Thursday, August 30, 2007

My Patient, Myself

I saw this abstract and wanted to post it. Entitled Psychiatrist Attitudes toward Self-Treatment of Their Own Depression, it's a survey conducted of Michigan psychiatrists regarding their opinions toward self-prescribing. A survey of more than 500 Michigan psychiatrists showed that more than 40% would medicate themselves for mild to moderate depression and that 15% had actually done so in the past. Seven percent of psychiatrists said they would treat themselves for severe depression or depression involving suicidal ideation.

The AMA code of medical ethics states: "Physicians generally should not treat themselves or members of their immediate families...It would not always be inappropriate to undertake self-treatment or treatment of immediate family members. In emergency settings or isolated settings where there is no other qualified physician available, physicians should not hesitate to treat themselves or family members until another physician becomes available. In addition, while physicians should not serve as a primary or regular care provider for immediate family members, there are situations in which routine care is acceptable for short-term, minor problems."

So why or when would a doctor consider treating himself? I don't know Michigan well, but I'd guess they probably have the same shortage of psychiatrists that other Midwestern states have. If you're a depressed psychiatrist you may be the only game in town. Maybe he'd be concerned about privacy and information-sharing among colleagues.

Or maybe the AMA would consider mild clinical depression to be a "short-term, minor problem" for which the self-treatment exception would apply. There are probably hundreds of physicians who at one time or another have written antibiotic prescriptions for themselves or for family members. I wonder if this also applies to prescribing for family pets? Should a psychiatrist prescribe Prozac for his obsessional cat? Thorazine for the nervous dog? A recent survey of neurologists showed that more than 90% agree that it would be appropriate to self-prescribe for acute minor illnesses. Another survey of young Norwegian physicians found that 90% had self-prescribed in the past year.

Don't ask me what Michigan surgeons would do...


Dinah said...

What a GREAT post!!

So, I'm going to toss out one idea, which you mentioned, but I'll throw a stronger bent to it. A doc can self-treat for a mental illness (maybe with samples) and there is no record created. Once it goes through health insurance, once it's in a medical record, it's no longer completely private. You want life insurance: have your shrink write a letter (yes, I regularly write letters to life insurers). Oh, and those little check off boxes on licensing and credentialling and malpractice forms: Do you have a mental illness that could interfere with your ability to practice medicine:--that suicidal depression could be a problem. If the doc just says NO (essentially lies), is it a problem? It's not like the licensing board can request psychiatric records they don't know about, but the issues get complicated. If the doc self-treats, it's almost like it hasn't happened, and there's no paperwork trail. Not to defend self-treatment, but you asked Why Would Someone?
In many places the psychiatric and or medical community is very small-- getting treatment from a stranger isn't an option.

I've seen many patients who've mentioned in their family history that they have a doc relative who prescribes their own anti-depressants, and I've seen patients who get their meds from relative shrinks. I don't think it's that uncommon.

On a more personal note, you know that years ago I gave a sedative to our first dog who barked incessantly every time we left the house, much to the distress of the neighbors in the next apartment- I was trying to find some way that we could go to a movie. The poor dog got delerious. But I know this is what you were referring to. Fortunately, Max has not required any psychotropics.

Roy, we know, feeds himself sudafed. We'll have to talk to him about this.

Great topic.

Roy said...

I am feeding myself green M&Ms now. The only paper trail is the torn wrapper (rapper?).

NeoNurseChic said...

I've determined that Tony needs medical/psychiatric help! I have definitively diagnosed him with separation anxiety, which in turn makes him very vicious towards me as he "acts out". LOL He'll be all sweet and then go nuts and bite me because he doesn't want to be held any more, but if I pay attention to the tv or get on the phone, he'll bite me because I'm not paying attention to him. And heaven forbid I try to go to bed at night...he chases me to my room and bites me every step of the way - even if he didn't want me touching him just 5 minutes ago, he still doesn't want me to leave.

So what can I give the poor critter? hehe

(I'm joking here. Well, the above is true - I think we ALL know my Tony stories, but I'm joking about the 'what can I give the poor critter' comment!)

He really is an interesting study in behavior!! I can see the conflict in him as he doesn't want to be touched, but he'll rub his face against the corner of the wall. It's like he really DOES want to be touched, but can't trust himself to let me touch him or something. He is a bizarre cat!!

On the topic of physicians prescribing for themselves...after a 16 hour day today and a 12 hour day yesterday (and another 12 hour day tomorrow), I have no comment on serious matters!

Take care!
Carrie :)

Mother Jones RN said...

I have known many doctors throughout the years who have treated themselves for many different conditions. One such doctor recently got himself into a heap of trouble with the government. He was self-prescribing, and his judgment became clouded and he started making some very bad decisions. It destroyed his practice, his marriage, and his relationship with his children. It was really sad to watch his decline.

Jayme said...

Shrinks treating themselves for mental illness? Hell yeah! Being able to avoid the stigma of mental illness is THE BEST reason to swallow those samples if needed. No paperwork? No insurance or job discrmination? This is an advantage that I feel belongs to everyone. If shrinks can have that advantage, go for it. (Of course, I am not on board of ethics for a reason.)

FooFoo5 said...

By analogy, the old adage, "An attorney who represents him/herself has a fool for a client," seems quite appropriate here. But having worked in large practices, I am not the least bit surprised by this report. Dinah makes an excellent point in that I have never seen an accounting for samples apart from a case note. I recall quick conversations with a nurse in the hall, "Would you mind calling drug rep because we're almost out of med. Who would suspect the antidepressant is for you?

Likewise, I know physicians being "treated" over the phone by a colleague and paying for meds out-of-pocket, rather than using their otherwise excellent insurance. I would note this first came to my attention as a cell phone rang during a football game.

I have also been uneasy with physicians who maintain their own in-house pharmacies (legal at least in CA). There is a vaguely worded sign that you are under no obligation to purchase from the physician... But it's a hell of lot easier than making a second trip to the pharmacy; for everybody, I suppose.

I believe the point I'm making is about access. Patients read ads in Rolling Stone and, even after perusing the "fine print" determine they'd like to give a med a "try." They simply lack access. Physicians (and you could include other healthcare professional) know the appropriate indications and statistical consequences, but have access. What's the commonality? Lack of objectivity.

All said, however, the study does specifically refer to "psychiatrists." I haven't checked, but how many studies do you imagine are even interested in, for example, the Midwife With a Knife who gets a positive throat-swab for Strep and asks a colleague for a script or takes care of it herself? But then again, I could tell you about (as I later found out) the narcotics-impaired orthopod who repaired my left knee..

Aqua said...

I hope this doesn't come across as judgemental or too harsh...I'm just thinking about what I feel is fair for everyone and what I need to feel safe as a patient.

I feel that it is unfair that I am on the radar in terms of having to disclose pretty much all that goes on in my sessions with my pdoc to my insurance company.

...I was FORCED, (by threat of non-payment...and thus no way to feed/house/clothe myself), to sign a document saying that in order for me to receive insurance payments my insurance company can have ALL my pdoc's notes. So much for confidentiality during my therapy sessions.

This affects what I tell my pdoc and I know it affects my getting well because I am scared to talk about things.

While personally I would rather neither of us have to disclose this info why should my future ability to receive insurance, or get a job, or keep my job be any different from a pdoc who has a mental illness, or suffers from mild/moderate depression?

I also think it is dangerous and a bit scary,(both for the pdoc and the patient), for a pdoc to treat themselves. What about the patients being treated by the pdoc who doesn't care if he lives another day, who feels amotivated, isn't sleeping, doesn't care about anything, is inattentive or having cognitive problems because of, for example, his being in a MDE.

Even if it is mild depression...that's how my MDD started mild depression turned into moderate turned into severe and chronic MDD. They may not see the slippery slope if they are not well.

When I am looking for a healthcare provider I would like to believe they care, they they are not having memory/cognitive problems and they are well enough themselves to help care for someone else.

I know when I am really sick that is not the case and I would not want a pdoc who is that sick treating me.

P.S. I would love to see a post on "confidentiality" and how patients are often left with none if they need to receive insurance. My case is a great example of what I would call "coerced consent" in terms of not want to disclose info to the insurance company, but not really having any choice.

Dinah said...

Roy: why GREEN (maybe don't go there).

Carrie: I thought you were talking about Tony Soprano.

Others: the confidentiality issue is awful, why does an insurance company need to see psychotherapy notes (and I have never sent mine out).

I believe it's illegal to prescribe controlled substances for yourself.

Oh, this is Clink's post, I'll let her respond to commenters.

Midwife with a Knife said...

clink: This is an oddly timed post, as I've been unable to kick a cold, and have now developed a bad cough (complete with post-tussive emesis), shortness of breath, and chest pain and started having fevers again. I tried to work and got myself sent home from work. I'm seriously considering writing a z-pack for myself. (however, I'm feeling better enough to get on the computer, so maybe I'm on the mend).

Now, I would argue that a little azithromycin is different from a psychiatric illness because hypothetically, pneumonia or bronchitis or whatever doesn't affect my insight, whereas mental illness could. However, people could make the arguement that either any illness that affects you could alter your insight (i.e. I feel so miserable, this has to be bacterial!) or one could argue that someone who knows they have a mental illness and decides to treat it is showing some insight (hm....).

Anyway, I'll stop rambling on now.

And foofoo, how did you know? ;)

RoseAG said...

Doesn't seem like they put too much faith into talk-based therapies.

I don't think that talking to yourself qualifies as therapy.

#1 Dinosaur said...

MWAK: (cough/post-tussive emesis/longer than 2 weeks) Consider finding someone to send an NP swab for a pertussis culture. Z-pack is the right treatment, but if positive then your household contacts should be treated. There's also the public health issue.

Anonymous said...


I never respond to online blogs..but this topic is one that ShrinkHusband and I just revisited last week in our own kitchen.

Full Disclosure:

ShrinkWife, that's me, is delighted to be on Cymbalta 60 mg qd. ( What would life be like without SSRIs? Not great.)

ShrinkHusband has suffered terribly with prolonged major depression/anxiety for over 30 years. Currently under excellent control with meds.

ShrinkHusband is treating his own depression.

SweetHusband, (we are at home now), would be under the care of a psychiatrist if he were not a ShrinkHusband.

Just last week I asked SweetHusband to tell me again why he can't just tell his personal doc about his depression hx and let him write the scripts for the meds he is taking.

My thinking was along the lines of~~

"the more High Functioning Men go public about this depression, the less stigma will be attached to it.."

ShrinkHusband, being an excellent psychopharmacologist and thoughtful friend, reminded me that:

A) Who is he going to see in our small town?

Excellent point.
He is the best.

Many physicians and one psychiatrist have come to see ShrinkHusband for eval/tx in our office.

Not to mention at least half of the staff at the inpatient facility he admits patients to.

I promise that I am not being biased~

Sadly there are too few excellent psychiatrists or therapists in our town.

But, wait a minute....

ShrinkHusband and I both know that our Internal Medicine Guru is an Outstanding Physician and Person...
so what gives here??

B) IF ShrinkHusband was assured that his doc would listen to his hx of major depression with AND keep this information CONFIDENTIAL AND OUT OF HIS MEDICAL RECORD, then he would not have a problem with disclosing this information.

At all. Period.
OK, I believe him.

**At least we can have fun with this** :-)

( ShrinkHusband keeps sensitive information told to him by his patients "in his head" and does not put "certain details" in the chart).

C) But what is the chance that his own doc will follow the same protocal? It is a gamble, I agree.

At this point I am thinking maybe he is being a tiny bit "paranoid" (read this in a playful way, guys).

REALLY, what is the worst thing that can happen if this diagnosis was on his medical record?

D) He basically stated every point that dinah and jamie have already well documented in this blog.

Side Note:

It is dangerous for physicians to disclose personal health data too..

Anyone out there ever treated a physician colleague with a substance abuse problem?

After detox, if the NewlySoberMD has been unlucky enough to have been turned in to the Inquisition, uups~ Medical Board, NewlySoberMD will spend years jumping through hoops to keep her/his license active.

ShrinkWife understands that rules and regulations have their place, but this organization is rigid to a fault.

E) Then there are potential problems with insurance carriers~ medical, disability and malpractice.

F) Not to mention those questions that need to be answered for license renewal. Or when applying for a medical license in another state.

MotherJones~ it sounds like the physician you refer to has very poor judgement. (There is no medication to fix that problem..)

Perhaps he didn't have the knowledge, skills or family support needed to navigate this difficult problem by himself.

For the record, clearly, no physician should ever write a perscription for a controlled substance.

Aqua~ may I respond to some of your points? (thanks!)

Some opinions/observations~

Insurance companies are equal- opportunity annoyances.

Your doctor cannot treat what he/she does not know. Think about who is being hurt here...

Don't let the fear of someone reading your medical record keep you from getting the help that you need.

Regarding the issue of having "a physican who is having cognative problems or doesn't care if he lifes another day"...

**My comments here do not apply to anyone who is acutely suicidal.**

Your may not be aware that many patients (and physician-patients) suffering from severe depression can "pull it together" when they are at work or are in public.

Some patients present only their "best self" to their doctor and don't get the treatment best suited for their particular need.

This may surprise you~

The symptoms associated with depression really come forward when the patient is in the safety of their own home and families.

I bet you have been treated by or worked with with other professionals, including doctors, airline pilots, teachers, nurses and firemen who are dealing with undiagnosed mood disorders. The statistics for these disorders are heartbreaking.

Think about this: airline pilots are not allowed to fly if they are under medical treatment for depression.

Who do you want navigating your next flight?

A) The pilot with a significant mood disorder under excellent medical control.

B) The pilot who self-medicates her aniety with a couple of drinks.

C) The pilot who is not allowed to get treatment for depression and is experiencing severe anxiety, insomnia, a very short temper while making plans for suicide.

D) All of the above??

E) None of the above??

Life is complicated and messy. Each person needs to find their own path to health.

Are there other ShrinkFamilies out there dealing with these issues??

Regards to all~

michigantrooper said...

The author references "the AMA code of medical ethics"

Question: How many psychiatrists belong to the AMA!?

Less than 17% of all doctors belong to the AMA. My guess is that the percent of psychiatrists is even lower.