Placebos for axis II

[st2205]

So the title of this thread may not be the best way to represent what I'm talking about, but it gets the general idea across. I'm curious what input people have on medications or supplements that can be given as a "lesser of two evils" when medicating people who otherwise don't need really need medication. What I mean by this is, for instance, all the borderlines who come in on a laundry list of either medications or medication trials to improve what is simply interpersonal difficulties and poor coping skills. Naturally, the answer lies more in pointing the patient to more appropriate (though still not very effective) care, or to at least develop a little more insight into what the problems may be (other than "my bipolar"). Unfortunately, these people end up on the medication carousel where they eventually try every medication class that "works really well!" for two weeks and then, mysteriously, stops working. Or they have bizarre side-effects or can't tolerate the medicine, or it makes them worse or etc., etc.

What got me more thinking about this was a really bad borderline we had on the unit a couple months back. She's been on everything "with no relief" (naturally). Because of some limited evidence stating that there's some benefit in a mood stabilizer, Trileptal was tried. She didn't tolerate this because she believed it would make her jerk at night. So Lamictal was started (wasn't to keen on the idea, but whatever). Somehow I end up getting scheduled with her for follow-up. In the interim between discharge and her clinic visit, she develops a rash. A week previous is seen by derm, they diagnose seborrheic dermatitis and make no mention of Lamictal, though the patient states they told her it was from the Lamictal. Anyhow, I was kind of fed up with continuing to try medications that aren't the safest (though I do not believe this was a Lamictal rash) for a very questionable benefit. I tried to sell her hard on Omega 3s as there had been some evidence suggesting mood stabilizing benefit in borderline personality. Though I believe this is more than likely total BS, I'd like to have some more options for giving options that are equally ineffective but at least safer and cheaper. There's always the expectation that you've "gotta do something" about their problem that involves medication to some degree. While we all would agree this isn't the answer, and is very ineffective, we at least have to own that we continue to do this out of frustration and limited options (this extends to people with mild depression or life problems who don't really need an SSRI or would have little benefit for one but refuse to be reassured otherwise, and other issues of the like).

So, what's your approach with the "gotta have a med!" crowd? I know what everyone's theoretical approach is, but when it gets down to it, what in reality do you shoot for (perhaps in terms of medications) to avoid the cluster B patient on expensive or less than safe medications? I'm curious to see how borderlines tolerate Omega 3s, though I think in practicality they need it to sound fancy, or dangerous, in order to believe in it. Folic acid? Buspar? B12? Vitamin D? This may sound crass, but what kind of BS options to you feel are reasonable that there's at least some kind of very limited evidence, even if irrelevant, so you don't look like a total clown recommending to the patient (not to say that what we're currently prescribing doesn't make us look like clown) and doesn't make it too obvious that you're giving it to humor the patient.

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[erg923]

Refer for therapy and/or DBT groups. Do not Rx any medications that there are not truly clinical indications for. I think this remains the most parsimonious and the only real ethical approach.

 

[erg923]

There's always the expectation that you've "gotta do something" about their problem that involves medication to some degree.

And who has this expectation? Administrators? Treatment choice is a clinical decision, so unless pressure comes from your direct supervisor, I might tell them to stuff it. Are these people your talking about physicians or clinical mental health professionals? Perhaps efforts should go into education of the others then, rather than what you are proposing here? In other words, the statement is wholly false, and you know it. So why would you go along with it?

 

[slappy]

Fairly certain he's referring to the patients' expectations.

 

[erg923]

Fairly certain he's referring to the patients' expectations.

K. Does that change things then? If so, how? And why?

 

[splik]

the reason that borderline patients end up on so many medications is because the demonstrate both the placebo and nocebo effect par excellance and play out the dynamics of their ambivalence about relationships in general in the transference meanings of medication. They experience temporary improvement often with any medication before becoming worse and thus end up on another med. Or they complain of side-effects that are intolerable. Usually inconsistently. The laundry list of medications usually is a sign of the treating clinician's therapeutic helplessness.

I prescribe promethazine for pananxiety in borderline personality organization which is recommended in the NICE guidelines and is helpful. There is minimal abuse potential, typically amongst those who are also on methadone and seek phenergan for the "nod" they get from the synergistic effects. It is unlikely to cause problems in overdose. When these patients do overdose on their medications, I take it as an opportunity to stop everything. And they are no better or worse off them (sometimes better) however they cling to their medications and can act out against the evil witholding doctor who took away their seroquel, prozac, depakote, xanax, and whatever else they happen to be on.

Typically patients (even if they have a major mental illness like an anxiety disorder) who get caught in this game of "what are you going to give me", are showing you how hopeless they are, how intractable their suffering, and invoke a feeling of helplessness in us which leads us to prescribe another medication that doesn't work. It's a game that you don't need to get caught up in. I saw a patient the other day who was an antisocial chap with some anxiety who had been on various different agents, liking benzos too much, and denouncing SSRIs, buspar, atypical antipsychotics, gabapentin, vistaril, diphenhydramine. He asked me "so what are you going to give me?" (I politely declined his request for clonazepam). I said "nothing". He wasn't expecting that! No one had ever said "no" to him before. They may have declined him benzos but they gave him something else. The message is inconsistent. It is counter-therapeutic to prescribe a drug you don't think will help (or that that patient refuses to allow to help) and leads to a stalemate in the therapeutic relationship. You need to break it. Sometimes acknowledging how hopeless the patient is, and how they are the most challenging patient you have seen and how helpless you feel will give them some little satisfaction and can lead to progress.

 

[erg923]

The above is a great and very thoughtful conceptualization. The American way is typically "more" but I think less is often times advisable.

There is no medication indicated here? Then don't give one. If that a "problem" per the patient, use clinical skill and see what's that's about. It's all grist for the mill. You guys have much, much more at your disposal than medications. Use it.

 

[PikminOC]

The above is a great and very thoughtful conceptualization. The American way is typically "more" but I think less is often times advisable.

There is no medication indicated here? Then don't give one. If that a "problem" per the patient, use clinical skill and see what's that's about. It's all grist for the mill. You guys have much, much more at your disposal than medications. Use it.

You are exactly right.
I'm in a case right now where the spouse is asking for the treatment.
And she is wanting therapy, which is exactly what I am willing to give.

 

[wolfvgang22]

Thank you for your comments. I think this is an important topic.
How do you deal with supervisors who push you to prescribe when it's not the best treatment?

 

[Ceke2002]

The above is a great and very thoughtful conceptualization. The American way is typically "more" but I think less is often times advisable.

There is no medication indicated here? Then don't give one. If that a "problem" per the patient, use clinical skill and see what's that's about. It's all grist for the mill. You guys have much, much more at your disposal than medications. Use it.

This! To be perfectly blunt, screw the patient's 'expectations' you do what's right by them.

 

[birchswing]

So the title of this thread may not be the best way to represent what I'm talking about, but it gets the general idea across. I'm curious what input people have on medications or supplements that can be given as a "lesser of two evils" when medicating people who otherwise don't need really need medication. What I mean by this is, for instance, all the borderlines who come in on a laundry list of either medications or medication trials to improve what is simply interpersonal difficulties and poor coping skills. Naturally, the answer lies more in pointing the patient to more appropriate (though still not very effective) care, or to at least develop a little more insight into what the problems may be (other than "my bipolar"). Unfortunately, these people end up on the medication carousel where they eventually try every medication class that "works really well!" for two weeks and then, mysteriously, stops working. Or they have bizarre side-effects or can't tolerate the medicine, or it makes them worse or etc., etc.

What got me more thinking about this was a really bad borderline we had on the unit a couple months back. She's been on everything "with no relief" (naturally). Because of some limited evidence stating that there's some benefit in a mood stabilizer, Trileptal was tried. She didn't tolerate this because she believed it would make her jerk at night. So Lamictal was started (wasn't to keen on the idea, but whatever). Somehow I end up getting scheduled with her for follow-up. In the interim between discharge and her clinic visit, she develops a rash. A week previous is seen by derm, they diagnose seborrheic dermatitis and make no mention of Lamictal, though the patient states they told her it was from the Lamictal. Anyhow, I was kind of fed up with continuing to try medications that aren't the safest (though I do not believe this was a Lamictal rash) for a very questionable benefit. I tried to sell her hard on Omega 3s as there had been some evidence suggesting mood stabilizing benefit in borderline personality. Though I believe this is more than likely total BS, I'd like to have some more options for giving options that are equally ineffective but at least safer and cheaper. There's always the expectation that you've "gotta do something" about their problem that involves medication to some degree. While we all would agree this isn't the answer, and is very ineffective, we at least have to own that we continue to do this out of frustration and limited options (this extends to people with mild depression or life problems who don't really need an SSRI or would have little benefit for one but refuse to be reassured otherwise, and other issues of the like).

So, what's your approach with the "gotta have a med!" crowd? I know what everyone's theoretical approach is, but when it gets down to it, what in reality do you shoot for (perhaps in terms of medications) to avoid the cluster B patient on expensive or less than safe medications? I'm curious to see how borderlines tolerate Omega 3s, though I think in practicality they need it to sound fancy, or dangerous, in order to believe in it. Folic acid? Buspar? B12? Vitamin D? This may sound crass, but what kind of BS options to you feel are reasonable that there's at least some kind of very limited evidence, even if irrelevant, so you don't look like a total clown recommending to the patient (not to say that what we're currently prescribing doesn't make us look like clown) and doesn't make it too obvious that you're giving it to humor the patient.

Not a psychiatrist.

My psychiatrist thinks that Vayarin helps everyone with everything and that it has no side effects. Personally, I don't understand how something that has an effect can't have a side effect. But she thinks it's great stuff. I was suspicious of it and haven't tried it, plus insurance doesn't cover it. I couldn't get a straight answer on how it's different from the fish oil I take plus the phosphatidylserine that's naturally in my diet (I eat a lot of beans).

But if you're looking for something that is a prescription and supposedly has no side effects and isn't really a drug, it's a way to go:

vayarin.com

The company that makes it even paid for her to go to Israel to learn all about it. I'd be curious if anyone here has used it and seen actual results.

 

[erg923]

Not a psychiatrist.

My psychiatrist thinks that Vayarin helps everyone with everything and that it has no side effects. Personally, I don't understand how something that has an effect can't have a side effect. But she thinks it's great stuff. I was suspicious of it and haven't tried it, plus insurance doesn't cover it. I couldn't get a straight answer on how it's different from the fish oil I take plus the phosphatidylserine that's naturally in my diet (I eat a lot of beans).

But if you're looking for something that is a prescription and supposedly has no side effects and isn't really a drug, it's a way to go:

vayarin.com

The company that makes it even paid for her to go to Israel to learn all about it. I'd be curious if anyone here has used it and seen actual results.

I have some snake oil that I would like to sell your doctor...

 

[Ceke2002]

Not a psychiatrist.

My psychiatrist thinks that Vayarin helps everyone with everything and that it has no side effects. Personally, I don't understand how something that has an effect can't have a side effect. But she thinks it's great stuff. I was suspicious of it and haven't tried it, plus insurance doesn't cover it. I couldn't get a straight answer on how it's different from the fish oil I take plus the phosphatidylserine that's naturally in my diet (I eat a lot of beans).

But if you're looking for something that is a prescription and supposedly has no side effects and isn't really a drug, it's a way to go:

vayarin.com

The company that makes it even paid for her to go to Israel to learn all about it. I'd be curious if anyone here has used it and seen actual results.

26 ways to spot quacks and vitamin pushers.

http://www.quackwatch.com/01QuackeryRelatedTopics/spotquack.html

 

[birchswing]

I have some snake oil that I would like to sell your doctor...

26 ways to spot quacks and vitamin pushers.

http://www.quackwatch.com/01QuackeryRelatedTopics/spotquack.html

I have to overlook a lot to find a halfway decent psychiatrist where I live. Does she take phone calls? No. Does she sometimes have whacky ideas? Yes. But she's the only one I've found who can manage benzo withdrawal, or even realizes that benzos are a problem, so in that way, she's a great doctor.

As far as Vayarin, I should point out in case you didn't look at the link, it actually is an FDA approved prescription treatment for ADHD. She thinks it works for other things as well. The company that makes it also sells different strengths for heart and dementia issues.

 

[Ceke2002]

I have to overlook a lot to find a halfway decent psychiatrist where I live. Does she take phone calls? No. Does she sometimes have whacky ideas? Yes. But she's the only one I've found who can manage benzo withdrawal, or even realizes that benzos are a problem, so in that way, she's a great doctor.

As far as Vayarin, I should point out in case you didn't look at the link, it actually is an FDA approved prescription treatment for ADHD. She thinks it works for other things as well. The company that makes it also sells different strengths for heart and dementia issues.

I did note that it is FDA approved for ADHD, but even the companies website states it's for people who can't normally absorb this particular nutrient or whose distinctive dietary needs cannot be met through diet alone. Your Psychiatrist throwing it at every condition she sees though, to me at least, isn't really practicing evidence based medicine. Not that I think things shouldn't be tried even if they perhaps don't have the peer reviewed data to back them up, but to make sweeping claims like 'this works for everything'...yeah, that's a little troubling to me and suggest that she has more of an interest in pushing a certain agenda than in treating you as an individual person. I don't think there's anything necessarily wrong either with a Psychiatrist having 'whacky ideas', which to me reads as code for 'alternative practices', it just shouldn't be presented as the panacea for all ills. With my own Psychiatrist we do incorporate a lot of alternative/spiritual practices into my treatment, as an adjunct for Psychotherapy and medication. He's a practicing Buddhist, I'm Wiccan so we're both pretty spiritual people and having that aspect to my over all treatment is important for me. Currently we're planning on starting some Pranic breath and energy work, which is really cool, but he's not presenting it to me as 'behold you shall be healed'. I do know what you're going through though, been through it myself, sometimes we end up seeing so many bad Psychs that when we finally get one that's even half way good we're more prepared to over look their short comings in terms of how they're going to approach our individual treatment plans, because 'what the hey, near enough is good enough'.

~~~~~

Just to get back on topic - If you indicate to a borderline patient that meds aren't the way to go and long term therapy is what is needed, and then reneg and prescribe medication anyway, this is the message that just might end up getting sent/heard - "Yes I know I said long term therapy is your best chance of treatment, but you're really not worth my time and I'm already planning to let you down as it is, so here are some pills instead". That might not be your intent, but chances are that's what a borderline patient is going to take away from it.

 

[heyjack70]

You can dip further into the naturopathy option you tried with Omega 3's. Do a pubmed search on complementary and alternative medication for bipolar or mood stabilization (or nutraceuticals instead of C & A). Find a review article and you will see things like Magnesium Supplements, Branched Chain Amino Acids, Chromium Supplements, etc. They all have studies backing them up for bipolar. And I write 'backing them up' extremely loosely. Most, if not all, of the studies you will find are very statistically problematic. They usually have small sample sizes (e.g. 10 or less), they are non blinded, no placebo, or just case series, and other problems. But at least it's somewhere to start.

Find something that is the lowest risk and give it a shot.

 

[heyjack70]

I have some snake oil that I would like to sell your doctor...

Snake oil has always been good business.

 

[whopper]

We're not allowed to prescribe placebos. We're not allowed to lie or mislead our patients, even if we believe it's in their best interests.

My answer to the "got to have a med crowd" is to try to talk them out of it, but if they really must, I'll only try one medication at a time, the results of what it does must be recorded. On rare occasions sometimes the patients do get somewhat better because it turned out what I thought was borderline was, but it was mixed in with some cyclothymia or another Axis I.

In the meantime, tell them they need psychotherapy.

If things turn out the way I think they will, the patient will likely not get much better if at all from the meds, and sooner or later they start believing me that they got a personality disorder that won't respond much if at all to meds. Either that or they've gone to the next psychiatrist who seems to fulfill their wish of being on medications galore.

It's always frustrating to see the ones placed on a benzo and they think they're "cured." Yeah--wait a few weeks to months. You'll either be addicted, dependent, and the med stopped working or a combination of 2 or 3 of them.

 

[ratched]

splik's post above is spot on, and I generally use that approach with the borderline population (not to mention the highly obsessional, somatizing, and other subgroups). However, every once in a while, when I think some "suggestibility" is warranted, I might start someone on Neurontin 100 mg daily.

It's not a true placebo, but is exceptionally low risk, and at that dose, likely has no direct, biological effects for most patients. I do this very sparingly. While I don't think it unethical, I do realize it enters what some may consider to be a grey area.

 

[clusterF]

The issue with this is that a lot of physicians are not fortunate to be in private practice. Once you are a hamster with a consumer/client/member that you have to satisfy to keep your job, you are screwed.
Benzo goody bags help your press ganey scores and lead to bonuses.
The customer wins, you win, the administration wins, press ganey wins. FTW all around except for the patient. However there aren't many of those left.

 

[erg923]

The issue with this is that a lot of physicians are not fortunate to be in private practice. Once you are a hamster with a consumer/client/member that you have to satisfy to keep your job, you are screwed.
Benzo goody bags help your press ganey scores and lead to bonuses.
The customer wins, you win, the administration wins, press ganey wins. FTW all around except for the patient. However there aren't many of those left.

Hmm. I see. So instead of delivering appropriate and beneficial psychiatric care, we simply give in to the patient's pathology? Uh...

Do we care about helping, or just the perception that we are helping people. Are we "mental health professionals" who treat patients or are we "sports agents" who are scared our clients will get "mad" at us?

Splik was right, folks. Buck up! If you don’t like the game of medication carousel, then don’t play it. Psychiatrists who are scared of their patients are not going to be very good psychiatrists. Work with the pathology, gentleman. Its why you are there.

 

[whopper]

This has been brought up several times by psychiatrists with the new billing incentives to make patients happy in the hospital. So far they don't apply to psychiatry but do apply to our ER physician friends because they too are stuck in the same boat we're in. They get several addicts wanting their choice drug of abuse and if an ER doctor says no--guess what? Bad review, less pay.

It doesn't affect us.....yet. There is a movement to push this on psychiatry.

The hospital I'm at had training courses on the new incentives program and my colleagues and I brought up how this can actually encourage doctors to enable patients that make bad choices such as drug addicts. The person conducting the course stated something to the effect of "I never thought of that."

 

[vistaril]

Hmm. I see. So instead of delivering appropriate and beneficial psychiatric care, we simply give in to the patient's pathology? Uh...

Do we care about helping, or just the perception that we are helping people. Are we "mental health professionals" who treat patients or are we "sports agents" who are scared our clients will get "mad" at us?

Splik was right, folks. Buck up! If you don’t like the game of medication carousel, then don’t play it. Psychiatrists who are scared of their patients are not going to be very good psychiatrists. Work with the pathology, gentleman. Its why you are there.

Well, I think an inpatient/outpt distinction has to be made here. On inpatient units, with some insurers if you aren't monitoring medications in some way then the pt is going to have to be discharged. And with outpts, the problem is that referring to dbt or whatever means that someone else is going to do the 'real' work, and we fee devalued.

in my opinion, very few psychiatrists are good working with borderlines. it's not economically in your best interest to do so. I've seen many pcps who are good with borderlines, as well as a number of psychologists and lcsws.

 

[whopper]

The problem with DBT is that very few people are good at it, even the ones that have the training. The other problem is a borderline has to want to get better or has to be forced into the therapy (e.g. court-ordered).

The really bad borderlines that frequent our PESs and inpatient units usually don't have enough insight or ability to maintain the treatment. It costs money, it requires enough insight and initiative to start and continue the treatment.

DBT does work but the ones that really can cause us bad counter-transference usually aren't the ones that are going to keep up with the treatment.

 

[birchswing]

This has been brought up several times by psychiatrists with the new billing incentives to make patients happy in the hospital. So far they don't apply to psychiatry but do apply to our ER physician friends because they too are stuck in the same boat we're in. They get several addicts wanting their choice drug of abuse and if an ER doctor says no--guess what? Bad review, less pay.

It doesn't affect us.....yet. There is a movement to push this on psychiatry.

The hospital I'm at had training courses on the new incentives program and my colleagues and I brought up how this can actually encourage doctors to enable patients that make bad choices such as drug addicts. The person conducting the course stated something to the effect of "I never thought of that."

I was in the ER not long ago with the presenting symptom of shaking and extreme agitation, crawling out of my skin. Because I am on psych meds, the ER doctor assumes it's a psych issue. Sees I'm on 4 mg of Ativan. "Man, I look at you—big guy—you're throwing peanuts at your anxiety. I'd get you up to 12 mg a day." I've seen a lot of ignorance on benzos from doctors, but this one took even me by surprise. I was in a bad state and didn't know how to convey to him how ridiculous of an idea that was for so many reasons—I hadn't gone from stability to uncontrollable shaking overnight due to anxiety or tolerance withdrawal obviously, I wanted to go down not up on the meds, there is no evidence that long-term benzo use helps with anxiety, and there is evidence that long-term uses increases anxiety, and if he wanted me to go up after taking all that in: why go from 4 to 12?! Thinking maybe he'd be more familiar with Valium dosing, I said, "Do you realize that's equal to about 120 mg of Valium?" And he said something along the lines of how he doesn't know much about these things, etc., etc. He had wanted me to take both that extra Ativan AND Abilify before waiting on lab results that I insisted be drawn while I was waiting 3 hours for a doctor. I actually told the nurse what he should test for, and it turned out I had Hashimoto's (not diagnosed then, but eventually).

So, to the point of this conversation, not all patients are drug-seeking idiots. And I did get a survey. And he got a bad review for the exact opposite reason you're suggesting doctors would get a bad review. Maybe it's because of the people I'm around, but I hear complaints from people about drug-pushing from doctors, including from simple things like a routine dental procedure. I think there are a lot of people who would rate a doctor poorly for pushing addictive meds.

 

[Ceke2002]

I was in the ER not long ago with the presenting symptom of shaking and extreme agitation, crawling out of my skin. Because I am on psych meds, the ER doctor assumes it's a psych issue. Sees I'm on 4 mg of Ativan. "Man, I look at you—big guy—you're throwing peanuts at your anxiety. I'd get you up to 12 mg a day." I've seen a lot of ignorance on benzos from doctors, but this one took even me by surprise. I was in a bad state and didn't know how to convey to him how ridiculous of an idea that was for so many reasons—I hadn't gone from stability to uncontrollable shaking overnight due to anxiety or tolerance withdrawal obviously, I wanted to go down not up on the meds, there is no evidence that long-term benzo use helps with anxiety, and there is evidence that long-term uses increases anxiety, and if he wanted me to go up after taking all that in: why go from 4 to 12?! Thinking maybe he'd be more familiar with Valium dosing, I said, "Do you realize that's equal to about 120 mg of Valium?" And he said something along the lines of how he doesn't know much about these things, etc., etc. He had wanted me to take both that extra Ativan AND Abilify before waiting on lab results that I insisted be drawn while I was waiting 3 hours for a doctor. I actually told the nurse what he should test for, and it turned out I had Hashimoto's (not diagnosed then, but eventually).

So, to the point of this conversation, not all patients are drug-seeking idiots. And I did get a survey. And he got a bad review for the exact opposite reason you're suggesting doctors would get a bad review. Maybe it's because of the people I'm around, but I hear complaints from people about drug-pushing from doctors, including from simple things like a routine dental procedure. I think there are a lot of people who would rate a doctor poorly for pushing addictive meds.

I really don't think the point was that all patients are drug seeking idiots, just that being more concerned with getting positive reviews or good survey scores rather than concentrating on patient care is bound to breed the sort of unwanted environment where the Doctor/patient dynamic becomes an inverse one and in the end the patient suffers. For every person out there like you and me who may rate a doctor poorly for being a perceived pill pusher (we don't have those survey things here, so in my case if it happens I just choose not to return to that particular practioner), I can almost guarantee you there are another 10 in line all baying at the moon 'cause they didn't get no stinking good stuff'.

 

[erg923]

I would be much more receptive to the whole original idea/post if I didn't feel like it was born out of a underlying fear of the patient/patients reaction.

I distinctly get the sense that this whole thing is a way to avoid difficult clinical work/interactions.

 

[clusterF]

Hmm. I see. So instead of delivering appropriate and beneficial psychiatric care, we simply give in to the patient's pathology? Uh...

Do we care about helping, or just the perception that we are helping people. Are we "mental health professionals" who treat patients or are we "sports agents" who are scared our clients will get "mad" at us?

Splik was right, folks. Buck up! If you don’t like the game of medication carousel, then don’t play it. Psychiatrists who are scared of their patients are not going to be very good psychiatrists. Work with the pathology, gentleman. Its why you are there.

Step 1, borrow a sense of humor (other options include beg or steal).
Step 2, read my post again.

 

[Armadillos]

The mention of placebos is sort of interesting from an intellectual standpoint, its been awhile since I've talked to them and their point of views may not represent the actual norm in their cultures, but I remember an Indian and a German exchange student both saying that in their countries almost all doctors will occasionally prescribe complete placebos to good effect in the treatment of several conditions. No idea if its true.

 

[smalltownpsych]

It is almost always best to tell the patient the truth. They won't always like it, but that is our job. I tell early stage recovering addicts what they are in for and how bad it is going to be and that no pill is going to make it any better. Most in our field try to ease their pain and I am not referring to first few days of withdrawal where some meds are clearly indicated. I am talking about the first year or two of biochemistry being all out of whack at the same time that you are learning how to cope without substances and put your life back together. What is amazing is how much they appreciate hearing the truth from me even though it is pretty harsh. The same goes for people with BPD. They know the truth deep down so any BS I tell them to placate their pathology is just one more invalidating response!

 

[whopper]

With the Internet being accessible to almost everyone, makes it harder to use a placebo if that's your strategy. Like I said, with our model of medicine we're not allowed to use them either.

 

[Hospital Dwelling Nomad]

Your medication sometimes becomes symbolic of your relationship. It is okay to offer medications/changes that have some possible symptomatic relief for Axis II patients (no addictive meds of course). If you say no, it can be perceived as, "you don't care." Acceptance is the first step of a therapeutic alliance. Addicts and many character patients may get the talk from me about thinking that something you take will fix everything, but working with them to really get them better comes later.

I agree with the above that many of my patients read the internet and know if you are trying to placebo them.

I also agree with Splik in many ways. I agree polypharm is not the way to go.

My two cents.