Saturday, September 13, 2008

I Have A Friend....

ClinkShrink is looking for something to climb. Roy is collecting links to Mental Health Blogs: Thanks for all your contributions and if you'd like to add another mental health blog to the list, please visit Roy's post and comment.

I titled this post "I have a friend..." because it's not an unusual way for someone to start a conversation with a psychiatrist about a mental health problem in a social setting-- maybe it's about a friend, maybe it's about themselves, I never ask, I take it at face value. Sometimes I later hear, "actually it's my problem."

So I have a friend (--really) ....

We're together in a public place, there are people around that we know, probably not within earshot, but who knows? The friend is, well, more of an acquaintance-- we don't know each other so well.

"I know you don't like Xanax, but it's the only thing that helps when my thoughts race."

I'm caught off guard. It was a statement, not a question, and I should have listened.
I mumble something. Whatever it was, it was probably the wrong thing to say.

"Why don't you like Xanax?" Friend asks.

Oy: if you haven't read Roy's post on Why Docs Don't Like Xanax (some of us), then by all means,

Issues with addiction, I say.

"I don't take it every day, just when I can't sleep and my thoughts are racing. What else could I take?"

Okay, at this point I retrospectively cringe at my response. What was I thinking? Roy and ClinkShrink would crawl under a rock and pretend they don't know me. I mumble something about Ativan and Valium being less addictive. I mumbled something about perhaps the Xanax wasn't a problem. Oh, I recommend these medications rarely, really rarely, and only to patients I've carefully evaluated. What was I thinking to suggest the names of other meds? Or what
wasn't I thinking?

The subject changed, we didn't discuss it any farther, but I was left obsessing about the weirdness of my response, the irresponsibility of it, the cavalierness of even hinting that certain medications (addictive ones at that) might be better than something already prescribed for a condition I didn't explore, by another physician, for a person I didn't know terribly well.

So this post will now have two themes:
1) When personal friends asks a psychiatrist (this psychiatrist in particular) for advice.
2) What I did wrong, which is basically everything.

Friends ask me for suggestions from time to time. ClinkShrink and Roy might (I'm not sure, I'm surmising this) say one shouldn't give any suggestions and that by listening, engaging, offering advice, that one essentially establishes a doctor-patient relationship and becomes responsible for them and becomes open to all the obligations inherent in any doctor-patient relationship, including the right to be sued for malpractice. Again, I'm putting words in their mouths, so Clink and Roy: do feel free to add to the bottom of this post.

I don't tend to worry about being sued. And when a friend wants to talk about a problem, knowing I am a psychiatrist, I listen and I don't usually immediately say, "Ask your Doctor" --because, well, it feels dismissive and I feel like the voice-over in one of the pharmaceutical commercials. I usually listen, answer what's asked to the extent that I can, and if the situation warrants, I gently suggest it might be worthwhile to have at least a one-time psychiatric evaluation. I never, ever, tell my friends they need long-term intensive psychotherapy or specific meds: that would be the job of the evaluating psychiatrist and I like having friends! I will refer friends to shrinks I think they'd like, if they want, though, hey, it's my best guess as to interpersonal/professional chemistry. I try to figure out an appropriate boundary -- somewhere that's caring but not opening myself up to to hearing all sorts of overly personal details-- and I try not to upset my friends or leave them feeling uncomfortable. Finally, I try to be of help.

Here's what I did wrong with my Xanax-for-racing-thoughts friend:
  • I didn't listen to the issue. Was there even a question or was it just a request that I hear that Xanax is helpful to this particular person? I never found that out.
  • If there was a question as to the appropriateness of this particular medication for this particular person, I really was in no position to comment or second-guess the doc who prescribed the med.
  • I jumped to a conclusion that, in the moment, I didn't even realize I was jumping to: The friend mentioned that Xanax helped with racing thoughts. I know this friend has trouble sleeping when there is a lot going on. "Racing thoughts" are a symptom of Bipolar Disorder-- it's a term used to describe the symptom of having one's thoughts go so fast that the patient can't keep up with them. They don't generally happen with conditions other than mania, and I assumed the friend wasn't really having "racing thoughts" but anxious ruminations associated with insomnia-- in other words, dwelling on daytime events and worrying which were interfering with sleep. I don't know any details, it was a quick assumption. It wouldn't have been appropriate ( nor would I have wanted) to ask all that I'd need to ask to figure out the precise phenomena, diagnosis, or if Xanax or something else was the appropriate treatment. I also assumed this friend doesn't have a substance abuse history and I'd have no way of knowing that....perhaps any addictive drug, be it Xanax, Valium, Ativan...might be the wrong choice. I should have kept quiet.

The subject changed, it took me a little bit to process what I'd said and what I hadn't said, and somewhere in there, we followed it up with a second, briefer conversation in which I said much of what I've said here.

Hoping my friend is now sleeping bette


ClinkShrink said...

This is a great post that illustrates what happens when your friends, neighbors or relatives know you're a psychiatrist. It's that inward cringe that comes right after you hear the phrase "this is what my doctor is doing...what do you think?" It's hard to be supportive without offering advice, and to set boundaries without making the person feel that they're being blown off. I think this may be one of those situations where "I don't know" is the correct answer.

I'm trying to get a new computer but the Apple Store isn't returning my calls. How can they do that to a geek fan?

Anonymous said...


Sorry you all have to experience that. It really does sound uncomfortable.

(There was more to this post, but I kept erasing and rewriting, and finally ended up with nothing.)

Unknown said...

Oh, I have so been there.

Awake and Dreaming said...

I think I give more advice to my friends then my clients... With my clients, I want to listen, reflect, listen, reflect etc... have goals, move towards something, NOT offer advice, empower them, etc... With my friends, I don't have that responsibility.

I'm a social worker, so things of course are very different, but if a client asked me about xanax I would probably give them information about benzodiazipines in general, remind them I'm not a doctor or pharmacist, and help them get in touch with their own or with further sources of info. If my friend asked, I'd tell them not to take it, to look for something else. That their doctor was a nut job for prescribing it... that sort of thing. I'd tell them that I see people on a zillion different drugs in detox, but never that one.

Anonymous said...

I LOVE that you are so responsible. It's the way all doctors ought to be. I think a short caveat that explains you'd need an hour to ask all the necessary questions before you'd REALLY know the right answer.

Meanwhile, many GP's out there prescribe psych drugs with carefree abandon and not a second thought about it. A female friend of mine (NOT ME!) has a GP who she bugged long enough about possibly being hypothyroid (because she's overweight in her eyes at 140lbs and 5'6") that he put her on 250 mcg of Levoxyl with no referral to an endocrinologist. I told her that my endocrinologist said the rule of thumb is 1 mcg per pound of body weight and she seemed possibly overprescribed but she loved the weight loss effects, but then she was overly anxious so he wrote a prescription for an anti-anxiety med which she LOVES. THAT verges on malpractice, having a social conversation with caveat attached does not in my opinion.

Anonymous said...

It seems to be a common phenomenon that the general public gets hold of a technical medical term and uses it to mean something different, meaning that doctors have to find a different term for what they want to talk about. Maybe this needs to happen for "racing thoughts".

(I've occasionally wondered if there is a term for the symptom of multiple trains of thought all going on at the same time, to such an extent that the pt gets confused and becomes incapable of following all of them. It seems similar in some ways to the symptom of racing thoughts, but I've never come across it written down anywhere.)

The medicolegal implications of having friends and family while being medically qualified are just things that you have to live with, I think - you poor things :-)

Rach said...

A dear friend of mine has a mother who is a general practitioner with a side specialty in something much more specialized and less practised... so we all bombard her with questions... but she puts a quota on how many questions we can ask!

But that's really very awkward, particularly in public and on the spur of the moment.
When in doubt, recommend chocolate? is that an option?

Anonymous said...

I went to a medical school where we were taught that Xanax is the "work of the devil." That imprinted. Despite my field, I have a policy of referring people back to their primary prescriber for xanax refills because I don't want to be a part of that problem. I live in a community where Xanax is the anxiolytic of choice among the PCP's. There are a lot of addicted people as well as abuse of this drug in our community. Even when Xanax use comes up in the professional realm (and not the drive by social realm) it can create some awkwardness.

Novalis said...

This is a good example of why psychiatry remains different from other specialties, and mental disorders different from straightforward medical ailments. Both the discipline and the disorders involve ambiguous and peculiarly private areas of human experience.

Not long ago a colleague asked if I would write her a few days of cipro for a bladder infection she had. I didn't hesitate to write it (she knew the symptoms and had taken cipro before). If she had asked for any psychiatric medication (not to mention Xanax), things would have been rather different.

So we remain "special," with all the pros and cons that entails.

Anonymous said...

I'm not sure this is specific to's all docs.

Dr. Pink Freud said...


In my opinion, you did nothing wrong. You were asked a question, and responded with an honest answer. To be disingenuous, or avoid the questions would have been equally inappropriate with a patient, or a friend. I always preface any sort of comment or advice with, "Because I know you personally, I can only comment on what I've observed..." This avoids the dual role issue for me. In any event, if honest, and passion about convictions are a character flaw, well then, maybe you're guilty of something. I respect and admire your sincerity and integrity.

On another note, this benzo thing has gotten out of hand. I often have new adjudications to my prison endorsing "racing thoughts", when it's really ruminative thought processes, so I can appreciate your observation regarding treating the appropriate symptom. Also, offering Xanax (alprazolam) as a front line of treatment, isn't, in my opinion the best option. I have found though, that with SSRI, or TCA therapy, if the patient is given the opportunity to have a small amount of Xanax to keep on hand, it can be helpful both PRN, and for anticipatory anxiety, if panic is involved. With other anxiety disorders, having a small ration of Xanax available can reduce anxiety, by affording the patient the peace of mind that if things get "out of hand", there is a fast acting option. I like prophylactic approaches like this.

This all being said, Xanax works very well in many instances where other options do not. Unfortunately, with psychiatrists, it's become for anxiety, what Oxycontin has for pain management; over-prescribed, and underutilized in appropriate instances.

A final thought. All this being said, the single best predictor of achieving and maintaining sobriety (in established addicts) is social support. How many psychiatrists actually assess this before prescribing a benzo? Granted, self-report is notoriously unreliable, but if your patient reported an intact, social support system, and no addictions (and there were no warning flags), would you be so hesitant to prescribe a benzo?

Anonymous said...

I just want to say that I have the same experience as your friend with Xanax. None of the antidepressants are effective for anxiety for me, and I have a prn script for Xanax 0.25 mg twice daily. I take between 5 and 10 pills per month, and I have had a script for 30 pills last from 3 to 6 months at a time. I don't even necessarily take it weekly, but just when my anxiety begins to feel out of control. I find this very effective, and I certainly don't have any addiction problems. I have taken it like this for years with never a need or desire to increase the dose. It also works very well for me.

ClinkShrink said...

OK, I'm back and done looking for something to climb. Just did a 30 foot technical 5.4 route blindfolded. (Really.) It was cool.

Now I've got reports to edit.

Dinah said...

Thanks, Clink, don't fall. And the blindfold is a bit too kinky for the blog.

Anon: Life has it's quite frequent moments of transient uncomfortableness. Friend didn't seem distressed, so this was pretty minor. Thanks for the support.

TigerMom: I was expecting you to say something, thanks for not letting me down.

Still Dreaming: I talk too much to everyone.

TP: Thank you. I wonder if thyroid meds would make me lose weight.... Oh, and in private practice, I take 2 hours to do an evaluation and often still don't have the answer.

Nardilfan: ? can I take a swipe at "Flight of Ideas"..some form of thought disorder. "Loose associations," maybe?

Rach, You are absolutely right that the spur of the moment thing caught me off guard. The same day another friend asked me for help but that didn't make it to the blog because I didn't say anything stupid. Chocolate is always good.

Cancer Doc and Anon on Xanax: It remains a mystery to me why one medication (any med) can be so helpful to some and so harmful to others.

Novalis, I think kind of yes and no. If your friend had had a bad reaction to cipro, or if it hadn't cured her infection but had then made it impossible to get an accurate culture, you might be feeling like this wasn't as simple. I think I agree more with "S" that it's an issue in much of medicine-- friends ask for suggestions and to really understand a problem, you need to understand all sorts of personal things-- maybe it's Do You Have a History of Bipolar Disorder, or what other meds are you taking, or maybe it's questions about bowel or sexual habits...sometimes it's just a little uncomfortable.

Dr. Pink, Thanks but I still think I'll be more careful in the future about making medication suggestions without knowing someone's history...