1? 2? 3? do I hear 4? Antipsychotics.

[heyjack70]

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What is the greatest number of anti-psychotics you've seen on a patient's active med list?

 

[goldennugget]

I had a guy come in for a consult to our mood disorder clinic. He was seeing someone in the private sector for reported major depression. his list included geodon 80 mg, abilify 20mg, and Risperdal 1mg po BID (in addition to wellbutrin). He had absolutely no psychotic symptoms. He said he was on these three antipsychotics for years.

 

[whopper]

Five.

Why?

I had a patient that had factitious disorder in addition to having a real psychotic disorder. I got her onto a medication regimen that was controlling her psychosis but she would sabotage me and make symptoms up. It was to the point of either having her psychotic and dangerous to others or factitious and giving her more meds than needed but she wouldn't cooperate to the degree where I could get her on the least amount needed. On several occasions when I lowered or tried to stop one of her meds, she'd act out in a a dangerous manner. I had to have the Court get her a guardian so I and the guardian could get her meds straight.

I didn't start her on the medication regimen she was on. I inherited the problem from another doctor that I thought was terrible. He had her on more than 5 psychotropics. There were around 10 in all when I got her.

 

[heyjack70]

Five.

Why?

I had a patient that had factitious disorder in addition to having a real psychotic disorder. I got her onto a medication regimen that was controlling her psychosis but she would sabotage me and make symptoms up. It was to the point of either having her psychotic and dangerous to others or factitious and giving her more meds than needed but she wouldn't cooperate to the degree where I could get her on the least amount needed. On several occasions when I lowered or tried to stop one of her meds, she'd act out in a a dangerous manner. I had to have the Court get her a guardian so I and the guardian could get her meds straight.

I didn't start her on the medication regimen she was on. I inherited the problem from another doctor that I thought was terrible. He had her on more than 5 psychotropics. There were around 10 in all when I got her.

My interest in bad med management and the way a physician might find his way there (and with that knowledge hopefully avoid it). I've seen a few patients like that from other doctors. I always wonder if they got caught in a cross taper, but in that case there would only be 2 antipsychotics. I've seen 3 on one patient, where they were at another hospital, delirious, hx of schizophrenia and they were chasing the delirium by adding a typical + atyipcal onto the current typical antipsychotic. They were transferred to us with altered mental status because we have inpatient neurology.

 

[whopper]

During fellowship, I moonlighted at a community mental health center. The psychiatrist whose place I took over, at first I figured there was a perfectly rationale and appropriate explanation for why there were so many patients not getting better.

After seeing every single patient a few times, I came to the conclusion that the guy didn't know WTF he was doing.

Panic disorder? He treated it with Wellbutrin. He
He had every single patient on a PPI, a benzo, and Topamax, no matter what. Some patients actually developed GERD after being put on the PPI. After being on it a few months, they stopped it on their own and had GERD, but didn't not have it before.

Several of the patients he treated that I saw in a group home were sedated into nigh-oblivion.

He put patients on Clozaril without documenting what was tried before.

I could go on, but all-in-all, after 6 months, I had about 1/2 of the patients on much less meds they they were on before, and they felt better. All patients on a benzo were weaned off, and placed on an SSRI if they had anxiety. Over 1/2 of the patients that were seen monthly were moved up to being seen every 3-6 months because they improved.

As much as I'd like to gloat, I was doing only what I believe should be average care. Giving a patient the "standard" med for anxiety-an SSRI should be average. What surprised me then (not now because I've seen it too many times), is that there's plenty of bad doctors out there. It's hard to become an attending doctor, but once a doctor is one, it unfortunately seems they can get away with too much.

 

[sunlioness]

I think my personal record for what I've seen is 3. I've personally prescribed 2 at once, but almost always in a "stuck in the cross-taper" situation.

 

[Chianti]

One of the things I learned in residency is that there are a lot of really, really bad psychiatrists out there.

Typical story: I saw a lady in my out-patient moonlighting gig. She was 33 or 34 with a history of Bipolar Type I (accurate diagnosis; another thing I learned is how many people are diagnosed with "bipolar" disorder who don't have it). Anyhow, she had recently been committed while hypomanic or manic. Prior to committment, she was off all meds. She was hospitalized for 16 days. During this time she was treated by a nurse practioner and did not see a psychiatrist a single time. While hospitalized she was started on:

Lithium
Zyprexa
Seroquel
Lamictal
Prozac
Topomax
Buspar
Vistaril

At her first out-patient appointment I stopped everything except Lithium and Zyprexa. At her second out-patient appointment I lowered Zyprexa and stopped it at her third appointment. Currently she is on lithium 600 mg bid (therapeutic) and "feels the best I've ever felt."

Most of my time is spent: 1) clarifying incorrect diagnoses and 2) getting pts off of unnecessary meds.

 

[atsai3]

One of the things I learned in residency is that there are a lot of really, really bad psychiatrists out there.

Typical story: I saw a lady in my out-patient moonlighting gig. She was 33 or 34 with a history of Bipolar Type I (accurate diagnosis; another thing I learned is how many people are diagnosed with "bipolar" disorder who don't have it). Anyhow, she had recently been committed while hypomanic or manic. Prior to committment, she was off all meds. She was hospitalized for 16 days. During this time she was treated by a nurse practioner and did not see a psychiatrist a single time. While hospitalized she was started on:

Lithium
Zyprexa
Seroquel
Lamictal
Prozac
Topomax
Buspar
Vistaril

At her first out-patient appointment I stopped everything except Lithium and Zyprexa. At her second out-patient appointment I lowered Zyprexa and stopped it at her third appointment. Currently she is on lithium 600 mg bid (therapeutic) and "feels the best I've ever felt."

Most of my time is spent: 1) clarifying incorrect diagnoses and 2) getting pts off of unnecessary meds.

kudos to you. The more and more patients I see, the more I find myself agreeing with Ghaemi's "hippocratic psychopharmacology" approach.

 

[whopper]

During this time she was treated by a nurse practioner and did not see a psychiatrist a single time. While hospitalized she was started on:

What I've noticed is some doctors (or in this case, an NP) first don't know how to dx. They'll for example dx bipolar on a spot-examination simply because they only see one symptom of the disorder.

Then some don't even know WTF they're supposed to prescribe in the first place. E.g. an SSRI for anxiety. No they'll do something like Wellbutrin or benzos without any acknowledgement that benzos often cause tolerance then dependence, and possibly addiction, and could be only a short-term solution.

Then, even if they know the right med class to give (e.g. an antipsychotic for psychosis--geez really? I thought you were supposed to give an antidepressant for psychosis), they have no command of what makes one psychotropic better or worse. Some docs give one med out to everyone. "I give Zyprexa to every patient I have with psychosis."

And then some don't understand the idea many patients with problems have problems that in no way are supposed to be improved with psychotropics. Some practitioners practice as if you're supposed to keep on giving meds until the person doesn't complain anymore. e.g if someone has factitious disorder, you give a med, and they want more, you're not supposed to give more. In fact you might not want to give any meds whatsoever. I had a guy in a group home with dependent PD and his previous doctor medicated the guy to the point where he was over-sedated all the time so he'd stop bugging staff members.

Often times I will tell a patient that I believe I cannot get the person better than they are with medications, and that they'll need to focus more on psychotherapy. How can I tell? Some of the time it's easy. E.g. no symptoms of an Axis I, but several Axis II symptoms. In other cases it's not so easy, in which case I tell the patient that this is merely my theory and I'm not overwhelmingly certain, but in cases like this psychotherapy is still the way to go in combination with med treatment, and we should be utilizing both, not just the meds.

The biggest take home I can give you as to what leads to the phenomenon of bad practice is a doctor whose lost sight of what being a good doctor is all about, and that is usually related to a doctor not enjoying his/her job due to loss of passion or not ever having it in the first place. Unfortunately I've seen too many medstudents go into the field because it was the one field where the residency didn't have a bad call schedule.