Let me just show you this....

[erg923]

This is not made up. This is a real medication regimen of patient I have been referred. Comments?

Buproprion XL 300 mg in am

buspar 15 mg twice daily

zoloft 200 mg daily

remeron 30 mg nightly

geodon 20 mg twice daily

Adderall XR 30 mg in am

Adderall 10 mg at noon

Lamictal 200mg- 2.5 tabs daily

minipress 10 mg nightly

elavil 100 mg nightly

restoril 15 mg nightly

imitrex 50 mg as needed

---

Members don't see this ad.

 

[st2205]

There's a lot of room to go up on Geodon. They probably wouldn't need therapy of you could bump that up.

 

[WisNeuro]

That Veteran seems to be missing Zolpidem for sleep, and qid hydrocodone for their pain. Oh, and depending on the facility, some kind of maintenance benzos for anxiety. Way too undermedicated.

 

[Mad Jack]

The only question I've got is how the hell is a regimen like that not malpractice?

 

[WisNeuro]

The only question I've got is how the hell is a regimen like that not malpractice?

This is not unusual. Throughout all of the settings that I've worked, VA/AMC this is not all that rare in a not insignificant number of patients. I doubt that the ethics boards could keep up with all of the cases if this was deemed malpractice.

 

[nexus73]

Some doctors seem to have a hard time taking patients off medications and you end up with an ever growing regimen. Not an excuse, but I can imagine how they fall into the trap:

Zoloft works some but still depressed, add wellbutrin. Now have better energy and focus but still depressed, add geodon to augment. Not sleeping well and have migraines, add elavil. Etc. Every medication is theoretically addressing some aspect of the patients suffering so how can I stop anything?

I'd worry about setting this patient up for serotonin syndrome with all the 5ht meds. Plus wellbutrin is going to slow the metabolism of Zoloft some, and its already a high dose. Watch out for the day this guy takes an extra dose of imitrex.

 

[Doctor Bagel]

There's a lot of room to go up on Geodon. They probably wouldn't need therapy of you could bump that up.

You also have room to go on the remeron, buspar and bupropion! Yeah, someone is forgetting to d/c meds, and the patient is likely resistant to that as well. This whole idea that medications are going to cure all that ails you needs to stop. Medications have a place, but they can't deliver complete alleviation of suffering.

 

[MacDonaldTriad]

“I’m here for a second opinion. It seems my last psychiatrist lost his capacity to rationalize the use of all of the polypharmacy drugs that I want. Do you think you can help me? I’ll begin by listing all of the complaints you will need to justify the simultaneous use of all kinds of uppers and downers. Are you ready? I impulsively shop, and I have trouble sleeping. I have terrible concentration and this isn’t helped by my panic attacks…….”

 

[wolfvgang22]

I inherit lots of patients like this in the VA, because the culture is such that a psychiatrist cannot say no to a veteran asking for a panacea and push therapy as a primary treatment modality without being accused of being unpatriotic, lazy, and not caring about veterans. The expectation is that complete symptom relief is achievable despite a very ill, low income population steeped in drug abuse and concommitant social chaos. Many such patients of course put minimal to no effort into working with our readily available psychotherapists. Most of the time there is an immediate informal investigation of a prescriber in the name of patient satisfaction in the VA these days whenever a physician declines to participate in polypharmacy to treat every single symptom like each is a separate disease. This is a toxic enablement of illness by the institution. After a while providers get tired of fighting against polypharmacy and burn out. This and red tape/paper work is what I dislike about the VA.
Everything else has been great.

 

[Medstudent2018]

I inherit lots of patients like this in the VA, because the culture is such that a psychiatrist cannot say no to a veteran asking for a panacea and push therapy as a primary treatment modality without being accused of being unpatriotic, lazy, and not caring about veterans. The expectation is that complete symptom relief is achievable despite a very ill, low income population steeped in drug abuse and concommitant social chaos. Many such patients of course put minimal to no effort into working with our readily available psychotherapists. Most of the time there is an immediate informal investigation of a prescriber in the name of patient satisfaction in the VA these days whenever a physician declines to participate in polypharmacy to treat every single symptom like each is a separate disease. This is a toxic enablement of illness by the institution. After a while providers get tired of fighting against polypharmacy and burn out. This and red tape/paper work is what I dislike about the VA.
Everything else has been great.

Do VA patients tend to come back for appointments? (I'm assuming this is outpatient) I guess I wonder how adherent they are when there is polypharmacy like this and perhaps one reason why they still have symptoms is that they aren't taking all of them as directed. (The prescribing doctor probably won't know which ones are being missed). And how would you safely reduce the number of meds? If you do more than one at a time, then you won't know which one to attribute relapse to.

 

[erg923]

perhaps one reason why they still have symptoms is that they aren't taking all of them as directed.

I really dont think so. Most patients I have ever seen who are already established in the MHC here in VA are on a boatload of medications and are, 99% of the time, still a hot mess.

 

[northernpsy]

Do VA patients tend to come back for appointments? (I'm assuming this is outpatient) I guess I wonder how adherent they are when there is polypharmacy like this and perhaps one reason why they still have symptoms is that they aren't taking all of them as directed. (The prescribing doctor probably won't know which ones are being missed). And how would you safely reduce the number of meds? If you do more than one at a time, then you won't know which one to attribute relapse to.

My experience is that vets do tend to show up for stuff (they're used to following orders after all). In fact the VA I was at (not sure if this is systemwide) has a policy that you have to call the vet right away if they don't show up to make sure they didn't commit suicide or something. That's not to say they are taking the meds as prescribed though - that is a problem in every patient population I've met.

 

[erg923]

My experience is that vets do tend to show up for stuff (they're used to following orders after all). In fact the VA I was at (not sure if this is systemwide) has a policy that you have to call the vet right away if they don't show up to make sure they didn't commit suicide or something. That's not to say they are taking the meds as prescribed though - that is a problem in every patient population I've met.

Infantilizing your patient with things such the 3 mandatory no show calls within 24 hour helps create the no show problem we have. Which is indeed a problem within VA MH nationwide-data backs this up. Obviously, some clinics and certain subpopulations will be have less of an issue with this

 

[WisNeuro]

Infantilizing your patient with things such the 3 mandatory no show calls within 24 hour helps create the no show problem we have. Which is indeed a problem within VA MH nationwide-data backs this up. Obviously, some clinics and certain subpopulations will be have less of an issue with this

Last I heard, the national policy was one no show call within the first 24 hours, a generated letter counted as the second contact, and a third call at some point in teh following week was sufficient. There is a slightly different subset of rules depending on whether or not they have a suicide flag.

 

[erg923]

Last I heard, the national policy was one no show call within the first 24 hours, a generated letter counted as the second contact, and a third call at some point in teh following week was sufficient. There is a slightly different subset of rules depending on whether or not they have a suicide flag.

Is that MH does at your VA, cause that not what we are told do here.

 

[WisNeuro]

Is that MH does at your VA, cause that not what we are told do here.

That may just be your VA, I'd urge you to look at the national guidelines and see if your admins will lighten up a bit.

 

[randomdoc1]

No, so many of you have got it all wrong! We have yet to try an MAOI! Don't forget to add an MAOI!

 

[Doctor Bagel]

My experience is that vets do tend to show up for stuff (they're used to following orders after all). In fact the VA I was at (not sure if this is systemwide) has a policy that you have to call the vet right away if they don't show up to make sure they didn't commit suicide or something. That's not to say they are taking the meds as prescribed though - that is a problem in every patient population I've met.

Jeez, my VA no show rate for my outpatient clinics in residency was probably like 50%. Made for an easy day!

 

[erg923]

That may just be your VA, I'd urge you to look at the national guidelines and see if your admins will lighten up a bit.

I was just informed that its our facility's "interpretation" of the national policy. Facepalm

No one seems to no where to actually locate either the national policy or our interpretation of it. I suppose I'll just snag the VA uniform services handbook off my nightstand when I get home.

 

[WisNeuro]

I was just informed that its our facility's "interpretation" of the national policy. Facepalm

No one seems to no where to actually locate either the national policy or our interpretation of it. I suppose I'll just snag the VA uniform services handbook off my nightstand when I get home.

http://www.va.gov/vhapublications/publications.cfm?pub=1

Directive 1230, in Appendix I. I've never seen a mention of 3 phone calls in one day, only mention of three contacts. I've actually seen it somewhere that at least two of teh contacts have to be on separate days, so, your facility may actually be violating policy if no contact is made after day 1.

 

[erg923]

http://www.va.gov/vhapublications/publications.cfm?pub=1

Directive 1230, in Appendix I. I've never seen a mention of 3 phone calls in one day, only mention of three contacts. I've actually seen it somewhere that at least two of teh contacts have to be on separate days, so, your facility may actually be violating policy if no contact is made after day 1.

Section A of that appendix states:
"Mental Health guidelines require three telephone calls. See https://vaww.cmopnational.va.gov/CR/MentalHealth/Publications/Business Operations/20130625 - Memo - No Shows.pdf NOTE: This is an internal VA Web site that is not available to the public. "

 

[WisNeuro]

Section A of that appendix states:
"Mental Health guidelines require three telephone calls. See https://vaww.cmopnational.va.gov/CR/MentalHealth/Publications/Business Operations/20130625 - Memo - No Shows.pdf NOTE: This is an internal VA Web site that is not available to the public. "

The quoted guidelines, if you follow them, actually state that 3 contacts need to be made, and nowhere is it stated that it needs to be all within 24 hours.

 

[Therapist4Chnge]

Jeez, my VA no show rate for my outpatient clinics in residency was probably like 50%. Made for an easy day!

It's amazing how workload and ability to treat varies between settings. I kept a <3% no-show (NS) rate in my neuropsych private practice. Ever since I assimilated into The Borg of academic medicine…I'm at 4+ months wait list and my NS rate is 50%, down from nearly 70% earlier in the year. I can't imagine trying to do meds management or therapy with those kind of NS rates.

 

[wolfvgang22]

Our clinic no show rate here is 12% over the last year. The year before it was 17%, before I showed up it was 19%.
Many of the older veterans tend to show up an hour or two before their appointment to drink coffee and visit, which is probably therapeutic.

The veterans under 30 years old and the veterans with substance abuse no show the most, as you might expect.

The rate of medication non-adherence is the same as I've seen outside the VA.

 

[Information Underload]

The only question I've got is how the hell is a regimen like that not malpractice?

If you want a reason, a malpractice suit requires that the patient is actually harmed. I haven't seen any evidence to indicate that this is the case here.

I have one patient with a wacky regiment like this (Depakote, risperidone, olanzapine, oxcarbazepine, baclofen, melatonin and Tenex) who I cringe over if anyone ever sees him without any context after speaking to me, but he has been stable on this regimen for going several years after multiple inpatient psychiatric hospitalizations and destabilizations. Attempts to wean the guy have resulted in him destabilizing (even with the seemingly minor meds like Tenex, oxcarbazepine or baclofen), and I've just accepted at this point that his med regimen is going to stay wacky for awhile. Guy is skin and bones, too, with great cholesterol, which you wouldn't expect on hefty doses of Depakote, Zyprexa and Risperdal, but you can't account for body chemistry; at least not yet.

 

[erg923]

That Veteran seems to be missing Zolpidem for sleep, and qid hydrocodone for their pain. Oh, and depending on the facility, some kind of maintenance benzos for anxiety. Way too undermedicated.

Add PRN Percocet from an outside PCM. Im not joking.

 

[Therapist4Chnge]

I recently saw a lady on 29 "herbal supplements" from an alternative med doc, to go with her Percocet, Adderall, and Xanax (PAX) from her PCP. She refused to take anything that wasn't "natural", but made an exception for PAX bc "they worked great together" Concussion case, prolonged symptoms, and pre-existing psych...shocker, right?

 

[st2205]

And how would you safely reduce the number of meds? If you do more than one at a time, then you won't know which one to attribute relapse to.

It doesn't matter. Whatever you do will be followed by a crisis that has more to do with the idea of medications being reduced/stopped than the medications actually being reduced/stopped. The ideal would be if you can get them off for a sustained enough time for them to see that they feel just as ****ty off the medications as they did when they were on them.

 

[birchswing]

It doesn't matter. Whatever you do will be followed by a crisis that has more to do with the idea of medications being reduced/stopped than the medications actually being reduced/stopped. The ideal would be if you can get them off for a sustained enough time for them to see that they feel just as ****ty off the medications as they did when they were on them.

They say for smokers giving you something similar to do with your hands helps. I think the same could be said for taking an innocuous supplement like fish oil in place of a pharmaceutical pill. I've finally realized this is what my psychiatrist has been trying to do with me (current assumption), or else she really believes in the power of a wide variety of supplements (former assumption). She underestimates however how afraid I am of new supplements.

 

[splik]

This is not made up. This is a real medication regimen of patient I have been referred. Comments?

Buproprion XL 300 mg in am

buspar 15 mg twice daily

zoloft 200 mg daily

remeron 30 mg nightly

geodon 20 mg twice daily

Adderall XR 30 mg in am

Adderall 10 mg at noon

Lamictal 200mg- 2.5 tabs daily

minipress 10 mg nightly

elavil 100 mg nightly

restoril 15 mg nightly

imitrex 50 mg as needed

my old adage is if a pt is on more than 5 different psychoactive drugs from at least 4 different classes they have borderline personality disorder until proven otherwise. at the VA I would also throw in TBI as these TBI patients (who are often personality disordered too) often end up on shed loads of drugs

 

[st2205]

They say for smokers giving you something similar to do with your hands helps. I think the same could be said for taking an innocuous supplement like fish oil in place of a pharmaceutical pill. I've finally realized this is what my psychiatrist has been trying to do with me (current assumption), or else she really believes in the power of a wide variety of supplements (former assumption). She underestimates however how afraid I am of new supplements.

The idea isn't just to get them on something more benign, though sometimes that's your only choice. The idea that people become so dependent on looking to an external source, validating the belief that they're just a passive victim in the process, unable to effect any change from within themselves (except as it relates to the choice to take medicine).

 

[st2205]

my old adage is if a pt is on more than 5 different psychoactive drugs from at least 4 different classes they have borderline personality disorder until proven otherwise. at the VA I would also throw in TBI as these TBI patients (who are often personality disordered too) often end up on shed loads of drugs

You could drastically loosen that criteria without sacrificing any specificity.

 

[WisNeuro]

my old adage is if a pt is on more than 5 different psychoactive drugs from at least 4 different classes they have borderline personality disorder until proven otherwise. at the VA I would also throw in TBI as these TBI patients (who are often personality disordered too) often end up on shed loads of drugs

I wish we could just replace mTBI with a diagnosis of iatrogenesis, it'd much more accurate.

 

[MacDonaldTriad]

Of course who is to say that the average bipolar patient isn't BPD. It seems to be a fad right now.

 

[OldPsychDoc]

No, so many of you have got it all wrong! We have yet to try an MAOI! Don't forget to add an MAOI!

I was trying to find something missing. I think you may have found it.

 

[northernpsy]

I imagine there is probably some regional variation as far as the no show rates go. While yes we did have the anti-social individuals and certainly some cases involving severe substance use, in many cases my outpatient veteran patients were actually reasonably functional (especially the WWII/Korean War ones, though sadly you don't see a whole lot of that generation left anymore). I definitely had fewer than 50% no shows. That kind of rate was more typical of my clinic for general community uninsured.

my old adage is if a pt is on more than 5 different psychoactive drugs from at least 4 different classes they have borderline personality disorder until proven otherwise. at the VA I would also throw in TBI as these TBI patients (who are often personality disordered too) often end up on shed loads of drugs

I definitely agree with this. Most of the very worst cases of polypharmacy I have seen involve borderline patients. I also feel that all the cases of "dissociative identity disorder" I have seen personally were really just very severe borderline personality disorder.

 

[DD214_DOC]

Only when you learn and embrace the power of, "No.", will you truly become a master....

 

[Therapist4Chnge]

... at the VA I would also throw in TBI as these TBI patients (who are often personality disordered too) often end up on shed loads of drugs

With ZERO efficacy to support the mounds of polypharmacy being prescribed.

 

[Jules A]

I also feel that all the cases of "dissociative identity disorder" I have seen personally were really just very severe borderline personality disorder.

Did someone say iatrogenic?

 

[randomdoc1]

my old adage is if a pt is on more than 5 different psychoactive drugs from at least 4 different classes they have borderline personality disorder until proven otherwise. at the VA I would also throw in TBI as these TBI patients (who are often personality disordered too) often end up on shed loads of drugs

I feel likewise. Other red flags in my book include if they see something like 20+ specialists and have more than six "allergies." Especially "allergies" to things like benadryl, epinephrine, and my fave: normal saline. At the very least, it makes me suspicious of some sort of personality pathology involvement, somatoform matter, something iatrogenic, just that there is something way more to the picture that is being missed. In other words, not a more bread and butter mood disorders matter, etc.

 

[birchswing]

my old adage is if a pt is on more than 5 different psychoactive drugs from at least 4 different classes they have borderline personality disorder until proven otherwise. at the VA I would also throw in TBI as these TBI patients (who are often personality disordered too) often end up on shed loads of drugs

What is the phenomenon's etiology? The few that come to mind:
A) Patient with BPD misdiagnosed with something else so doctor keeps throwing more drugs at problem.
B) Patient with BPD less able to discern bad judgment of doctor who prescribes a lot of drugs.
C) Patient with BPD seeks more drugs and doctors give them.

 

[Crayola227]

Of course who is to say that the average bipolar patient isn't BPD. It seems to be a fad right now.

Not sure what you meant with this.

Please God no. I think this is one of the worst things about someone being bipolar - the stigma that comes with assumptions about BPD. That and the fear of the sufferer going psychotic. That and that they don't "miss" the sleep. That and they they take their meds, feel great, and that's why they stop them, because they either don't think they need them, or they "want" to be manic again.

Sorry, just my want on what I think are common provider beliefs about BPAD that aren't strictly true, although I can't say that the above isn't ever true.

 

[FlowRate]

Based on several patients I've admitted (to medicine!) recently, he's missing chronic Benztropene (Cogentin.)

One of them: Lady with "depression" (per her psychiatrist) whose only psych med is Depot Haldol...

 

[PistolPete]

This is what happens when you can't say "no" to a patient and don't realize or don't want to realize that the customer/patient isn't always right.

 

[nexus73]

You could get probably $3-400 on the street for a month supply of this regimen?

 

[Ψ-117]

Sheesh, I'd hate to be the one making the copays on all those meds every month. I wonder how much better off this patient is than when they started? If they're still having problems with their mood and sleep, be sure to add some Cytomel and melatonin.

 

[birchswing]

Sheesh, I'd hate to be the one making the copays on all those meds every month. I wonder how much better off this patient is than when they started? If they're still having problems with their mood and sleep, be sure to add some Cytomel and melatonin.

Melatonin would be the least illogical on that list as it actually replaces an endogenous hormone that some of those meds deplete.

 

[wolfvgang22]

Perhaps some hydroxyzine 25mg TID is also missing.

 

[AnnoyedByFreud]

This is not made up. This is a real medication regimen of patient I have been referred. Comments?

Buproprion XL 300 mg in am

buspar 15 mg twice daily

zoloft 200 mg daily

remeron 30 mg nightly

geodon 20 mg twice daily

Adderall XR 30 mg in am

Adderall 10 mg at noon

Lamictal 200mg- 2.5 tabs daily

minipress 10 mg nightly

elavil 100 mg nightly

restoril 15 mg nightly

imitrex 50 mg as needed

Is the pt truly taking all of those meds or did someone just not clean up the med list in the EHR?

 

[WisNeuro]

Sheesh, I'd hate to be the one making the copays on all those meds every month. I wonder how much better off this patient is than when they started? If they're still having problems with their mood and sleep, be sure to add some Cytomel and melatonin.

Well, depending on the SC of this individual, you, as a taxpayer may actually be paying the copays on all of those meds