Thursday, March 21, 2013

The Basic Treatment Plan

There's a lot of discussion going on in the comment section of the post where I asked people to take a survey on mandatory reporting of dangerousness.  Our favorite commenter, Anonymous, mentioned a therapist who refused to treat him/her unless s/he got rid of her gun.  Then Jesse and Clink got into it over whether it's reasonable to ask patients, on the first appointment, to get rid of their guns.  Clink said, "Jesse, the problem with the approach that you're suggesting is that the therapist has then taken on the responsibility of caring for a patient who has announced at the outset that they will not follow the most obvious treatment recommendation."  Clink later noted that a therapist would not likely take on a patient who announced at the outset that he'd be late to every session and pay the bill late.  This all made me think.

So enough with guns, I want to discuss treatment plans.  Clink would be appalled: some of my patients are late to every session, and some take their time with paying the bill.  I don't really press people on the payment issue, I just like to be paid eventually.  I'd say it's because I don't have a dollar-to-dollar cash flow need, but when I was younger and my lifestyle was limited by cash flow, I didn't hassle people about paying in a timely fashion either, so I think it's me and my distaste for discussing money issues, not my generous spirit.  

It occurred to me that I frequently take on patients who 'announce' at the outset that they will not follow the most obvious treatment recommendations.  They don't want to take the medications I suggest.  I can live with that, so long as they aren't demanding I prescribe medications I feel are  not indicated for their condition, or that will do them more harm than good.  Then I say no, and yes, I do screen patients quickly before I see them, so that if their only reason for seeking care is to come in briefly every three months to get a specific controlled substance (for example, Adderall or Xanax), then I can say that I'm not the doctor for them.  Not because I won't prescribe those medicines, but because I don't like to see someone who is looking for a very specific service that I don't feel comfortable providing.  

I often suggest that people work on putting more structure into their lives, exercise, eat healthy foods, experiment with different diets to see if that has an impact on their psychological state, drink a little coffee, don't drink a lot of coffee, and don't drink alcohol if that seems to be adding to their problems.  If they taking sleeping pills at night and sedatives during the day, I suggest this might be a reason why they feel tired all the time, and perhaps they should come off.  I always recommend that people stop smoking.  I often recommend a frequency for therapy visits at a rate that is more often than some patients want.

So what's my success rate with getting people to follow my most obvious treatment recommendations?  Honestly, it isn't so good.  Most people take the medications I recommend and nearly everyone pays their bills, eventually.  The people who like exercise anyway will exercise.  It's not unusual for people to call me in a crisis, in which case I usually see them within a day or two.  During those periods of distress, we will formulate an immediate treatment plan.  During those episodes, people generally follow my recommendations for about two days.  Every now and then, someone is so resistant to following any recommendation at all despite continued difficulties, or they change the dose of their medicines so often without consulting with me, that I wonder if they are really patients, because the state of patient-hood does require at least the willingness to collaborate and consider treatment recommendations.

Is it me?  My impression from how people react, is that I'm not particularly intimidating.  No one seems to shy away from telling me they never filled the prescription I gave them or they aren't going to stop drinking.   I sort of figured it was the nature of the work, and that part of the job entails treating people as they come, and respecting the fact that not everyone is willing or able to do what I might think is best, and most people get better anyway.

But I don't need to ask people to give up their guns to know that I'm fine to work with people who won't follow the most obvious of treatment recommendations.  What about you?


jesse said...

I'm very much like Dinah in this regard. Since the discussion on guns began I asked a few patients if they have guns and lo! several did, even ones I had been quite worried about. They have had these guns a very long time and certainly were not interested in, much less going to, follow any recommendations I had on the issue. they are doing well in treatment and that is the major thing that counts.

Treatment plan? Yes, I determine the medications but the pastients decide whether they will take them, and not infrequently they stop taking them without having consulted me first.

The basic plan is to help the patients with the issues they have, but not only the issues they consciously identify. Sometimes there are other issues that are below the surface and take a long time to resolve.

ClinkShrink said...

Dinah, you've already told me you really don't treat dangerous patients so the gun removal scenario doesn't really apply to your practice. The discussion about not following treatment recommendations was related to basic safety issues, not just about taking medications. The kind of clincial situations you're talking about aren't the life-or-death safety kind of things I was talking about in the gun post.

Dinah said...

Clink, I don't have the after-the-fact bad outcomes you do. I don't screen patients for dangerousness. I screen for 2 things: 1) I'm not in your insurance network and you'll have to file for out-of-network benefits, and 2) I don't see patients who are in therapy with someone else. Aside from that, and the person seeking something unusual or specific ("I have self-diagnosed my ADD and I only want to come in if you agree to give me stimulants before you evaluate me"). My patients are the same as every other private practice psychiatric practice.
Many of my patients have suicidal thoughts, some have had prior suicide attempts, some serious, and many have had prior hospitalizations. Pretty much no one tells me they plan to hurt other people, except at the clinic where everyone responds, "If someone hurts me, I'm gonna hurt them." Rough 'hood.

Anonymous said...

Well, I'm a patient who hasn't always followed treatment recommendations. Is there a patient out there who has always followed every single thing their doctor recommends? If so, I would like to meet them because they are perfect.

There was a time I didn't fill a prescription before the next appointment with my psychiatrist. The reason was not to be difficult. The reason was, I was afraid. When the psychiatrist wrote the script for the drug, I had never heard of the drug so I didn't know enough about it to ask certain questions. After the appointment, before I got the script filled I started reading about the drug (from reputable websites) and I read about a particularly scary side effect. I wasn't sure from what I read how common the side effect was, and I decided before I took the pill I wanted to talk more with my psychiatrist about how common that particular side effect was with patients he saw. This was me trying to look out for myself, not me being a difficult patient. What is a patient supposed to do in that situation? Bug the psychiatrist before the next appointment? I didn't do that because I wanted to be respectful of his time, so I just waited until my next appointment. Was I supposed to just go ahead and take the drug before I had a chance to discuss some of my concerns? I don't think most patients are trying to be difficult.

There are all kinds of reasons why patients don't always follow treatment recommendations, and a lot of times it's not to be irritating or resistant or whatever, it's because the patient has concerns or because they are finding it difficult to stop a particular behavior, etc. I think most people would rather please their physician than not.

Anonymous said...

One time, I had a physician (not an ENT) recommend that I do nasal rinsing. I knew based on my previous lack of success with it, that it wasn't going to work.

But since I didn't want to be deemed as a difficult patient on my first visit, I figured I would give it a shot. I gave it more than 1 shot as I tried 6 times.

Unfortunately, I would feel great for about 30 minutes before having a rebound effect. I have read this is common for some people.

Anyway, on my return visit, when I mentioned I hadn't been doing this, you would have thought I had committed murder judging from the doctor's reaction. No attempt to find out why it didn't work or what my next step should be.

Of course, maybe because I stupidly disclosed my psych med history, that might have had something do with it. Hard to say.

It seems that many doctors don't seem to understand that a one size fits all solution is not for everyone even something seemingly benign as nasal rinsing. It is so frustrating.

Joel Hassman, MD said...

I have been practicing 20 years now, and have worked both community mental health and private practice together for most of that time. I have left private practice this week for what will be an extended period, unless I can develop a small practice near me that is realistically cost practical, because I see people in general as more entitled, more narrow minded, and more quick fix focused than ever before.

You wrote this near the end of the post,"Every now and then, someone is so resistant to following any recommendation at all despite continued difficulties, or they change the dose of their medicines so often without consulting with me, that I wonder if they are really patients, because the state of patient-hood does require at least the willingness to collaborate and consider treatment recommendations."

Well, I think the business model has inundated the medical profession with cost only, product/services maximized at minimal effort, to the perverse point that people come in with the attitude of "the customer is always right". For one, who came up with this extremist adage, must have been a narcissist, and second, we are not treating customers, we are treating patients. I will not accept a business model to health care, because it will inevitably make profit a goal, and we are not physicians to make a profit, an income yes, but once focused on the wallet first, the care process will forever be tainted.

And that is what we see, hear, and read of late at blogs exposing the corruption in the field these past 15 years, primarily thanks to the pharmaceutical industry. So, a question I propose to readers here is simply this: are we just aiding and abetting this limited, primary focus on meds and just pushing the role of therapy out the window of a 20 story building by letting patients think they will get better just taking a pill, because all their illness is just a biochemical imbalance?

I see it almost prevalent in community mental health these days, and frankly, I would propose something read as heinous by some, but what I see now: aren't we just trapping the chronically ill by letting them get away with meds only visits, and just minimizing the role of therapy for them?

Hope the question is pondered.

As for guns, well, I see much trouble with legislation that mirrors the NY law if it demands reporting by providers!

Cardiacarrested said...

Patients go off meds without consultIng or informing because docs usually just tell them to stay on and don't want listen to concerns about massive weight gain, diabetes, arrhythmias and changes to the brain that make it tough to ever get off the drug. I fear these drugs. They have not improved my overall quality of life and from what I read, they could kill me 25 years or so before I might normally die from natural causes . Given that I am middle aged, it wouldn't make much difference then if I die in two years as a suicide following a relapse or stay on the meds and die in two years of med related disease. As of today, I do not really wish to die so soon but I do think docs underestimate the med problems and don't care if i die an early death so long as it isn't suicide. It feels like they get to kill me in their own way and I need to take back some control of my own demise.

jesse said...

Instigated by Dinah I am now conducting my own firearm possession poll of patients for whom such questions are relevant. Discovery: quite a few have firearms. I was quite surprised.

catlover said...

I do believe that this entitled patient as customer thing is an issue, as Dr. Hassman said - My husband had a total knee replacement several months ago, and I could not believe the services offered at his hospital. We were clearly customers, both of us, not him as a patient. It was weird. WEIRD. There were lots of marketing gimmicks that were nice, but again, WEIRD in a hospital.

Especially since I've been a psychiatric inpatient at that same hospital a few times (not recently) and it was crappy and sometimes abusive (mostly to others) there. But as I've mentioned here before, I complained in detail, and the complaints were heard. I wonder if they offer room service on the psych wing now too, but I doubt it, since I don't think hospitals make money on that like knee replacements.

I mentioned the customer service stuff to my psychiatrist, who works at a different hospital, and he had many funny things to say, which I will not repeat here without his permission.

Anonymous said...

I think if physicians are noticing that patients are decreasing dosages of medication without discussing it first, it might be a good idea to communicate to the patients that you would like them to call you even if it's not an emergency if they are having bothersome side effects. Communicate that if they are having bothersome side effects this means it's okay with you if they call you on the weekend, after hours, and/or on holidays if that's when the patients are having the problems which are causing them to dose reduce.

From a patient perspective, I know that I have dose reduced because my appointment was 2 weeks away, I could not get in sooner, and I didn't want to call the physician after hours and bug him for a non-emergency. If you want patients to call you for non-emergencies, then that should be communicated because most patients (there are always exceptions) are not going to want to disturb you after hours. That's patients trying to be respectful of their physicians.

Patients can't win for losing. In trying to deal with a situation on our own so as to not bother the physician unnecessarily, apparently we are still irritating.

Dinah said...

Joel, did you want to talk about your feelings?

So if the patient is better on the medication, and doesn't want to come for psychotherapy, are we letting them "get away with" it? It seems to me that some people find it helpful to talk, and others sit there and say they have nothing to say. Maybe psychiatry isn't a one-size fits all.

Jesse-- so now what do you do? If you decide that someone is dangerous with their guns, do you insist they relinquish them? What if they refuse and leave treatment instead, and later go on to shoot people at a it your fault? And if they say they will get rid of the guns, how do you prove they did? How do you prove they got rid of them all?

Cardiacarrested, I don't think people should take meds that aren't working.

Catlover: What does a knee replacement cost? Room service for psych patients is probably not necessary, but I'd be all in favor of delivery options. Hospital food looks awful and shockingly non-nutritive.

Anon: personally, everyone can find me (cell phone, home phone, people text me all the time, email if they request it, and I return all my calls within a day).

Clink: I did know we weren't talking about guns anymore. I simply wanted to point out that you made me think. :~) I liked it best when you were obsessed with soap making and I was the direct beneficiary of something good. I'm ready to be done with birds already and I'm afraid this is only the beginning.

I didn't mean to make anyone who alters a medication dose feel badly or like their doc with see them as non-compliant. For the most part, I try to take people as they come and work with them on their terms to achieve what they want in the way they want. As with most things, sometimes it works that way and sometimes it doesn't.

jesse said...

@Dinah: with one person I voiced concern about guns in a house where someone is depressed, but that is all I thought was indicated. Now, if the clinical situation changes then I reevaluate. What to do is always predicated on our trying to do our best for our patients.

The Anon post above assumed that patients have no access to discuss medication issues. All of the pychiatrists I know are very reachable and want to know if there is a problem, and that is communicated to the patients. Yet, as Dinah noted, often medication is changed without a phone call. I heard Dinah as encouraging patients to call in such circumstances.

Unknown said...

Hi Dinah,

When patients tell me they did not start a medication or lowered the dose, or stopped it, or stopped their psychotherapy, or made any change for that matter, I ask the person how things went? Was it a helpful trial? I am all in favor of what works best for that person. I make no claims that I know everything that is best for the person or all the factors that weigh in for them.

I think being genuinely curious about the person and what makes them tick and tick well cements the relationship, makes it more likely the person will tell me what's going on for them, and is more interesting for me as a doctor.

I do not take it personally if the person is not into my recommendations. Or at least I try not to take it personally...

Joel Hassman, MD said...

My interpretation of Dinah's post is simply why bother to come to the doctor for treatment if you as the patient are not willing to follow through with the recommendation for at least the period of time the intervention is intended to have an impact? It really does coincide with my perspective that more and more people (not EVERYONE, but more than just 15-20% these days) come in to have their point of view validated, not looking for expertise and experience.

And, I am totally in agreement in her comment in not signing off in controlled substance RXs needs with the growing population that is looking for validation of using controlled substances for alleged ADD or Anxiety disorders that are more likely life issues, if not frank dependency seeking. Think about it colleagues, why bother the illicit risks with pursuing coke and heroin, with some booze as a chaser, when you can get a doc to give you stimulants, Rx opiates, and benzos. People doing honest recovery work will tell you that was the agenda in pursuing those scripts.

As to your last comment here on the thread, Dinah, I am not talking about patients who are stable and not struggling with major Axis 4 problems, but those just coming into care or allegedly a relapse of symptoms and noting a major life stressor is in place. You really think I should just tell the patient all is needed is adding meds, changing dosages, or just tell them they have a biochemical imbalance? I hope that clarifies my earlier comment to why I push for psychotherapy, and why I advise a return if the patient is suddenly failing a response.

You know what bothers me the most after practicing in Gaithersburg and then Frederick for the past 20 months? Think that 20% of a private adult practice should have ADD as a primary diagnosis? And that 30% or more should be asking for benzos? Oh, and patients telling you to your face when coming in for first time care that recommending psychotherapy, with another provider who would be less expensive to see, is a waste of time? That is why I know that private practice is doomed!

Let the PCPs and other non psychiatrists find out what hell they have created in selling psychotropics fit all. Me, at least the CMHC I work at does insist in therapy contact to some degree, or the patient will not be allowed to continue meds only treatment. You really think that chronic schizophrenics do not benefit from some monthly to bimonthly therapist visits?

Good luck defending that meds only premise and practice psychiatry for another few years!

Dinah said...


My only point to the post was that patients often don't follow the most basic of treatment plans, and that's okay with me, I treat them anyway, they get better anyway, and that I don't expect people to do everything I suggest.

I wish I hadn't made a comment about people being so far from that I wonder if they are even "patients." That side tracked readers and I didn't mean people who stop a medication because of side effects, or won't take a specific medication or who do or don't want psychotherapy...I was talking about a rare extreme or repeatedly doing this despite my questions about Why? reinforcement of my availability, and pointing out that they are not following my recommendations and are not getting better, and keep asking me what to do then not doing it. Not the usual patient. I should have left that for a separate post.

"Good luck defending that meds only premise..." Huh? I'm a psychotherapist. Where did that come from? I simply meant one-size doesn't fit all. Some of the patients I see who are stable on meds, doing well, who don't want therapy, have already had years of psychotherapy.

I'm all in favor of anything that helps. Bottom line.

Anonymous said...

Jesse, no I don't assume patients don't have access to their psychiatrists. I have always had access. He has a phone number and has said to call if I'm having any issues. But, I didn't want to bother him after hours for a non-emergency out of respect for his time. I think if the psychiatrist really wants patients to call them on the weekend, after hours, and on holidays if that is when the patient is having a medication issue, even a non-emergency medication issue, then please stress that to the patient. Most people don't want to bug their physicians and will worry that contacting them after hours, etc might bother them.

Once I held a psych med because I needed to take a drug for an upper respiratory infection that interacted with the psych med. I was given a prescription, it was after hours, and a holiday. I didn't want to call my psychiatrist after hours on a holiday to ask what he wanted me to do about the psychiatric med I just tried to make the best decision I knew. So, I held it until I finished taking the drug for the URI and could get back in to see my psychiatrist. Hopefully my psychiatrist looked at my intent (not wanting to disturb him after hours on a holiday) and didn't just assume I didn't want to follow his treatment recommendations.

jesse said...

@Aon: thank you for clarifying that. It was your consideration for your psychiatrist's free time that kept you from calling. It is always a judgment call, and I (and most of my peers) simply trust our patients to make reasonable decisions regarding whether to call, during or after hours, or not. I would much rather field a number of calls that might have waited to the next day rather than risk a patient suffering because he did not call.

So, when patients don't take medication, or change the dose, I treat it just as Tigermom suggests, and inquire into what happened that led them to do that. Sometimes it turns out that not taking the medication was the best possible decision. As Dinah says, there is no one size fits all.

Joel Hassman, MD said...

No, the point of responsible psychiatry is there is no "one size fits all" mentality, even when medication is used, a psychiatrist does not consider the same medication for a diagnosis because the patient in front of the doctor may not fit the rationale for drug A.

But, let's have a little moment of brutal candor here, I have no idea how Dr Miller practices, and by her writings, probably very responsibly, but, we are not writing here to claim what Dr A does is equal to what Drs B-J are doing. I think having practiced for the time I have, spoken with colleagues in various venues, and read at blogs like this for the past 3 years, there is a basic consistency going on. And that is too many psychiatrists, and non psychiatrists too, sell the biochemical imbalance model and just dismiss psychotherapy as an afterthought, if not dismiss it altogether for patients who NEED it.

What did I write earlier that gave the illusion that ALL patients need psychotherapy? No, I am talking about those who are initiating care or are symptomatic of relapse features AND are revealing there are substantial Axis 4 stressors playing a role to their struggles.

I have to say, to give the sense there is a debate to what I offer seems to validate my concern that providers are thinking meds only. I hope Dr Miller would agree that one reason I am tired of private practice as is when I was getting referrals from therapists who were telling patients to see a psychiatrist because they needed meds, and, oh, didn't need to follow up with therapy. WTF is that!?

I know my blog is a bit harsh a times, because the environment I am seeing on a daily basis is telling patients to get more invasive and more focused on narrow minded approaches. And, too many docs are just acquiescing to alleged supervisory players who really aren't that role. Sorry, politicians, non psychiatrists, KOLs who are just pharmacy whores (yes, that word fits here), and patients just demanding drugs are what they need and get, all of these players do not dictate care interventions.

Tell me I am wrong with my appraisal. And when you do, tell me what your background is that validates meds are the first intervention to people with biopsychosocial factors to their illness.

Yeah, that paradigm was left adrift out to sea years ago the way I see colleagues practice today!

NotCompliant said...

As a patient I dont want to waste my time in any docs office unless it is helping me so I make an effort to follow treatment recommendations.

As I have multiple chronic illnesses and specialists that I see (and am required to be the messenger between them all) I do find myself arguing with doctors more often than I like. At this point I find I waste a lot of time explaining why I can not take meds that cause weight gain (or screw with my liver or kidneys). I think it is obvious that an overweight diabetic with respiratory issues that limit mobility and exercise ability should not be taking anything that adds more weight to the problem. And shaming me about not exercising or eating crap before you look at my food or exercise logs is really being a jerk. Part of me wants to make the doc go get approval from my other docs before pushing these sorts of meds and shaming me as non-compliant.

I'm also angry about how often I have to justify why I dont see a psych doc. Somehow the answer "none of the meds we tried for 10 years made any difference so now I only do therapy" is never good enough. Having a mental illness and not taking meds is viewed as noncompliance - no matter how often or how much I spent on therapy. So much so that my current primary care doc decided to stop writing for my provigil because she wants me to see a pych doc and have them write for it

It comes down to feeling like the docs get hurt feelings because I cant take their favorite med. Or cant go run a marathon. I'm sorry but the allergy immunotherapy prevents me from having beta-blockers no matter how effect they are for my blood pressure, migraines, heart rate or anxiety. Thankfully calcium channel blockers help some. Its hard to run when the pollen count wont let me walk to my car without resting half way - but I wear a mask and cover my hair to try and help and water aerobics is at an indoor pool. Oh and I gave up the benzos that helped the anxiety because they are a risk when mixed with the high amount of antihistimines I take. Must remember to hold the magnesium while on this round of antibiotics even if that means more headaches. Too many other cns depressants on the med list so I get zofran and not phenergan for the migraine nausea. Rebound headaches from all the nsaids taken for carpal tunnel and degenerative disk disease means I've very happy the release surgery worked for my hand and the intensive PT helped me walk without a limp and gave me some pain free days because life with those problems and without OTC meds hurts.

No one but me looks at me as a whole person trying to balance everything. In the end I make the choices that say the weight gained from depakote taken to help reduce migraine frequency isnt worth the shorted life span it gives with my diabetes but that the increase in blood sugar from this round of oral steroids is needed so I can breathe.

So when I sit across from you and say "no, I dont think that is something I can do, what other options do we have" - do not treat me like someone who wants to stay sick. Understand I am trying to problems solve a complex set of issues with only a high school level of education.

DreamingTree said...

I work as a MHRN and would agree that there are those who simply want their pills. There are also those who only want a sympathetic ear. My experience is that those who do not end up doing their "homework" rarely feel better.

I take a flexible approach - they do not have to follow my exact recommendations, but then I ask for alternatives. The basic point I teach is that if nothing changes, then nothing changes. Most can understand this, and they make effort to participate in ways to change.

David Bowyer said...

Knowing the alternatives or options is really good. I think the treatment is going to be effective if the person is also part of the decision-making. Like what others say here, there are different issues in a person's life that might affect his compliance. But non-compliance to a particular treatment plan doesn't mean that he wants to stay sick.