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I do not have said magic pills...

Discussion in 'Psychiatry' started by randomdoc1, Apr 10, 2018.

  1. randomdoc1

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    Sorry, just a small vent. Wish there was a way to get through to patients that our interventions can treat mood disorders, anxiety disorders, thought disorders, etc. However, it will not divorce appropriate emotional reactions to significant things. Nor do these medications replace life style changes like diet, exercise, serve as a replacement for social engagement or treat things like sheer boredom you have from having no structure in the day. Having a string of patients saying they just don't want to do therapy and "I just want to wait for the meds to kick in...." *face palm*
     
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  3. PistolPete

    Physician

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    If I had a penny for every time I had this exact conversation, I'd be rich. It's just part of our culture. "Just fix me with a pill"
     
  4. calvnandhobbs68

    calvnandhobbs68 I KNOW NOTHING

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    Just embrace it like plastic surgery and derm.

    “Hey you don’t like your body? We can fix that no problem!”
     
  5. finalpsychyear

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    wonder how many of these patients are "disabled" and on medicaid or similar plans. These tend to always be the most difficult, treatment resistant population in my opinion. Some i'm sure are valid. Others i feel get used to the luxuries of not working and getting a monthly check for their condition and play the game indefinitely always looking for said pill when the biggest reason they fail to improve is their foundations of life : sleep, appetite, structure are vastly impaired due to their lifestyle.
     
  6. wolfvgang22

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    Yeah. Had a patient today with blood glucose through the roof because said patient stopped taking insulin two weeks ago. Wanted me to change her psychiatric medications because she felt terrible. Neither the nurses nor primary care nor the patient liked my advice. I bet you can guess what it was was.
     
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  7. resident1985

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    What I hate is how offended some people are when you suggest alternatives to medication. Like the overweight depressed female with improved symptoms but continues to complain of poor energy. When you suggest better diet and exercise to improve energy vs med changes they disagree and are upset. Or like the axis 2 patient who has tried over 25 psychiatric medications with no effect. When you suggest shifting focus from meds to therapy and other interventions in a respectful manner they get upset. I’ve had two patients complain to their therapist who then relates to me they are upset “I want to take them off all their meds!?” Unfortunately therapist usually colludes with them. One patient is “disabled” by anxiety yet somehow visits Disneyland on a regular basis. The other is applying for disability and smokes pot all day. Both on Medicaid. It’s taking a toll on me to the point I know I need to seek therapy or maybe leave the field.
     
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  8. randomdoc1

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    You can always offer them a second opinion and give them a handy dandy list of other providers. I generally phrase it as tactfully as I can saying we seem to have trouble making progress. Perhaps they can seek a second opinion. I'd emphasize I still stick to my recommendations but we can consult another psychiatrist if that makes them feel better or they have other insights. Usually I never hear from them again (they may have found someone who will just hand out what they ask for) and I try to keep my panel full of motivated patients who are willing to follow your recommendations. Sometimes it is rewarding when they find the other psychiatrist has essentially the same recommendations and they decide to follow your recommendations after all...
     
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  9. resident1985

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    Yes I used to try harder but I’ve gotten pretty frank with people. I frame it as recovery is possible but not likely if we keep going down the same path that we’ve proven is not effective. One patient was so offended that I said people can be recover from ptsd with therapy and complained to her therapist. If these people fire me I don’t care because I’m not going to help them anyway if I’m not doing therapy with them and just managing meds. I also prefer to fill my practice with motivated people who will not waste resources and are not just looking for secondary gain. I’ve become much more comfortable with conflict and confrontation so this is now easier for me to do. People need to step up to the plate at some point if they’re not motivated or ready for change there’s someone else out there waiting for care that is.
     
  10. resident1985

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    Check out the work of Theodore Dalrymple. He has a lot to say on this.
     
  11. Trismegistus4

    Trismegistus4 Worried Wellologist
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    No one wants therapy for panic disorder once they have experienced the glories of a benzo. Why would they want to do therapy? Xanax "works!" "It's what works! Why won't any doctor just give me what works?" My favorite are the patients who tell you they have panic attacks "all day, every day." I recently saw a follow-up who, as I interviewed her, told me she was having a panic attack "right now" as she sat there with a depressed affect, no hyperventilating, speaking calmly in complete sentences, no agitation, not curled up in a ball.

    Reminds me of my former patient whose strongest source of identity in life was having PTSD from getting fired from her civil service job 18 years prior. This alleged PTSD supposedly prevented her from basically doing anything with her life for 18 years other than sitting around agonizing over how she got fired from that job. I couldn't help myself and eventually suggested to her, as gingerly and politely as I could, that PTSD is something that people get from exposure to actual or threatened death, serious bodily injury, or sexual violence. She never came back.

    Therapist collusion is a big problem. On the PTSD issue, master's level therapists seem to think that meeting criterion A is diagnostic of PTSD. That is, they're always diagnosing patients with PTSD solely on the basis of exposure to some traumatic event, seemingly unaware that you also have to have a bunch of, you know, actual symptoms in order to have the disorder. I've also seen people whose therapists were the first to bring up the possibility of ADHD to them. Thanks a lot, people.
     
  12. Onions

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    Not to hijack the thread, but this seems interesting to me. If this purported PTSD diagnosis had formed the foundation of her identity over the past 18 years, then is it possible that there really would not have been any way to confront her honestly--no matter how gingerly--and expect that she would return? How might you have offered her something in place of this identity that she seems to have perceived you as robbing? Could you have?
     
  13. resident1985

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    What good would it be for her to return? I’m assuming you were providing medications and not therapy. The service you were able to provide would offer no benefit and would continue to reinforce victimhood status. If you were providing therapy that’s another story.
     
  14. smalltownpsych

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    These types of patients and they are legion are a big reason I am interviewing with a private pay residential treatment in a couple of days. Just getting tired of the victimhood and the disability, medication, amotivated lifestyle. Our culture is missing the boat on this one and I see no signs of it shifting. Wish me luck.
     
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  15. Shikima

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    Holy hell. I had this same convo, with non-medicaid, 8x in the past 2 days. Good 'ol MI works every time. Either they embrace the suck or they get pissed off and leave. Either way, I win.
     
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  17. wolfvgang22

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    I bet Tshirts and hoodies with this printed on them would sell. Also a great book title.
    I'm considering setting up a merchandise table in the waiting room. All proceeds would go toward the Human Fund.
     
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  18. Ceke2002

    Ceke2002 Purveyor of Strange

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    All the best. Would it help if I spread the word about your possible new job amongst some nice, motivated patients? Depending on what you'll be specialising in with the residential program? I'd be happy to do that for you. :)
     
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  19. Ceke2002

    Ceke2002 Purveyor of Strange

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    So do you guys ever get patients who actually come in and say 'No thanks, I don't want medication, I just want to work through my issues with therapy?' (Do you have to pick yourself up off the floor if you do?).

    I don't get people that think a pill is going to magically fix everything. Therapy worked far better for me in the long term than any amount of medication ever did (barring when medication did become necessary of course).
     
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  20. WingedOx

    WingedOx Not here for your bullsh-t
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    I've been getting hammered by SSD paperwork requests from patients, only one of which I think actually meets the definition of disabled. The extraneous paperwork requests (not just SSD stuff, but I've also got a lot of patients in legal trouble) I've been getting in my clinic are getting to the point that I've been fantasizing about moving over to a full-time inpatient role if one opens up soon where I'm at.
     
  21. randomdoc1

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    I have a resolution for that! We discussed that the AMA, APA indicate a treating provider is not to participate in these forensic matters. It even indicates so in the AMA Causation. I tell that to patients and it helps maintain our therapeutic alliance and I recommend they just get an IME.
     
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  22. Shikima

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    Say that you don't complete SSD paperwork because it interferes with the doctor-patient relationships as you're there to help heal them. However they are welcome to request records sent to whichever entity that is representing them.
     
  23. PSYDR

    PSYDR Psychologist

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    I am extremely happy to hear you say this.
     
  24. resident1985

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    Yes sometimes and sometimes I recommend no meds and they are ok with it. I always try to keep people medication naive if possible.
     
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  25. Ceke2002

    Ceke2002 Purveyor of Strange

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    You definitely sound like my sort of Doctor. Good to know there's still a few of you out there that don't just jump straight to pills for everything that ails someone. :)
     
  26. Shikima

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    Be aware of the vitriol from the cluster b helicopter mother.
     
  27. randomdoc1

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    Speaking of what works, I found a 60 yo pt on my schedule who's on high dose benzos. PDMP shows she's getting 7 day supplies, so previous MD probably had an issue with early refills. Called her before her appointment, told her I'd be recommending she taper off and if she does not agree with this, I have numbers to other providers she can schedule with. She said "well, lots of doctors prescribe like this." I replied discussing that it does not mean it's correct, saying many doctors handed out pain pills and all the morbidity and mortality that has caused....I win.
     
  28. resident1985

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    yes I’m becoming immune to vitriol for better or worse
     
  29. smalltownpsych

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    The nice thing about the motivated patients that have financial resources is that they are also very selective so providing quality service matters. Most of the patients have already spent years receiving the typical community care and are willing to pay for effective treatment. Don't know if they get very many patients from down under. :)
     
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  30. Ceke2002

    Ceke2002 Purveyor of Strange

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    No, I can't imagine they would get too many from across the pond. I did mean patients in your neck of the woods. ;) Glad to hear though that it sounds like this program will attract more the type of patient you want to work with at this stage of your career. I can imagine the burn out factor from having a bunch of patients just yelling 'fix me!' whilst refusing to actually do anything to help themselves would be rather high.
     
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  31. SeniorWrangler

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    It's all resistance and it's all good. It gives you a great chance to practice your motivational interviewing skills every single day.
     
  32. MedMan80

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    "FATALITY...randomdoc1 WINS!"

    I recently had a helicopter mother come into the dev peds clinic I'm rotating at and demanded stims for her daughter, who was diagnosed with ADHD by the therapist...kid had great grades in school..she got pissed after we requested the kid get seen by cardiology due to having Ehlers Danlos for clearance (meaning she was going to get the stims anyways)..i mean sure one pill could kill your kid, but why would we with-hold these meds to your honors student for a month more than is needed?
     
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  33. txpharmguy

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  34. txpharmguy

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    You should know those high dose atypicals are the sole reason his blood glucose was out of whack
     
  35. randomdoc1

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    I hate it when other providers carelessly throw around diagnoses too. The ADHD bomb was tossed to two of my patients, and of course the therapist never screens for AODA. Both patients do not have a pediatric history. One smokes pot daily and the other drinks.

    I don't get parents demanding stims for their kids either. They're so scared of antidepressants yet flock to stims, that's so a$$ backwards. Also, do you really want your kid going through life thinking they can't succeed or even function without daily schedule IIs? That's so self defeating (not to mention fosters a very dangerous relationship/dynamic with medication) and they may feel committed to taking them for life when they may not even have the diagnosis.
     
    #33 randomdoc1, Apr 15, 2018 at 4:31 PM
    Last edited: Apr 15, 2018 at 4:42 PM
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  36. justfolks

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    Just a patient, just wanted to say that I really, really appreciate this thread. I always feel guilty about my no-meds stance, I imagine that my psychiatrist would rather just write scrip and be done with me instead of wasting so much time talking to me. Not necessarily rational, I know. Hence the therapy.... Anyway, it's helpful to hear this from people who aren't talking to/about me and have no reason to be "nice." So thank you.
     
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  37. erg923

    erg923 Regional Clinical Officer, Cenpatico National

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    None of my young children have any said problems. But if they did, I would ride it out, seek intervention if I could afford it (fortunately we can), and would probably object until the last minute before putting any of them on any of the stuff that I see Rx everyday. What does this say? And its not even like I'm a health nut or something like that-They eat chocolate, and prob watch to much TV before school.

    Is it weird that I work in the profession, but would so vehemently object to our diagnoses and standard medication interventions....I dont know. Food for thought.
     
  38. randomdoc1

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    Therapy, and good non pharm interventions (there's too much crap therapy out there) at that are way under utilized. Medications do have their place, but we also need to have good coping and problem solving, it carries everyone so much further.
     
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  39. WingedOx

    WingedOx Not here for your bullsh-t
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    not at all... I have a friend who I'd been advising to get some MH help for anxiety and a few other things, but at the same time I worry about the quality of the help they'll get if they take my advice. Like, some dumbass is going to give them TID xanax or something.
     
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  40. WingedOx

    WingedOx Not here for your bullsh-t
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    I was joking with one of the therapists in my clinic that I was referring a patient so that she could tell the patient to improve his self-care and physical activity weekly because me telling him the same thing q8 weeks wasn't doing it.
     
  41. randomdoc1

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    That's exactly what happened to my aunt actually. And she has classic GAD. Now she won't consider any medication at all and it's pretty significant GAD too...

    She dc'ed her Xanax cold turkey without telling her provider too and that was what scared her. Now she thinks all psych meds are like that.

    Her son, my cousin is also very anxious. But she's so afraid of the MH field she won't even get him evaluated. I think she gets the impression it's all pill mill or something. So instead she just has him pray a lot and make sure to go to church....I haven't noticed much change in his anxiety.
     
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  42. resident1985

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    Out of curiosity does your psychiatrist perform your therapy?
     
  43. resident1985

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    I think this all the time. I tell my family to be very wary of mental health practitioners because there’s so many bad ones. My sister went through a crisis and the first therapist she saw was terrible. I won’t get into it but more harm than good. Thankfully she found a new therapist who was good. As far as medications people just view them as so benign including physicians. I try to counteract this in my practice.
     
  44. SourceOfDenial

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    If you're using a strict conceptualization of criteria A to diagnosis PTSD you are missing a lot of trauma related disorders.
     
  45. Onions

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    The converse to the magic pill subject: parents who bring their children to the ED "because I didn't know what else to do, she needs help," but then they do me a big favor by consenting to so much as PRN Milk of Mag. I try to reframe their expectations of what a psychiatric hospitalization means and what we can hope to accomplish, but sometimes no matter how much time I take to do this, some people can't let go of the fear that "you're going to turn my kid into a zombie."

    Meh, I guess I don't really blame them. Most people don't actually want to have to bring their kid to a psych hospital and it can be confusing and stressful. Maybe I'm the one not doing my job well enough.
     
  46. randomdoc1

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    I should frame this and put it in my office...passive aggression.
     
  47. Ceke2002

    Ceke2002 Purveyor of Strange

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    Patient here too, and you're definitely not the only one with a no meds stance. Sometimes I feel like we're a dying breed, but give me therapy over medication any day. It's good to know there are Doctors out there willing to limit going down the meds route and do therapy as well. :)
     
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  48. Jules A

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    Which is why my friends and non-psych colleagues are given the short list of competent local psychiatrists and therapists when in need. And conversely when non-psych care is needed for self or family I defer to colleagues who can recommend someone competent in whatever specialty.
     
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