his practice? It's common for psychiatric residents to discuss whether it's necessary to have a personal psychotherapy in order to become a psychotherapist. No one talks about how their own responses to illness and treatment effect their own practices with regard to diagnosis and treatment.

Docs are human, I imagine that if a doctor finds a medication helpful, or has a horrible reaction to it, his practice will be influenced. If I've had a rare but extreme adverse reaction, how can I possibly order such a treatment without fearing my patient might have the same rare but extreme adverse reaction, even if the odds of the same reaction might be a zillion to one? Don't we all get sensitized by our personal experiences?

Plop plop, fizz fizz?


HP said...

Interesting point. I can't see how personal experience wouldn't bias thinking.
And medication for rumination? It's not necessarily a bad thing, dependent on whose conceptualisation you follow.

ClinkShrink said...

I dunno, having an allergic reaction to, say, amoxicillin would not necessarily mean a doctor would never prescribe amoxicillin. Maybe Zoloft would have been a good idea at the time, but knowing you as a clinician I know you wouldn't then start giving out Zoloft to everyone. I guess I just trust that most reasonable clinicians act reasonably; that may or may not be true for all.

Sarebear said...

I would think that you asking yourself these very questions is the very best measure to take against such a problem.

I sound like my shrink, lol. Not that I'm trying to shrink you.

jw said...

I cannot see how anyone could not be effected by their own experience. Such effect --such change in opinion-- is a core part of the human experience.

I think it is important to know how much of what we think/feel is a result of our own experience. To know such is an important part of knowing yourself.

Thus knowing that you have had a very bad experience with Effexor modifies your own thinking in a way which partially offsets the bad experience.

Those who read my posts know that I have had very bad (gender) experiences with the therapeutic community: My knowing that changes my own fury to skepticism ... thus a much better condition.

Shiny Happy Person said...

Interesting post, but I don't know that using ones personal experiences is any different to using ones patient experiences, except perhaps that one has the experience of multiple people to go on when using patient anecdotage. We all use anecdote-based practice, perhaps even more than evidence-based practice.

I was talking to (desperately trying to get away from, truth be told) an Effexor rep last week. Of course, it would have been easier to just tell her it's the best drug ever and I give it all my patients and always will, but I'm too honest for my own good sometimes. She was asking me about my hesitancy in using it, and I realised that it's probably got a lot to do with the fact that when I took it many moons ago, it did nothing but make me feel sick and gave me a headache. But added to that is the fact that I haven't actually had very good results with it on my patients either.

Lamotrigine isn't yet licensed for use in bipolar dsorder in the UK, and only a few experienced psychiatrists are using it. I take it and have found it very good so far, and would therefore probably consider prescribing it myself, whereas most of my colleagues wouldn't even think of it.

I think if I'd had an unusual adverse reaction to a medication it wouldn't affect my prescribing of it, in the same way that, as Clinkshrink points out, my own allergy to penicillin wouldn't stop me prescribing it for a patient.

Alison Cummins said...

I think there’s a case to be made for trying out psych meds oneself before prescribing them to others. There’s definitely a case to be made for taking into account both the literature and one’s experiences with one’s patients when prescribing.

I’m not a medical person. I’m someone who has always scored as non-depressed on depression scales even when in the midst of a major depressive episode. I’m 42, bipolar II, with episodes of moderate to major depression once or twice a year from the age of fourteen. I was never able to manage enough momentum to graduate from college. The first time I was asked to fill out a depression questionnaire I was 34.

Do you feel guilty? (No. I feel depressed.)

Has your libido changed in the past six weeks / six months / two years? (No. I haven’t had sex in four years and don’t miss it. I used to be a randy little thing, but that was then.)

Have you lost pleasure in things you usually enjoy? What’s “usually?” I’m up and down. It’s not that I can’t feel pleasure, it’s that it’s too much trouble. I’ll say no.)

Do you want to die? (No. I don’t want to feel like this any more, that’s all. If I had no hope anything would change I would feel life was not worth living, but I know from experience that if I hang on long enough things will get better. Plus, I’ve finally engaged a treatment program!)

How do you feel right now? (Pretty good, actually. I was just interviewed by the head of this department who believed I was depressed and who offered me a referral to a psychiatrist once the depression tool proves I’m depressed, so I’m feeling pretty hopeful. And I’m in the process of filling out a form, which I’m good at, so I’m feeling relaxed and competent.)

Test results: not depressed! In fact, no clear indication of any problem at all! No referral to a psychiatrist! Placement with the least competent member of the team, who had no idea what he was supposed to be treating me for!

From the time I filled out that first depression scale, it took me two years, lost jobs, lost opportunities and paying money I didn’t have (from a revenue of $300 per month, paying $100 per month to a puzzled shrink on sliding scale) to finally be referred to a psychiatrist. I am now taking meds (50 mg sertraline, 100 mg lamotrigine) which are not a lot but enough to keep me on an even enough keel to earn and keep a good job. I’ve married and bought a house. I have sex and like it. But my answers to a depression rating scale wouldn’t be much different from what they were when I was spending all my time lying on a couch trying not to breathe.

The literature would not include me. However, I am among your patients. So yes, take the literature very seriously. But interpret it in the light of your experience, because your experience will tell you things not measured in the literature.

The Locum said...

SHP, the easy way to get away from the Effexor rep is to looks wise and murmur, "Of course, my A&E/medic mates reckon it's really interesting in overdose..."

I chuck NSAIDs around like they don't have side effects. Can't take them myself. Wish I could - diclofenac's a cracking drug...

Steve & Barb said...

I agree with Alison that trying different meds can help you better understand what your patients go thru with side effects. I don't think a bad experience would necessarily cause you to not prescribe something... though it might make you a wiser prescriber.

We all know that side effect and efficacy experience is so variable, that only an egotist would reason that, because Effexor made my blood pressure go up, I won't prescribe it (though you would be wiser to monitor blood pressures). But trying it yourself helps you understand the nausea, headaches, and yawning it causes in *some* people.

My medical school used to have students (voluntarily) take Haldol, so you'd have a better understanding about the side effects. I think this stopped when someone had way too much understanding about what acute laryngospasm feels like.

Dinah said...

Gee, Roy, I don't know if I want to know what you're taste testing. I'm still processing the whole sudafed thing.

SHP: nice of you to bring up the lamital issue...I use it a fair amount, patients like it, works well, generally well tolerated, though I've seen a few rashes and had to stop it. A friend had an otherwise healthy young patient have a severe, near-fatal response and after sitting by the ICU bed for days, told me she could never again prescribe this medicine--I still use it, but I actually do tell my patients this story (--I would never do this for a rare report in the literature, but this was the patient of a good friend and so it felt closer to home) far, despite the horror story, every patient I've offered it to still agrees to try lamotrigine.

I'm not sure what good trying meds to experience and empathize with side effects does given the variability of them: I've seen patients gain 100 pounds on clozaril and I've seen patients hold their weight totally steady; I've seen people feel slowed and awful on haloperidol, and I've seen people begging for it. If I try a med and have no side effects at all, might it make me Less sympathetic to someone's distress? In a world of total logic, No, but come on, you've never heard someone say "that wasn't so bad."?

Oh, and to everyone who wants to feed me Zoloft: whatever I was ruminating about in that story, I wasn't terribly distressed. Patients walk in the door suffering--I had no sense of this. My point wasn't that maybe I needed Zoloft then, it was that my friend was quick to diagnose and suggest treatment based not on a full psychiatric evaluation, but on her own experiences. This is not at all uncommon.

ClinkShrink said...

For the record:

Dinah, I don't think you need meds. Just a nice casual Saturday afternoon in the climbing gym with me :) C'mon, I'd even hold the rope.

Fat Doctor said...

Have you seen this website?

I definitely think my personal health experiences influence my decisions as a physician. Lately, for example, I've been trying to find RAS in each and every hypertensive. Just fishing, but some day I'll catch one.

BTW, I love my zoloft. I think you would, too. I can call some in for you if you're interested...

(Smiley face, smiley face)

NeoNurseChic said...
This comment has been removed by the author.
Sarebear said...

I bet that was a heart-wrenching experience for your friend doctor, Dinah.

Lamictal was the first my shrink tried me on, right out of the gate from the first appointment. Three weeks in, rash. I was starting to notice possible signs of changes, and had minor side effects, and having read it can be hard to find the right drug, was happy to try it and wanting it to work out.

I got a rash. I kept telling my hubby no that's not a rash, but after a few minutes I let my hopes back down again.

Dang it! I have heard, that if you go back down to the earlier week's dose, and then go up slower, like real slow, that that can actually avoid the rash (the non-fatal one, which is in most cases the rash people have, I've read), and then after 8 weeks or something on it, the danger has pretty much passed, for the most part . . .

I don't say this asking for medical advice on my situation, but in commentary that I wish my doc had done that. But then, he got suspended right around then, so I couldn't ask him plus he scared and intimidated the ****** out of me at our first appointment . . .

Anyway! I'm wondering, then, in a more general way, if all the warnings about reactions influenced him, OR, what is more likely, is that the experiences and findings (possibly mostly anecdotal?) from other docs about the slower titrating aren't much known, yet, and that he hadn't come across them or researched that.

I guess I wasn't turned off of the drug by the reaction, since I wish I hadn't had to give it up so early. And, it didn't zonk me out like my current one does sometimes. I don't have a life, though, so that's ok. Helps pass the time; time asleep is less time I have to realize I have no life.

Anyway! Sorry to go on . . .

I think I've commented a few salient points, in the midst of all those peppery ones . . .

HP said...

Just wanted to clarify my badly written comment - I meant that rumination isn't necessarily a bad thing, not that medication for rumination wasn't a bad thing.

Note to self - drink coffee BEFORE posting :)