The Opinionater on The Age of Anxiety

Before I start, two things: 1) if you'd like to hear our interview with Dan Rodricks on WYPR today, go here.  2) If you've ever been forcibly certified to a psychiatric unit and you haven't taken our poll yet, please do so here.  And now for our next post:
 
Over on the New York Times "Opinionator," Daniel Smith has an article called ""It's Still the Age of Anxiety.  Or is it?"  Smith talks about W.H. Auden's Pulitzer Prize winning1948  poem, The Age of Anxiety, (it's boring, he tells us, as well as 'illusive, allegorical and at times surreal') and he tells us about his own anxiety.   Smith writes,


From a sufferer’s perspective, anxiety is always and absolutely personal. It is an experience: a coloration in the way one thinks, feels and acts. It is a petty monster able to work such humdrum tricks as paralyzing you over your salad, convincing you that a choice between blue cheese and vinaigrette is as dire as that between life and death. When you are on intimate terms with something so monumentally subjective, it is hard to think in terms of epochs.

And yet it is undeniable that ours is an age in which an enormous and growing number of people suffer from anxiety. According to the National Institute of Mental Health, anxiety disorders now affect 18 percent of the adult population of the United States, or about 40 million people. By comparison, mood disorders — depression and bipolar illness, primarily — affect 9.5 percent. That makes anxiety the most common psychiatric complaint by a wide margin, and one for which we are increasingly well-medicated. Last spring, the drug research firm IMS Health released its annual report on pharmaceutical use in the United States. The anti-anxiety drug alprazolam — better known by its brand name, Xanax — was the top psychiatric drug on the list, clocking in at 46.3 million prescriptions in 2010.

Just because our anxiety is heavily diagnosed and medicated, however, doesn’t mean that we are more anxious than our forebears. It might simply mean that we are better treated — that we are, as individuals and a culture, more cognizant of the mind’s tendency to spin out of control.

Smith concludes that it's not the world we live in, and that it's perhaps dangerous to make that assumption.  He notes, " If you start to believe that anxiety is a foregone conclusion — if you start to believe the hype about the times we live in — then you risk surrendering the battle before it’s begun."

What do you think?  Are we more anxious than we used to be?  And why is that?  Is it the world we live in--now or in 1948?  Or is it just our own personal psyches?   

Note, the graphic above is from a book by Andrea Tome. 

The Secret Lives of Patients

In yesterday's post on e-prescribing, the issue of patient confidentiality came up in the context of doctors being able to see a patient's full medication history in an electronic program, and one commenter brought up that she doesn't necessarily want to tell her shrink about a yeast infection, perhaps because she finds it embarrassing.  The writer of the post, a guest blogger, suggested that this might lead to useful information that should be addressed in therapy, for example the patient's sexual life. 


Years ago, I remember being a bit taken back when a patient brought up some rather problematic (to him) sexual issues in his marriage.  It wasn't the nature of the issues that surprised me (I spent more than a decade consulting to a sexual behaviors unit and I spent several months of residency training on an inpatient sexual disorders unit: it takes a lot to shock me).  What surprised me was that this was the first I was hearing about this issue after seeing the patient for 5 years of psychotherapy.  He had a secret life.


There's not really much to do about this.  One can only help people with the things they bring forward as problems, and we don't, as one commenter pointed out, get notified by the bars every time a patient drinks, or doesn't exercise, or begins yet another dysfunctional relationship, or surfs over to a porn website.  Oh, and I am so glad.  


When it comes to hiding medications, or treatments, then perhaps that's different.  Is it okay for a patient to see one doctor for a Xanax prescription, and if he's not happy with the dose, to see another doctor for more Xanax?  If he's not selling it, I don't think this is illegal, but we'd (meaning docs) all agree that this is wrong, that the patient is deceiving us, and wouldn't  prescribe to someone doing such things.  Is it okay for a patient to hide the fact that he has AIDS, a condition with known psychiatric complications, from his psychiatrist?  We might say that if we're not aware of the medications a patient is taking, then we can't be liable for the interactions, but please-- in therapy it's not just about the fears of lawsuits between strangers, it's also about not wanting to see your patient get sick for completely preventable reasons.


So where is the line?  Is it okay to hide manic behaviors from a psychiatrist---it's none of his damn business if I wanted to sleep with 8 gorgeous women last night and buy them all diamond rings!  Is the psychiatrist entitled to know every behavioral transgression? That he's worth millions when he's getting a discounted fee from the shrink?  That mom thinks he's getting sick again?  Every fantasy that pops into his head?  Is it okay to withhold your dreams from your psychoanalyst?

I won't go on.  You tell me where the exact line is.  I have no idea.

No More Xanax

I'm posting this because Roy fell asleep at the wheel and missed the Xanax article on the front page of yesterday's  New York Times.  In "Abuse of Xanax Leads a Clinic to Halt Supply,"  Abby Goodnough writes about a clinic where they've stopped prescribing Xanax because to many people are abusing it.  Goodnough writes:

“It is such a drain on resources,” said Ms. Mink, whose employer, Seven Counties Services, serves some 30,000 patients in Louisville and the surrounding region. “You’re funneling a great deal of your energy into pacifying, educating, bumping heads with people over Xanax.”
Because of the clamor for the drug, and concern over the striking number of overdoses involving Xanax here and across the country, Seven Counties took an unusual step — its doctors stopped writing new prescriptions for Xanax and its generic version, alprazolam, in April and plan to wean patients off it completely by year’s end.

If you want to know how the Shrink Rappers feel about Xanax, do read Roy's post on Why Docs Don't like Xanax (Some of Us).  It's been our all-time most popular post.  


So I was a little (not a lot) surprised that this was "news."  I've worked in four public clinics-- I've never seen a prescription written for Xanax, and for the most part, the clinics where I've worked have had a sort of non-stated ban on prescribing controlled substances.  It's not that benzodiepines and stimulants are never helpful, but in the clinics, the issues concerning abuse, and the drain on the system gets to be very hard, plus we worry that the harm these medicines can do will be worse than the problems they 'cure.'   It's very rare that I've written for controlled substances, and I've never written for Xanax in a clinic, or seen a chart from another patient where Xanax was prescribed. I'd be shocked by the article, but during the two weeks I was in Louisiana after Katrina, I did see many patients who had been on high doses of long-standing Xanax that were prescribed by docs at community clinics, so I know it's done.  But you know, ClinkShrink doesn't like benzos at all, ever (per The Benzo Wars, if you'd like to hear us shriek at each other), and the rest of us Shrink Rappers don't like Xanax in particular.


Time to wake up, Roy.

How to Drive ME Crazy

The last post was stolen from another blog and was meant as a joke.
Here's my personal list, it's not a joke.

1. Don't show up for an appointment. Don't call. Don't answer your cell phone. Don't return my concerned calls.
2. Don't show up for an initial appointment where I've blocked out two hours for you. Don't answer your cell phone, never contact me again. Ignore the fact that I made a point of requesting a call if the appointment wasn't going to be kept.
3. Insist that Xanax is the only medication that works for you and refuse to try anything else, even once, even if you've never tried it before.
4. Insist that a 90 day supply of a very expensive medicine must be written because that's the only way you can afford it through the insurance, and two weeks later announce that it suddenly no longer works.
5. Present in a crisis, sit through a session where we develop a plan, then return having done none of it.
6. Decide that the medication that was the only thing that worked for you after years of trying to find something, anything, that would work suddenly is something you don't want to take, even though you've been on it, stable, and doing well for a few years with no side effects. When your psychiatrist reminds you how awful your last 7 episodes of illness were, how hard it was to get you better, and that statistically the chances are extremely high that you might get sick again and it might be hard to get you well again, say, "I'm not going to get sick again."
7. Attribute your flagrant mania to "real emotion" and insist your psychiatrist can't understand because they aren't Italian/Irish/whatever. (Oh, this doesn't really bother me.)
8. Spend the session discussing just how suicidal you're feeling and how badly things are going, and at the end of the session announce that you need to decrease the frequency of the sessions.
9. Promise to call between sessions when your shrink is very worried, then don't. Rest assured, shrink will remember you didn't call at 3 AM.
10. Ask your shrink very intrusive personal questions. I'll spare you the examples.
11. Cancel ten minutes before a session. Tell shrink you suddenly remembered a conflicting appointment that was scheduled a month ago.
12. Leave treatment without a word after years of therapy and leave shrink to wonder how you are and how all the details of your life turned out.

I could probably go on for a while. I liked some of the ones people put in the comment section of the last post.

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, CLICK HERE.

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 better....

When A Shrink Picks A Benzodiazepine

I'm still talking about our not-so-favorite shrink medications, those calming, addictive benzodiazepines: valium, librium, ativan, klonopin, and everyone's favorite: Xanax.

If you listened to our podcast The Benzo Wars, you know this is a heated topic among the three Shrink Rappers, and then ClinkShrink had to go post again in Sober Thoughts. Okay, it finally happened, I finally agreed with something Clink said about benzos. She writes:

Doctors aren't soothsayers or mind readers, and taking a good history or talking to relatives won't always turn up the problem prior to writing a prescription. We want to care for people and relieve distress and a prescription is one way to do that. Unfortunately, it is also possible to create a new addiction in a person who never had one before and we have no way of knowing ahead of time which patient this will happen to.

ClinkShrink is right here: some patients take a medicine and it gathers a life of it's own, an addiction forms. And there's not a way of knowing if that post-operative Percocet will start an addiction or make the patient vomit or simply relieve the pain. Clink has made the point that it's never worth the risk in the case of benzodiazepines: take them and your life could dissolve and you could end up being her inmate.

While she's right about the unknown risk, I'll make the point that life is full of uncertainties. With her thinking, one should never try a drink-- it could (oh, and it often does) lead to alcoholism. I don't know when I prescribe any medication who will get diabetes from it, who will have a bad side effect, whose kidneys and thyroid will be compromised, who will become suicidal from that SSRI, or who will have a horrible time with withdrawal symptoms when they decide to stop it. I don't know who will become addicted, I do my best to take a guess.

I do prescribe benzodiazepines for short-term use for acute anxiety. I don't see a problem with giving someone a tablet of Ativan for an MRI or a few to deal with post-9/11 flying anxiety. And if someone is having panic attacks, they are a good temporary measure until a prophylactic agent kicks in. I've seen plenty of patients on benzodiazepines (yes, even Xanax) where I tell them to stop the medicine, and they do so without arguing, bargaining, complaining, or insisting it's the only thing that helps. I only prescribe them in my private practice where I follow the patients very closely and know them well. In the clinics where I've worked, very few doctors have used these medications, and it is very rare that I'll start them in that setting.

So what helps me feel a little more comfortable prescribing a benzodiazepine?

1) If a patient has been on them in the past and stopped them without difficulty. I don't hesitate to check with old docs and pharmacies.
2) If the patient has never had a problem with alcohol-- benzodiazepines bind to the same receptors and there is cross-tolerance.
3) If there is no personal history of substance abuse or addiction
4) If there is no family history of substance abuse or addiction
5) If the patient understands that it's a short-term solution, not a permanent thing.
6) And yes, I've had patients come to me already on these medications where I just can't get them to taper off and I can't really pinpoint how exactly the medication is hurting them. I will continue such a patient on a low dose. It's been just a handful of people over the years, most people don't seem to need or want chronic benzodiazepines.

Funny, but ClinkShink writes:

I say: "Respect your gut." If you think it may be a problem for you, it could be. If your loved ones or doctor is encouraging you to take more and you're not comfortable with that, say so. Repeatedly if necessary.

My experience-- and I have no data to support this, it's just my "gut"-- is that when I tell patients that the medication can be addictive, the people who express concern are the ones I worry least about-- you're supposed to worry about getting addicted, you're supposed to watch out for a craving for the drug. It's the people who immediately say, "Oh, I won't get addicted," that I worry about the most.

Life is full of risks-- I'll give you a list if you'd like, but they'll include the heart attack you can have when you get on the treadmill and the concussion you can get when you fly off your bicycle.

At this point, I feel a little anxious when I write a new prescription for almost any medication.

Sober Thoughts

[I'd like to thank Clinking By Proxy for helping me post while my Comcast was down. I owe you chocolate. And yes, Dinah, I'll babysit Max. He's adorable.]

I used to think that I wouldn't write about substance abuse because I wasn't an "official" substance abuse expert, at least not on paper. I didn't do an addictions fellowship and addiction per se was not usually the primary focus of treatment in my outpatient clinic. Then came my Dose Dependent post and the Benzo Wars podcast and all the subsequent comments, positive and negative, about the issue. I discovered I had a lot to say, mainly as a result of several years of direct practical experience.

Many doctors, as a rule, do not like patients with substance abuse problems. They fill up the emergency room, they suck down psychiatric resources, they fill up the psychiatric inpatient beds looking for detox or housing, they fill up the inpatient medical wards with conditions resulting from their lifestyles. They take a lot of time and work and they're not always nice people to deal with.

Those are the folks with the severe addictions, the ones that result in arrest and incarceration or homelessness and poverty. There are lots of other addicts out there whom I never see, the middle-class non-criminal addicts whose addiction touches the lives of their families and loved ones but never quite sinks to the level of the streets. These addictions are no less serious. I think I get vocal about these folks (and about things like prescription controlled substances) because I can see where things are headed. I know how bad they can get and the human wreckage that will be left along the way. I can tell you story after story about people who have never done a thing wrong in their lives until that on-the-job accident and the first opiate prescription, or that first hit of cocaine (or the first benzo prescription) and the next thing you know the wife is gone, the job is gone, the house is gone, and they're in prison. It does happen, more often than you think.

Doctors can't always tell who is or isn't an addict among these nice, educated, relatively well-heeled genteel non-criminal folks. Addiction is a hidden disease, a disease of denial, a thing that's carried in secret and buried away even from the addict. Addicts can hide their problems even from people living in the same household. Shame is a powerful motivation for secrecy. Doctors aren't soothsayers or mind readers, and taking a good history or talking to relatives won't always turn up the problem prior to writing a prescription. We want to care for people and relieve distress and a prescription is one way to do that. Unfortunately, it is also possible to create a new addiction in a person who never had one before and we have no way of knowing ahead of time which patient this will happen to. Giving a warning about addiction potential or cautions about continuous use is one way of approaching this problem, thus leaving the responsibility for the addiction back with the patient ("I warned you this could happen, I have it documented in the informed consent section of my progress note.") but this would be little comfort to me when I see these folks in prison.

When I read comments from people who say they're reluctant to take more of their prescribed controlled substance, I say: "Respect your gut." If you think it may be a problem for you, it could be. If your loved ones or doctor is encouraging you to take more and you're not comfortable with that, say so. Repeatedly if necessary. You're the one carrying both the symptoms and the addiction risk. As one of our anonymous commenters said:

"We didn't wake up one day addicted. It was one or more of your colleagues with an MD after their name who started all of this for the vast majority of us so as someone else said, why don't you take it up with them at your conferences or in professional writings or wherever it is that you all gather to talk down about us and the problem your crew created?"

That's exactly why we're blogging and podcasting about this. Thank you.

My Three Shrinks Podcast 42: The Benzo Wars (or, Xanax Reloaded)

[41] . . . [42] . . . [43] . . . [All]

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Dinah, Clink and I get into a podcast brawl about the use of benzodiazepines (such as Xanax/alprazolam, Ativan/lorazepam, and Valium/diazepam) in the practice of psychiatry. See how many rounds we go, and who is left standing at the end.

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February 16, 2008: #42 The Benzo Wars

Topics include:

• Round 1: Why Docs Don't Like Xanax (or, Xanax Reloaded). This is what started it. Then there was Xanax Blues in Podcast 19. Also, this one from Oct 10.
  
  
• Round 2: Dose Dependence. Our blog commenters dissent.
  
  
• Round 3: Just Say No! Clink offers sage advise to fellow prescribers.
  
  
• Round 4: The Trouble with Tapering. How slow can you go? See Perchance to Dream.
  
  
• Round 5: Need It Versus Want It. Is there a difference?
  
  
• Final Round: Last Shrink Standing. What are the situations where you feel very uncomfortable prescribing benzodiazepines? Roy wraps things up by quoting from his Jan 12 comments from Dose Dependent.
  

[Ed: I forgot that I had transcribed a few comments from the podcast when I was on a plane recently. I've added them below, including the time in the podcast where they occur]

15:06 Dinah: "So, shut up a minute!"

17:20 Roy: "Benzo's modulate GABA receptors... You've got glutamate, which is an excitatory amino acid, and you've got GABA, which is an inhibitory amino acid. So, they kinda balance each other. If you have too much glutamate, that's bad, you can have ... seizures... If you have too much GABA, that's bad because then your brain is s-o s-l-o-w-e-d d-o-w-n that you can't do anything."
17:45 Dinah: "What's his point?"
18:00 Roy: "So, benzo's effectively increase the role that GABA plays in the brain. So does alcohol. In fact, for the most part, your brain can't tell the difference between alcohol and a benzo."

20:20 Roy: "You can be dependent but not addicted."
21:00 Clink: "Why is it that this [coming off Xanax] is so bothersome to you?"
21:22 Clink: "When you start hearing that 'this is the only thing that works', then the red flags should go up."
22:20 Clink: "I see the addictions that are started by physicians, and we need to address this as a reality."
24:00 Dinah: "We have this dilemma... is this a medicine that this person needs versus is this somebody who's addicted?"

24:20 Dinah: "There are circumstances where I encourage people to take benzos, and I'll tell you what they are..."
24:27 Roy: "Like now!"

Feel free to add your favorite quotes in the comments.

The background music is from the mash-up I made for podcast #24, Dr. Phil on Skype.

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Find show notes with links at: http://mythreeshrinks.com/. The address to send us your Q&A's is there, as well (mythreeshrinksATgmailDOTcom). This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.

Here's When You Need A Psychiatrist

Have we written this one yet? I seem to think that Roy, our Consultation-Liason Boy, may have done this.

This is just my opinion, it's written with the non-shrink doc in mind, and it assumes access to psychiatric care:

So when should a patient be referred to a psychiatrist for care?

• When their distress due to psychiatric illness is such that they can't contain it and are driving the primary care doc nuts.
• Any patient with the new onset of a psychotic illness should initially be stabilized by a psychiatrist (this is just my opinion) if they are willing to go. Psychotic illness: any illness accompanied by hallucinations and/or delusions. Psychosis is frequently seen in Schizophrenia and Bipolar Disorder, but can also be seen with depression, delirium, and a host of other non-psychiatric illnesses. If the patient's hallucinations are caused by a brain tumor and they resolve with removal of the brain tumor, then the psychiatrist may not be necessary. Maybe Roy can write us a "causes of psychosis" post.
• For depression: my conservative rule would be to refer after the patient fails one antidepressant medication given at a therapeutic dose for long enough. What's a therapeutic dose: I go as high as a) the patient will tolerate or b) to the highest recommended dose (which ever comes first). If a patient can't tolerate more than 50mg of zoloft, well, this isn't a full trial. Switch to another med and try to get the patient up to a full dose. Wait AT LEAST four weeks (the mantra is 3 to 6 weeks) on a good dose. It's not uncommon to get a patient who has been on small doses of many anti-depressants, none for very long. And primary care docs aren't the best at augmentation strategies.
• Any patient with Bipolar Disorder needs a psychiatrist to stabilize them, and a psychiatrist available for management of episodes. If someone has been stable on Lithium for the past 8 years, they don't need a psychiatrist to prescribe it.
• When prescribing that first antidepressant, ask every patient with depression if they've had a manic episode: "Have ever had a time when your mood was too good, when you had excessive energy and needed less sleep, when you talked faster than usual, your thoughts raced, you were more impulsive than usual with regard to spending or sex?" Anyone who doesn't look at you like you're nuts for asking this needs to be questioned in more detail about manic episodes. If the patient has a history of even one manic episode, you're dealing with Bipolar Depression and prescribing antidepressants could be very risky-- not a bad time to refer.
• Don't prescribe Xanax for a chronic anxiety disorder. It's hard to treat patients who get dependent on xanax and it's hard to refer them if they end up on high doses.
• Any patient with a recent serious suicide attempt or recent psychiatric hospitalizations should be stabilized by a psychiatrist.
• Any patient with any psychiatric disorder that is compromising their ability to function, who does not improve after two to three months of treatment, should be referred for psychiatric care-- so OCD or Panic Disorder that is not getting better quickly.
• If a psychiatric disorder puts anyone's life at risk, it's probably more than a primary care doc wants to or should deal with.
• Any patient who is being treated by a primary care doc for a psychiatric illness should be asked if they want to see a psychotherapist (a shrink or a psychologist or a social worker or a nurse therapist). The patient may say that the pills have cured their depression and they don't need to talk. In the absence of information, this should be respected. But the gentle offer of a psychotherapy referral should be made early.

Sorry, a little haphazard, maybe Roy can come in and add an addendum....

Dose Dependent

Sometimes I wonder how much free society doctors know about what their patients are doing. Without going into detail about specific patients, I can tell you I see guys coming in to prison on Valium, Xanax, Klonopin and other medications (or claiming to be on them) from their family doctor or their neurologist or their surgeon. They get the meds for chronic pain, back spasms, anxiety, PTSD, sleeplessness and now (the latest trend) restless leg syndrome. Occasionally the meds get prescribed for panic disorder, but I'm amazed that these folks also seem to be able to tolerate daily amounts of cocaine while suffering from panic disorder.

I don't doubt each of these doctors is acting in good faith, with reasonable care and consideration, in the best interest of the patient. I'm sure each doctor has their own particular 'red flags' to watch for which would trigger concern about addiction or abuse. I would be surprised if they all knew about each other.

Good doctors can be deceived and manipulated just like any other human being. Manipulation and deception go hand-in-hand with addiction. (Just look at the number of times people find Shrink Rap by googling 'how to manipulate my psychiatrist' and 'how to get a shrink to prescribe Xanax'!) Sometimes the doctor only finds out about the substance abuse problem after the arrest. I imagine the hard part then is not getting really pissed off at the patient when you find out you've been deceived. Sometimes when I hear free society docs talk about their cases I suspect substance abuse and suggest that perhaps the patient may not be telling the entire story. Those docs get offended. "You just say that because you work with criminals," they say, "My patient isn't a criminal." Well, a lot of addicts have problems without getting caught.

So what can I do about substance abuse in prison? The key element is education. When I have a patient lobbying for benzodiazepines (Xanax, Valium, Klonopin or something like that), I teach them about the effects of substance abuse on mood or other psychiatric disorders. I teach them about the physical effects of controlled substances, the potential for dependence and addiction, and the legal consequences of using illicit drugs. Finally, I encourage abstinence.

To which the patient usually replies: "I know all that, doc. Stop bullshitting me. The only thing that works is Xanax."

At least I try.

Perchance to Dream

I've been having trouble sleeping sometimes lately. Oh, who am I kidding? I've always had intermittent insomnia, lately it's bothering me more for some reason. I'm lucky: if I don't sleep well, I don't feel it the next day, and so I've learned not to worry so much about it. If I go a few days with restless nights, I start getting irritable, and then I usually sleep well for a bit until the cycle repeats. A friend insists I'd sleep better if I turned off the computer and TV by 10 or 11 pm. I'm usually IN bed by 11:30, and I'm not much of a TV watcher, so I don't think that's it-- I sometimes get on the computer after that if I can't sleep, but I've tried first. Then she said it's the Diet Coke I have with dinner. Fine, I've given up caffeine after 9 am. I've had no Diet Coke in almost two weeks. I don't miss it, but it's not making much difference. Some nights I sleep well, others I don't. Last night, by the way, Roy was in my dreams....

So with that as a prelude, the New York Times has an interesting piece on sleep medications. I prescribe sleep medications sometimes, and I really don't think they're a problem for short term issues-- someone who sleeps poorly because of an acute stressor. And SSRI's often disrupt sleep, for some people the combination of an SSRI with trazodone seems to be helpful for both sleep and depression. Getting back to the New York Times article, "Sleep drugs found mildly effective but wildly popular"-- Stephanie Saul writes,

But if the unusual pitch makes you want to try Rozerem, consider that it costs about $3.50 a pill; gets you to sleep 7 to 16 minutes faster than a placebo, or fake pill; and increases total sleep time 11 to 19 minutes, according to an analysis last year. If those numbers send you out to buy another brand, consider this, as well: Sleeping pills in general do not greatly improve sleep for the average person.

The article goes on to say that while total time asleep is increased by 25 minutes or so, that sleep satisfaction amongst insomniacs is greatly increased. The article goes on to theorize why that is, to talk about some specific problems with certain hypnotics, and to say that the perfect sleep agent hasn't been found.

And with this thought, I've changed the sidebar poll-- Please vote for your favorite sleep medication. In Roy's honor, I've tried to be a bit more complete. And once again, in my pursuit of useless data, I don't care who you are, if you take or prescribe it, or if you merely like the idea, just tell us your favorite.

Oh, and finally, I should have put this on my last post about the Red Sox, but if you didn't know it, Red Sox pitcher Curt Schilling is a blogger-- do check out 38pitches.com . Funny, but his posts get more comments than our Shrink Rap posts get. I wonder why.

More On Everyone's Favorite Medication: Xanax

First, check out Roy's post below from earlier today; he tells us how to cure alcoholism! Click Here.
[I do nothing of the kind, don't listen to her.]

So the New York Times has a health blog, and if you ask me, today it's trying to be Shrink Rap. In today's Post, For Some Bereaved, Pain Pills Without End,
the unnamed author talks about the ease with which physicians ( primary care docs) prescribe benzodiazepines for acute grief, the ease with which they refill these scripts-- often for years at a time--, the ease with which these patients become addicted and suffer from side effects:

Powerful benzodiazepines such as Xanax, Valium and Ativan are widely overused in older patients, many experts fear, leading to serious health worries, including sleep troubles, cognitive difficulties, car crashes and falls. Yet doctors in the survey seemed willing to offer unlimited amounts of these addictive drugs to help patients cope with death.

The study is small-- it consists of 33 primary care docs in Philadelphia, and interviews with 50 older patients who've taken benzodiazepines for years: 20% said they began taking benzodiazepines during a period of grieving. Want details? Read the original article HERE.

As always, the reader comments are as enlightening as the blog post itself (ah, that's true here at Shrink Rap as well).

Interesting stuff, but I guess I think the sample here is so small as to be useless. Half the docs said they'd prescribed benzos for grief (so at least 16.5 primary care docs) and 10 patients started chronic benzodiapine use after a death. I'm not surprised, I'm not commenting on anyone's practice, I guess I just don't like the tone of the blog post which somehow paints the docs as ignorant, perhaps lazy, may be even negligent or sinister.

Finally, please note that I stole my "grief" graphic from a Red Sox blog: http://redsoxdiary.blogspot.com/

My Three Shrinks Podcast 19: Xanax Blues

[18] . . . [19] . . . [20] . . . [All]

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Last week's Grand Rounds podcast was very successful. We've had over 300 downloads in the past week and over 3000 hits from iTunes. For the Grand Rounds post itself, we've had over 6000 page views in the past week from over 3000 unique visitors. Thank you.

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May 7, 2007: #19 Xanax Blues

Topics include:

• Q&A: Emailing patients
• Q&A: What is Psychiatry doing about asexuality?
• Q&A: Talk about Munchausen's disease and Dissociative Identity Disorder (DID).
• Is denying care malpractice?
  
• California forensic psychiatry staffing problems
• More troubles with Xanax

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Find show notes with links at: http://mythreeshrinks.com. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.

Why Docs Don't Like Xanax (some of us)

[BTW, you might also be interested in checking out our related podcast, #19: Xanax Blues.]

This is in response to JW's question below about the "rules" docs use about prescribing Xanax/alprazolam. Not all docs feel this way, but here's how I think about it. Of course, I am not suggesting that, if you are taking this anti-anxiety drug, you should stop it. I'M NOT. Talk to your doctor if you have concerns.

The half-life for Xanax is short... on the order of 6-20 hours. Halcion is the only similar sedative that has a shorter half-life (and that one has even more problems). Thus, it doesn't stick around long. It is also quite lipophilic, meaning that it quickly gets into the brain. So, it has a quick on, quick off way of working. Sounds great, right?

The quicker a drug works, especially one which makes you feel good in some way, the more addicting it is, as the cause (taking it) and effect (feeling it) are close in time, making it very reinforcing. This is fine if you just take it on those rare anxious moments where you need something to get through it. However, since it works so quickly, many folks start taking it more and more often, until it gets to the point that they are taking it daily. Then they start taking it as soon as they feel it wear off. Before you know it, you are taking it 3-4 times per day. Now, that's not the big problem.

The big problem is all because of your brain's laziness. See, your brain makes it's own natural Xanax-like substance, called GABA. GABA works by inhibiting the brain's natural tendency to speed up. It's like a brake pedal, where the accelerator is stuck in the pedal-to-the-metal mode. GABA keeps your brain from over-working. Xanax (and other sedatives, and alcohol) works by acting like GABA in the brain (sort of). If you start taking it daily, your brain starts thinking "I guess I don't need to make so much GABA because this Xanax stuff is here, so I'll only make 20% of what I usually make." It takes a week or more for your brain to stop making the GABA (which is why just a few days on Xanax won't lead to much trouble), and a week or more for it to start making it again when you stop taking the Xanax.

Here's where the trouble begins. If Xanax wears off in just a few hours, but it takes a week for your brain's natural Xanax to kick back in, what happens in the interim? Withdrawal. What does that feel like? It feels like a panic attack, but worse. High blood pressure, rapid heart beat, tremors, confusion, delirium, hallucinations, seizures. What do folks do when they feel a panic attack coming on? Take another Xanax.

As a hospital-based physician, I see lots of folks, often older, who wind up with severe withdrawal problems from Xanax. It's usually because they run out of the drug, decide to cut back or stop taking it, or something else happens (eg, stroke, get sick) and they forget to take it. Or they don't tell their surgeon they are on it, and 2 days after their hip surgery I get called because they are hallucinating.

Some prescribers think it is a good antidepressant (it's not). Or that, because of the short half-life, it's not as addictive (it is).

So, here are my rules of thumb about Xanax:

1. Avoid it.
2. Keep the doses small.
3. Do not use in older folks or forgetful folks (more likely to forget it, thus more likely to have problems).
4. Do not use in anyone with a history of alcoholism or addiction (yes, that means you have to ask).
   
5. Tell folks to avoid from daily use.
6. If they are on it, warn them that stopping it suddenly, even for a day or two, can result in confusion, hallucinations, seizures, and even death.