Irrational Polypharmacy

[DD214_DOC]

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Was there a time in psychiatry during which completely irrational polypharmacy was the standard of care? I'm talking really irrational things, like augmenting a non-stimulant medication for ADHD with an atypical before the dose of the non-stimulant is even within the therapeutic range, or starting a stimulant and atypical simultaneously for ADHD, or putting an adolescent female on depakote as first-line treatment for irritability.

Maybe it's just me, but I try my best to NOT medicate kids unless I absolutely have to.

 

[Shikima]

You're not the only one.

 

[MacDonaldTriad]

In my perspective, we seem to be at a peak of irrational polypharm. The problem is "my poly pharm is rational and everyone else's isn't". I'm sure everyone has a rationalization every time they put pen to script pad.

 

[Shikima]

In my perspective, we seem to be at a peak of irrational polypharm. The problem is "my poly pharm is rational and everyone else's isn't". I'm sure everyone has a rationalization every time they put pen to script pad.

I think it's more of the continued standard where one medication isn't enough and not fully optimized prior to changing/adding.

 

[FlowRate]

We once had a patient who had been stable for a few years on her antipsychotics come in for hallucinations. Her outpatient psychiatrist had her on 1,000 mg of modafinil QD.

That's in the range of overdose case reports, with hallucinations being one of the reported symptoms.

 

[DD214_DOC]

I mean honestly, probably more than half of what I see doesn't need medication. A slight (or big) adjustment in perspectives to match parental expectations with reality goes a long way. My goal with meds is to always evaluate whether their continuation is necessary, and I don't push them on patients. If a parent/patient wants to d/c a medication, I talk to them, educated them, make clear the risks of stopping and, if they still desire stopping, work with them to do it, even if I think it's a terrible idea. I would rather it be done safetly and with good monitoring than for them to go home and do it on their own (which is what will happen anyways)

ADHD is about the only diagnosis I treat initially with meds. The other behavioral stuff really doesn't work given how I conceptualize ADHD. Trying to teach an untreated ADHD kid to pay attention and be better organized is like telling someone with crappy vision to start seeing better.

I start breaking things down in my mind with, "Problems of Living" and, "Mental Illness". The former is most of what I/we see and doesn't need meds.

 

[DD214_DOC]

I have to share this because it's too funny not to. Saw this earlier in the week

Pt started on Risperdal, on it for a few months. Basleine PRL checked was normal. Checked after a few months of treatment and was elevated (40ish or so). Next step? Clearly, order an MRI looking for a sellar mass and -- when none is found -- referral to endocrinology to solve the mystery.

Kid started on Abilify, titrated to 10mg daily. over the course of 6-8 months gains about 20-30 lbs (BMI ~ 27) with dyslipidemia (LDL slowly increases and peaks around 170). Next step? Obviously, refer to nutritionist for counseling and a medical subspecialist to eval for some rare metabolic disorder.

Can't make this up...

 

[Therapist4Chnge]

Wow….

 

[clausewitz2]

I have to share this because it's too funny not to. Saw this earlier in the week

Pt started on Risperdal, on it for a few months. Basleine PRL checked was normal. Checked after a few months of treatment and was elevated (40ish or so). Next step? Clearly, order an MRI looking for a sellar mass and -- when none is found -- referral to endocrinology to solve the mystery.

Kid started on Abilify, titrated to 10mg daily. over the course of 6-8 months gains about 20-30 lbs (BMI ~ 27) with dyslipidemia (LDL slowly increases and peaks around 170). Next step? Obviously, refer to nutritionist for counseling and a medical subspecialist to eval for some rare metabolic disorder.

Can't make this up...

Honestly this seems like the kind of thing that significantly weakens the case for limiting prescribing privileges, as it suggests the provider is not even looking up SE...

 

[nitemagi]

Honestly this seems like the kind of thing that significantly weakens the case for limiting prescribing privileges, as it suggests the provider is not even looking up SE...

Actually it speaks to raising the bar higher than it is now.

 

[clausewitz2]

Actually it speaks to raising the bar higher than it is now.

True enough. But also complicates "well, we're physicians so we know how to handle the medical angle in a way no one else can" rhetoric.

 

[WisNeuro]

Honestly as a neuropsychologist, I would only want prescribing privileges to taper my patients off ridiculous meds. Like my 85+ year old patients who are already on some anticholinergics and their family practice doc on the outside prescribe them some xanax to help with some mild anxiety. I usually see the case for simplification of med regimen instead of the necessity to add things.

 

[smalltownpsych]

I have to share this because it's too funny not to. Saw this earlier in the week

Pt started on Risperdal, on it for a few months. Basleine PRL checked was normal. Checked after a few months of treatment and was elevated (40ish or so). Next step? Clearly, order an MRI looking for a sellar mass and -- when none is found -- referral to endocrinology to solve the mystery.

Kid started on Abilify, titrated to 10mg daily. over the course of 6-8 months gains about 20-30 lbs (BMI ~ 27) with dyslipidemia (LDL slowly increases and peaks around 170). Next step? Obviously, refer to nutritionist for counseling and a medical subspecialist to eval for some rare metabolic disorder.

Can't make this up...

The challenge as a psychologist when I see these obvious side effects is to communicate that to the MD or NP without them becoming defensive or get in the untenable situation of having the patient ask me what they should do. "Do you think I should stop taking this med that caused me to gain 50 pounds in two months?"

 

[DD214_DOC]

Well, I have seen psychologists recommend silly things to primary care docs as well.

I really don't know what to think. I always assumed I'm an average to slightly-above average physician, so either I underestimate my abilities or a lot of docs are really, really terrible at their job.

 

[birchswing]

One thing I've noticed as a patient in areas beyond psychiatry--in fact, they're not really specific to psychiatry at all--is an assumption on the part of doctors that patients will want something in particular when in fact they may come into a situation with little to no bias on a subject. I would mention the subject on which I've done some research which best exemplifies this, but it's controversial and I don't want to derail the thread.

A worse example would be in dentistry, in which a dentist assumes a patient does not want to tolerate any discomfort (it's a worse example because I think it's also the dentist not wanting follow-up calls), and so the dentist prescribes some sort of codeine product automatically with extractions, etc. The patient assumes the dentist knows what is best and takes the pills. What if the patient is comfortable with discomfort, though?

I don't know that this is very specific to psychiatry, but in my own anecdotal experience with psychiatrists I've found that as soon as I want to learn more (that is, ask questions, express concerns about side effects), some psychiatrists will, instead of convincing me of the merits of something and reassuring me that it is the right choice, say instead, "Well why don't we try this instead?" Maybe that's a personality quirk unique to me. I vet everything to the nth degree. I notice some doctors take that as, "Well if you don't like the option I mentioned 5 seconds ago, how about this option?" I'm not usually against Option A. I just want to be sold on it and have all my concerns addressed. Option B isn't going to be any better if you can't do the same for it.

I think assuming what the patient wants or doesn't want could lead to more irrational choices. I'm not saying that doctors necessarily defer to patients' whims--but perhaps they're hypersensitive to perceptions that a patient won't go for something. I've found it a bit unusual that some doctors don't take on more of an expert role in some situations. I think there's bad communication on both sides with both the patient and doctor assuming something about the other.

 

[DD214_DOC]

One thing I've noticed as a patient in areas beyond psychiatry--in fact, they're not really specific to psychiatry at all--is an assumption on the part of doctors that patients will want something in particular when in fact they may come into a situation with little to no bias on a subject. I would mention the subject on which I've done some research which best exemplifies this, but it's controversial and I don't want to derail the thread.

A worse example would be in dentistry, in which a dentist assumes a patient does not want to tolerate any discomfort (it's a worse example because I think it's also the dentist not wanting follow-up calls), and so the dentist prescribes some sort of codeine product automatically with extractions, etc. The patient assumes the dentist knows what is best and takes the pills. What if the patient is comfortable with discomfort, though?

I don't know that this is very specific to psychiatry, but in my own anecdotal experience with psychiatrists I've found that as soon as I want to learn more (that is, ask questions, express concerns about side effects), some psychiatrists will, instead of convincing me of the merits of something and reassuring me that it is the right choice, say instead, "Well why don't we try this instead?" Maybe that's a personality quirk unique to me. I vet everything to the nth degree. I notice some doctors take that as, "Well if you don't like the option I mentioned 5 seconds ago, how about this option?" I'm not usually against Option A. I just want to be sold on it and have all my concerns addressed. Option B isn't going to be any better if you can't do the same for it.

I think assuming what the patient wants or doesn't want could lead to more irrational choices. I'm not saying that doctors necessarily defer to patients' whims--but perhaps they're hypersensitive to perceptions that a patient won't go for something. I've found it a bit unusual that some doctors don't take on more of an expert role in some situations. I think there's bad communication on both sides with both the patient and doctor assuming something about the other.

I think part of the problem is that we really don't have time to sell you on a treatment when something else may be just as effective. I get around this a bit by presenting several options, explaining them and the potential differences between them, then asking the pt to choose. If they ask what I would recommend, then I tell them which one I would go with and why.

EDIT: Added benefit I forgot to mention: this places the responsibility and locus of control for treatment on the patient. People are less likely to sabotage or be noncompliant with a treatment that they actually chose, and if it doesn't work, it makes it much more difficult to blame the provider.

 

[smalltownpsych]

Well, I have seen psychologists recommend silly things to primary care docs as well.

I really don't know what to think. I always assumed I'm an average to slightly-above average physician, so either I underestimate my abilities or a lot of docs are really, really terrible at their job.

As some of my patients are fond of saying, "the problem is all of these stupid people". One problem is that we all fall victim to a self-serving bias. I say and do dumb things everyday, but I know that I really meant to say something intelligent or I have a great rationalization for why I did it; whereas, when you say or do something that I think is dumb, I am amazed at how stupid people can be. On the other hand, there really are some incredibly misguided and inept people in this field. Don't even get me started about bad systems.

 

[WingedOx]

Was there a time in psychiatry during which completely irrational polypharmacy was the standard of care?

yeah, like a half hour ago. I haven't seen any patients since then, so not sure if anything has changed.

 

[WingedOx]

In my perspective, we seem to be at a peak of irrational polypharm. The problem is "my poly pharm is rational and everyone else's isn't". I'm sure everyone has a rationalization every time they put pen to script pad.

Oh, mine is irrational. Usually I'm inheriting cases with a WTF set of prescriptions, but the patient develops ridiculous nocebo effects to any changes. The secret is to do your best not to start them in the first place.

 

[Armadillos]

This sort of thing (a tendency towards over intervention) is a problem in all of medicine and has been for awhile. I'm a big fan of about half of house of god's laws, but this one is by far my favorite and the most important in my opinion. They need to emphasize this in medical school more, our default clinical decision should be always to "do nothing" and it should take a weighty amount of evidence to push us to prescribe/operate/test/image/etc.

THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

 

[shan564]

It pains me to say this, but I feel like irrational polypharmacy IS the standard of care. Every once in a while, I'll read a forensic case (just for education) from one of our professors who does a lot of civil forensic work. Quite often, he is consulted in malpractice cases, so he has to assess whether the psychiatrist was following the "standard of care." When we've discussed this principle, it always bothers me to learn where we set the bar for "standard of care." He often says something like "well, I'm not sure I agree with the diagnosis, and I think it's suboptimal management, but this is not outside the range of what is generally considered to be the 'standard' in the community." Sometimes I want to pull my hair out to see how my patients are managed when they end up at some of the local for-profit hospitals.

One example: 10-yo girl with h/o ADHD and unspecified anxiety and very strong family history of bipolar I is admitted for an episode of elevated/expansive mood, grandiosity with delusions, auditory hallucinations, racing thoughts, pressured speech, decreased need for sleep, etc... quite convincing for an early-onset bipolar I manic/psychotic episode. She was admitted because she was running out into busy streets, and at baseline, she's smart enough to not do those sorts of things. In the hospital, they diagnose her with bipolar I manic/psychotic, increase her Zoloft from 25 to 50, increase Seroquel from 25 to 50, switch Vyvanse to a comparable dose of Adderall XR. I see her a couple of days after discharge, and she is still floridly manic (I know, you could say that she is too young to be manic and she's probably just ADHD, but she was quite convincingly manic, and several doctors saw her and agreed with that diagnosis) and still engaging in high-risk behaviors (trying to run around outside the house in unsafe environments). Mom says that the inpatient doc never talked to her directly throughout the whole hospitalization. She noticed a slight improvement at discharge, but when I saw the patient, she was marginally better than she was when she was admitted. The discharge summary said the standard "patient was admitted to the inpatient unit, received a full spectrum of biopsychosocial interventions, and has no SI/HI on discharge."

So in short, she was diagnosed with mania/psychosis, but her SSRI was increased and her Seroquel was left at an antihistamine dose. I just don't understand...

 

[AcronymAllergy]

Honestly as a neuropsychologist, I would only want prescribing privileges to taper my patients off ridiculous meds. Like my 85+ year old patients who are already on some anticholinergics and their family practice doc on the outside prescribe them some xanax to help with some mild anxiety. I usually see the case for simplification of med regimen instead of the necessity to add things.

In my case, I'd honestly consider taking it just for the increased knowledge of DDIs and the like, with no actual intent to prescribe. Given the lengthy medication lists of the average patient I see (VA), it seems as though in the majority of cases, the reported cognitive changes are due to combinations of medication effects, poorly-controlled health conditions, disrupted sleep, chronic pain, and aspects of emotional distress than to a new-onset neurodegenerative condition. Problem is, particularly in the incipient stages, it can be tough to differentiate one from the other (or from "all of the above").

 

[smalltownpsych]

It pains me to say this, but I feel like irrational polypharmacy IS the standard of care. Every once in a while, I'll read a forensic case (just for education) from one of our professors who does a lot of civil forensic work. Quite often, he is consulted in malpractice cases, so he has to assess whether the psychiatrist was following the "standard of care." When we've discussed this principle, it always bothers me to learn where we set the bar for "standard of care." He often says something like "well, I'm not sure I agree with the diagnosis, and I think it's suboptimal management, but this is not outside the range of what is generally considered to be the 'standard' in the community." Sometimes I want to pull my hair out to see how my patients are managed when they end up at some of the local for-profit hospitals.

One example: 10-yo girl with h/o ADHD and unspecified anxiety and very strong family history of bipolar I is admitted for an episode of elevated/expansive mood, grandiosity with delusions, auditory hallucinations, racing thoughts, pressured speech, decreased need for sleep, etc... quite convincing for an early-onset bipolar I manic/psychotic episode. She was admitted because she was running out into busy streets, and at baseline, she's smart enough to not do those sorts of things. In the hospital, they diagnose her with bipolar I manic/psychotic, increase her Zoloft from 25 to 50, increase Seroquel from 25 to 50, switch Vyvanse to a comparable dose of Adderall XR. I see her a couple of days after discharge, and she is still floridly manic (I know, you could say that she is too young to be manic and she's probably just ADHD, but she was quite convincingly manic, and several doctors saw her and agreed with that diagnosis) and still engaging in high-risk behaviors (trying to run around outside the house in unsafe environments). Mom says that the inpatient doc never talked to her directly throughout the whole hospitalization. She noticed a slight improvement at discharge, but when I saw the patient, she was marginally better than she was when she was admitted. The discharge summary said the standard "patient was admitted to the inpatient unit, received a full spectrum of biopsychosocial interventions, and has no SI/HI on discharge."

So in short, she was diagnosed with mania/psychosis, but her SSRI was increased and her Seroquel was left at an antihistamine dose. I just don't understand...

At least they got the dx correct, maybe. What about the possibility that her symptoms are being caused by her current medication regimen? I seem to remember some research that showed some kids can react to SSRIs with manic symptoms. Also, stimulants can cause psychosis and mania in high enough doses or sensitive enough people.

 

[675015]

At least they got the dx correct, maybe. What about the possibility that her symptoms are being caused by her current medication regimen? I seem to remember some research that showed some kids can react to SSRIs with manic symptoms. Also, stimulants can cause psychosis and mania in high enough doses or sensitive enough people.

Or maybe the wasn't manic. Maybe he/she reconstituted quickly with the structure and safety of the inpatient unit and the inpatient team thought it couldn't be mania and rash medication changes aren't required? a lot of outpatient providers will question in patient providers not because their reasoning was flawed but because they ultimately didn't do what they wanted.

Going on a tangent, I also get calls in the ED (and I love calls from providers! It's a necessary part of the puzzle!) from providers that say "I'm sending this person over for admission!" And don't understand that it's my job to independently evaluate and decide if admission to our facility is appropriate. I had one doctor say "my patient is coming over. If you won't admit him let me know now so I can send him somewhere else!" Not realizing I need to actually evaluate the person. I had one provider say I had to admit her acutely suicidal patient. When I asked where the patient was she said she hung up on the patient to call 9-1-1 and then call me and let me k ow he was coming... Before she made sure the patient was safe! (I'm venting at this point...)

 

[shan564]

At least they got the dx correct, maybe. What about the possibility that her symptoms are being caused by her current medication regimen? I seem to remember some research that showed some kids can react to SSRIs with manic symptoms. Also, stimulants can cause psychosis and mania in high enough doses or sensitive enough people.

Or maybe the wasn't manic. Maybe he/she reconstituted quickly with the structure and safety of the inpatient unit and the inpatient team thought it couldn't be mania and rash medication changes aren't required? a lot of outpatient providers will question in patient providers not because their reasoning was flawed but because they ultimately didn't do what they wanted.

Yes, we considered all of those possibilities (along with several others) and did a thorough hx/exam to convincingly rule them out, but I didn't want to get bogged down in those details because it would take forever to explain the intricacies of the case. None of that explains why they would have increased her SSRI dose. Also doesn't explain why they didn't talk to the mom and didn't contact her outpatient doc or request outpatient records.

Going on a tangent, I also get calls in the ED (and I love calls from providers! It's a necessary part of the puzzle!) from providers that say "I'm sending this person over for admission!" And don't understand that it's my job to independently evaluate and decide if admission to our facility is appropriate. I had one doctor say "my patient is coming over. If you won't admit him let me know now so I can send him somewhere else!" Not realizing I need to actually evaluate the person. I had one provider say I had to admit her acutely suicidal patient. When I asked where the patient was she said she hung up on the patient to call 9-1-1 and then call me and let me k ow he was coming... Before she made sure the patient was safe! (I'm venting at this point...)

I think this is particularly frustrating because the doc sending the patient over is often somebody who hasn't worked in an ER or an inpatient unit in the last decade (or longer), and don't understand how things have changed. For instance, I once had an emeritus professor send a patient to the ER for direct admission after having told her that she'd get ECT tomorrow, not bothering to consider the fact that there were several logistic issues preventing that - we no longer do direct admissions unless the admitting doc wants to personally care for the patient in the hospital (which he wasn't going to do) inpatient unit is usually full these days (patient would have had to wait a day or two for a bed) it was already Thursday afternoon (too late to get all of the logistics done in time to start ECT on Friday morning, so she'd have to wait until Monday), etc. And that's not even considering the fact that the patient didn't even remotely meet criteria for inpatient care (no signs of elevated risk, could have had it done as an outpatient) and probably wouldn't even be appropriate for ECT (she seemed to have a primary anxiety disorder). When I called him and told him about the logistical issues, his response was something along the lines of "I'm an emeritus professor and I've directly admitted lots of patients this way over the last several decades, so you should do this for me," not considering the fact that things are different now from how they were several years ago.

That said, I've sent patients straight from my clinic to the ER saying "I am sending this person to the ER because I think he/she needs to be in the hospital." But that's given the fact that I worked in that ER last year, I know how things work there, and the ER resident is a PGY2 who usually wants me to tell him/her what to do, since that makes their decision easier and I know the patient better anyway.

If an outpatient doctor feels strongly about admission, they should say "I feel strongly about admission because..." rather than "I demand that you admit the patient."

 

[hamstergang]

On the other extreme, I recently saw a small, young child with autism that was having tantrums with transitions. Someone thought the tantrums were due to anxiety and so started Prozac 2mg (not a typo). On 3 month follow up, there was no improvement and so the Prozac was discontinued. 😵

 

[DD214_DOC]

On the other extreme, I recently saw a small, young child with autism that was having tantrums with transitions. Someone thought the tantrums were due to anxiety and so started Prozac 2mg (not a typo). On 3 month follow up, there was no improvement and so the Prozac was discontinued. 😵

 

[smalltownpsych]

On the other extreme, I recently saw a small, young child with autism that was having tantrums with transitions. Someone thought the tantrums were due to anxiety and so started Prozac 2mg (not a typo). On 3 month follow up, there was no improvement and so the Prozac was discontinued. 😵

I hope you were able to coach parents how to ease the transitions. That tends to be one of my most effective interventions with parents saying things like "Wow! That worked really well".

 

[whopper]

I really don't get all of this irrational polypharmacy other than to say there's too many idiots out there with a license to practice.

Some polyphmarmacy makes sense if you know the specifics of the case. E.g. I've had a few patients where several meds were tried and only a specific combination that seemed odd worked. These cases are rare. In long-term psych units with treatment-resistant cases I've had to do regimens such as the following only after trying several meds by themselves or in a 2 med combination only to fail:
Olanzapine 40 mg Q HS
Depakote 1000 mg Q BID
Lithium 600 mg Q BID
Haldol 10 mg Q BID

But these were very treatment resistant cases and I've never had such a case in private practice unless I got these patients already started on a similar regimen by someone else and I was able to always wean them off many of the meds or they had panic disorder or OCD. I did get legitimate polypharm cases in community practice because I was running a forensic ACT team (people who were found not guilty by reason of insanity, stayed in the hospital for years, but were fine in the hospital and discharged by a judge).

If the patients were stable for several months I even tried to slowly wean off some of the meds only to find that they got worse, e.g. "Doc I appreciate what you're doing but when you lowered the Haldol down to 15 mg a day the voices came back."

So what I'm saying is that polypharm can be legitimate but these cases are very very rare and usually only in forensic, long-term care, and community practice settings.

I know of five doctors that specifically started patients on 5 meds on the first visit, all at dosages not recommended at starting dosages such as...
Abilify 30 Q daily
Paxil 40 mg Q daily
Cogentin 2 mg Q BID
Zyprexa 10 mg Q HS
Clonazepam 2 mg Q BID

and some of these patients had nothing severe with them. I even asked one of those doctors why they were doing this and she smiled at me and said "you know." I replied, "no I don't know." She told me how I was young and idealistic and when I get older I'll be doing what she's doing.

I wish I could've put that encounter on video and video-shamed her to the community.

One other polypharm type of patient I've seen and this is the only type I've seen in private practice would often go like this.
1-Got them on the maximum dosage of an SSRI. It would lower the panic attacks from something to many a day to a few a month.
2-Added Buspirone and raised it to the max, lowered them more but pt still had them.
3-Add Beta-blocker. Again lowered it but pt still has a few a month
4-Then add benzo PRN at only an amount of 1-2 more than the number of panic attacks per month.

e.g. Pt is now down to maybe about 3 panic attacks a month so I'd give Ativan 1 mg PRN for a panic attack only 5 pills per month.

When patients were stable on this regimen with no evidence of substance abuse I started giving it out 30 at a time because it was a big pain in the butt for them to go to the pharmacy monthly when they were not abusing the med. Patients also had to sign contracts where they stated they understood that benzos are addictive and that if they were not responsible with the med I'd have to stop prescribing it.

Such a pt would have the following regimen:
Citalopram 40 mg Q daily
Buspirone 30 mg Q BID
Propranolol 200 mg Q BID
Ativan 1 mg Q daily PRN anxiety #5/month

As for OCD, in severe cases, I've been able to get them under control (except for 1 case where I was going to refer the patient for psycho-surgery) but I was never able to get the patient completely symptom free from OCD. Such patients would get to max dosage of an SSRI, Buspirone and a low dose atypical because data shows atypicals help OCD but at low dosages as augmentation agents.

 

[DD214_DOC]

Had this one today. kid dx as, "bipolar". Actually is depressed, doubt the bipolar dx. lots of family problems that have been completely ignored over the past two years. This is what he was on

Wellbutrin xl 150
strattera 60
trileptal 300 am, 150 pm, 300 hs
lexapro 10
melatonin 9

oh, he also is > 70kg. tons of problems with the regimen. not surprisingly it wasn't working for more reasons than the pharmacology. This is the mess I'm trying to fix while having any next avail f/u almost 2 months out.

I seriously don't get it. Are most of us really this ignorant?

 

[whopper]

One thing I've noticed is when you work in an ER or inpatient setting you start noticing who the idiot polypharmacists are.

I know of four doctors in St. Louis that diagnose everyone, I mean EVERYONE with bipolar disorder and put them on a bunch of meds. Most of these patients don't have bipolar disorder but a cluster B disorder and most of their patients tell me they never really got better or if they did it was because "the Xanax he prescribes makes me feel better so I know I got bipolar disorder."

Everywhere I worked I saw this happen. I saw this in Atlantic City, Camden, Philadelphia, NYC, Cincinnati, Kentucky, counties about 1 hour from Cincinnati, St. Louis....

This is one of the few areas where I actually agree with the Scientologists that there are too many psychiatrists that do poor practice, but this is also true of all fields of medicine. Even a broken clock is right twice a day, and it's one of the only things that I agree with them on.

 

[DD214_DOC]

le sigh

 

[Shikima]

My worry are those that show up with strong genetic components of a mood disorder who struggle with depression incessantly and refuse to undergo ECT.

 

[shan564]

I really don't get all of this irrational polypharmacy other than to say there's too many idiots out there with a license to practice.

Some polyphmarmacy makes sense if you know the specifics of the case. E.g. I've had a few patients where several meds were tried and only a specific combination that seemed odd worked. These cases are rare. In long-term psych units with treatment-resistant cases I've had to do regimens such as the following only after trying several meds by themselves or in a 2 med combination only to fail:
Olanzapine 40 mg Q HS
Depakote 1000 mg Q BID
Lithium 600 mg Q BID
Haldol 10 mg Q BID

But these were very treatment resistant cases and I've never had such a case in private practice unless I got these patients already started on a similar regimen by someone else and I was able to always wean them off many of the meds or they had panic disorder or OCD. I did get legitimate polypharm cases in community practice because I was running a forensic ACT team (people who were found not guilty by reason of insanity, stayed in the hospital for years, but were fine in the hospital and discharged by a judge).

If the patients were stable for several months I even tried to slowly wean off some of the meds only to find that they got worse, e.g. "Doc I appreciate what you're doing but when you lowered the Haldol down to 15 mg a day the voices came back."

So what I'm saying is that polypharm can be legitimate but these cases are very very rare and usually only in forensic, long-term care, and community practice settings.

Agree - I think it's important that the OP mentioned "irrational" polypharmacy, since there are many examples of rational polypharmacy.

I know of five doctors that specifically started patients on 5 meds on the first visit, all at dosages not recommended at starting dosages such as...
Abilify 30 Q daily
Paxil 40 mg Q daily
Cogentin 2 mg Q BID
Zyprexa 10 mg Q HS
Clonazepam 2 mg Q BID

and some of these patients had nothing severe with them. I even asked one of those doctors why they were doing this and she smiled at me and said "you know." I replied, "no I don't know." She told me how I was young and idealistic and when I get older I'll be doing what she's doing.

I wish I could've put that encounter on video and video-shamed her to the community.

Yeah, that's horrible, but I've seen the same thing many times from some of the more entrepreneurial doctors. I call it "broad spectrum coverage"... saves a lot of time if you just give a drug from every class instead of figuring out what the patient actually needs. Somebody in my program once jokingly likened it to starting vanc/cefe/azithro for pneumonia, but of course, it's much more appropriate when you're giving short-term treatment for a life-threatening condition. And I know plenty of older doctors who don't do anything remotely like this.

One other polypharm type of patient I've seen and this is the only type I've seen in private practice would often go like this.
1-Got them on the maximum dosage of an SSRI. It would lower the panic attacks from something to many a day to a few a month.
2-Added Buspirone and raised it to the max, lowered them more but pt still had them.
3-Add Beta-blocker. Again lowered it but pt still has a few a month
4-Then add benzo PRN at only an amount of 1-2 more than the number of panic attacks per month.

e.g. Pt is now down to maybe about 3 panic attacks a month so I'd give Ativan 1 mg PRN for a panic attack only 5 pills per month.

When patients were stable on this regimen with no evidence of substance abuse I started giving it out 30 at a time because it was a big pain in the butt for them to go to the pharmacy monthly when they were not abusing the med. Patients also had to sign contracts where they stated they understood that benzos are addictive and that if they were not responsible with the med I'd have to stop prescribing it.

Such a pt would have the following regimen:
Citalopram 40 mg Q daily
Buspirone 30 mg Q BID
Propranolol 200 mg Q BID
Ativan 1 mg Q daily PRN anxiety #5/month

As for OCD, in severe cases, I've been able to get them under control (except for 1 case where I was going to refer the patient for psycho-surgery) but I was never able to get the patient completely symptom free from OCD. Such patients would get to max dosage of an SSRI, Buspirone and a low dose atypical because data shows atypicals help OCD but at low dosages as augmentation agents.

Again, that's rational polypharmacy.
A group of med students recently asked me about a practice question that they were having difficulty with. Patient had panic disorder (I think), and they were trying to understand why they should start an SSRI rather than Xanax. I said something like "Xanax will rarely be the right answer on a test because..." The student asked something along the lines of "well, I guess I can see why that's ther right answer on the test, but in the real world, you'd give that patient Xanax, right?" When I explained the answer to that question, some of the students were quite disturbed by my response. It was clear that some of them were getting defensive because their PMD had started them on Xanax for an anxiety disorder instead of an SSRI.

 

[whopper]

My unfortunate experience is the medstudents that do a primary care rotation before they do their psych rotation (maybe it's their psych elective cause I thought you HAD TO DO PSYCH before the primary care elective) told me that the primary care doctors are giving out Xanax left and right saying there's nothing wrong with it, then they come to us and we're telling not to give it out left and right.

I have seen psychiatrists contribute to this problem but from my own experience it's PCPs at least as much if not more.

While I was at U of Cincinnati I brought it up to Lawson Wulson the head of their combined psych and FP residency program. (BTW he's a heck of a nice guy and a great PD). http://www.psychiatry.uc.edu/FacultyStaff/FacultyProfile.aspx?epersonID=wulsinlr

Dr. Wulson told me that from his own experience at least the attendings and residents under his training actually were a little bit too strict in not giving out benzos.

IMHO this was because Wulson was a good doctor and teacher not because this problem wasn't happening. Wulson and I agreed that there's a time and a place for benzos (e.g. pt takes it only a few times a month, takes it at a one time thing such as a plane flight because they have a fear of flying, etc).

 

[whopper]

Yeah, that's horrible, but I've seen the same thing many times from some of the more entrepreneurial doctors. I call it "broad spectrum coverage"... saves a lot of time if you just give a drug from every class instead of figuring out what the patient actually needs. Somebody in my program once jokingly likened it to starting vanc/cefe/azithro for pneumonia, but of course, it's much more appropriate when you're giving short-term treatment for a life-threatening condition. And I know plenty of older doctors who don't do anything remotely like this.

A graduate of the residency program I was in that graduated 2 years behind me is a Facebook friend. She wrote on her page that she saw a patient and thought to herself "what the heck" and started the patient on a polypharm regimen. The patient did get better.

All of the "Friends" wrote down how this was so cool. It was my first impulse to write down how this is really not acceptable because aside from the patient never really being established as treatment-resistant she didn't tell the patient the options, the risks and the benefits, and chose for the patient-and chose the option that was not 1st, 2nd, or even 3rd-line.

I didn't and you know why? Cause I knew 95% of the people reading the post wouldn't understand WTF I was talking about. To my disappointment but not surprise the program director even was saluting her.

To my disappointment but not surprise the same colleague signed up into that idiotic "Top Psychiatrists" bull**** where you pay this bogus group $500 and they give you a plaque saying you're one of the nation's top psychiatrists. I'm not joking. You just pay these people to feed your narcissism and they give you a plaque that cost about $50 to make but charge you $500 for it.
http://abcnews.go.com/Health/top-doctor-awards-deserved-abc-news-investigation/story?id=16771628

The person I'm talking about is not in the link below but this is a doctor that did pay the money to this organization for this vanity honor. Hey she put it on her website I figure it's public info right?
New link...
http://www.consumersresearchcncl.org/Healthcare/Psychiatrists/images/2015_Psych_Book.gif

(edit-ah, I decided to cut the link cause I really don't know the lady whose link I put on. Vain? Yes but I really don't know her so I shouldn't make her a target).

I'm going to start a company called the BESTEST DOCTORS IN THE MULTIVERSE! You pay me $1000, I'll give you a plaque that cost me $50 to make and you got the plaque!

 

[DD214_DOC]

A graduate of the residency program I was in that graduated 2 years behind me is a Facebook friend. She wrote on her page that she saw a patient and thought to herself "what the heck" and started the patient on a polypharm regimen. The patient did get better.

All of the "Friends" wrote down how this was so cool. It was my first impulse to write down how this is really not acceptable because aside from the patient never really being established as treatment-resistant she didn't tell the patient the options, the risks and the benefits, and chose for the patient-and chose the option that was not 1st, 2nd, or even 3rd-line.

I didn't and you know why? Cause I knew 95% of the people reading the post wouldn't understand WTF I was talking about. To my disappointment but not surprise the program director even was saluting her.

To my disappointment but not surprise the same colleague signed up into that idiotic "Top Psychiatrists" bull**** where you pay this bogus group $500 and they give you a plaque saying you're one of the nation's top psychiatrists. I'm not joking. You just pay these people to feed your narcissism and they give you a plaque that cost about $50 to make but charge you $500 for it.
http://abcnews.go.com/Health/top-doctor-awards-deserved-abc-news-investigation/story?id=16771628

The person I'm talking about is not in the link below but this is a doctor that did pay the money to this organization for this vanity honor. Hey she put it on her website I figure it's public info right?
New link...
http://www.consumersresearchcncl.org/Healthcare/Psychiatrists/images/2015_Psych_Book.gif

(edit-ah, I decided to cut the link cause I really don't know the lady whose link I put on. Vain? Yes but I really don't know her so I shouldn't make her a target).

I'm going to start a company called the BESTEST DOCTORS IN THE MULTIVERSE! You pay me $1000, I'll give you a plaque that cost me $50 to make and you got the plaque!

I would totally make that plaque and display it as a joke. I'm serious. Why not, I already proudly display my Sigmund Freud action figure.

 

[whopper]

I was actually thinking of buying into this thing so that during a grand rounds I could make all the attendings, students, and residents all chant in unison: "Dr. Whopper is one of the Top Psychiatrists in America!"

In all honesty, legit or not, this type of bull does make you look better in front of a jury and I am a forensic psychiatrist......

 

[shan564]

We recently had an M&M conference on the topic of Xanax overprescription. I didn't realize until last week that Xanax is still the most prescribed psychotropic drug in the US. Also, 90% of benzo prescriptions aren't written by psychiatrists.

This is something that we need to address better in med school. I agree that there is a time/place for benzos, but that time/place is when everything else (including CBT) has failed (as in the case that you described earlier with Ativan prescribed as 5 pills per month). And if a PCP is prescribing the benzo, then that tells me clearly that the patient hasn't tried everything else, since they're not even seeing a psychiatrist.

 

[birchswing]

We recently had an M&M conference on the topic of Xanax overprescription. I didn't realize until last week that Xanax is still the most prescribed psychotropic drug in the US. Also, 90% of benzo prescriptions aren't written by psychiatrists.

This is something that we need to address better in med school. I agree that there is a time/place for benzos, but that time/place is when everything else (including CBT) has failed (as in the case that you described earlier with Ativan prescribed as 5 pills per month). And if a PCP is prescribing the benzo, then that tells me clearly that the patient hasn't tried everything else, since they're not even seeing a psychiatrist.

I'm not sure where the data comes from, but if 90% of benzodiazepine prescriptions are not made by psychiatrists, you still can't deduce that psychiatrists don't prescribe benzodiazepines at higher rates than other specialists, and of course you would have to take into account the nature of the prescription (for a procedure vs. taken long-term).

 

[whopper]

So the way I see it, as someone who is only $500 away from being a "Top Psychiatrist in America," what Shan is really saying for you students out there is you get an ink stamp with the word Xanax 2 mg Q QID #120 so you don't have to actually write it down on be prescription pad.

It'd be funny if it weren't true but this over-prescription thing is going on big time.

 

[sunlioness]

You know, sometimes I think I'm a bad doc who doesn't know what she's doing. But then I read threads like this and well .... I might still not be that great. But there are a lot of people WAY WORSE. Scary.

At my old place, there was a PCP who'd write for a lot of benzos, but then he'd refer to us to continue prescribing. Like Xanax 2mg TID, but you have to be seen by psychiatry and they'll continue it. I didn't. I didn't even offer a taper because we're in the same system and I'm not cleaning up his mess. Patients got pissed. I told them to take it up with him. I don't think he liked me very much.

Oh. And then there was the time I had a patient who was .... I don't remember. Bipolar depressed? I think I was ramping up lamictal and he still felt like crap. His therapist decided he needed to be on celexa. He told her he couldn't be on that kind of med because it gave him erectile dysfunction. She tells him "celexa never does that". So he reluctantly agreed. She gets PCP to rx celexa and d/c lamictal. I don't know about it. He shows up at his next visit to tell me this, feeling worse and with a non functional dick. Yeah. "No-sex-uh" NEVER does that. I was pissed. And so was he. We had to start lamictal all over again.


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[whopper]

I have said this a lot of times. I don't think I'm one of the best doctors out there or should be one of the best. I do think, however, that I work hard, keep up with journals, try to at least do the standard of care if not better, and I end up being better than most I see.

And this frightens me.

What I do should be average, perhaps somewhat above average. People should be able to go to a doctor and be confident that their doctor is at least doing the standard-not by community standards but by academic standards.

This is a reason why I tell residents to work in academia a few years (unless they're just too swamped with debt) cause IMHO you're still too green and at least you can be surrounded by what I hope would be a at least a few good doctors to innoculate you against the poor practice that's out there.

Call it narcissism, what have you, but when I see a psychiatrist giving a patient Seroquel because "she's blue and Seroquel's a warm medication" despite that the pt was doing fine on her previous medication regimen Abilify, and ends up gaining 50 lbs from the Seroquel and becoming diabetic but that doc still adheres to the "she's blue" bull**** I'm going to think I'm better than that psychiatrist.

And I wish I wasn't making that story up. Triple facepalm. I felt bad for the patient. I told her to demand her doctor to switch meds. She was trapped in a forensic hospital and told me she was about 6 months from being released and didn't want to risk changing meds because it could keep her back for several more months.

I used to go home mad everyday from this type of dung. My wife told me that I either have to leave the job or figure out some way to not be mad about this. This is major reason why I left the state hospital/private practice and joined U of Cincinnati despite what was about a 75K paycut. There I was no longer the best in the hospital. I saw doctors that were better than me, just as good, maybe some worse but very few significantly worse. I'd go to department meetings, sit in a chair, and peer at literally over as dozen colleagues that were in the top 100 doctor category (the real one vs that BS one I mentioned above), or had several other prestigious real accomplishments that were great doctors but also good people. I was happier with that. It was a joy to see a guy know something I didn't and learn from that person and not have to deal with the "she's blue" bull**** anymore.

 

[sunlioness]

Wait, what? She is blue and Seroquel is warm? Who makes that sh** up? That's a new one.

There was a psychiatrist at my old place who left precipitously under mysterious circumstances and I inherited some of her folks. They loved her. One person "needed" her 8mg of Xanax per day. And when I asked her why she was also on 60mg of adderall, she said "because the Xanax makes me too sleepy." I clarified that she'd never been diagnosed with ADHD. And she said, "yeah, she said I had that." What did she base that on? "Well, sometimes it's hard for me to read a book." There were a few people like this on high dose benzos and stimulants. And they all told some version of the same story, "Dr. So-and-so explained it so well. It's just like a car. One's the brake and the other's the accelerator." They loved her and hated me as soon as I started doing tapers. "My doctor said I needed to be on this! My body needs it! I saw her for years and you're going to decide to stop these meds after just talking to me for an hour??" And well, yes. But super gently. Still lots of complaints. And then I left them too shortly thereafter. But wit three months notice and lots of transparency.

And wow. That's a huge pay cut. You're to be commended for that. In leaving my last place I took around a 40K one to move to a higher cost of living area. I liked the docs I worked with there, that one aside. But I didn't like the organization's business model. I realized this when I went to a required meeting with the CEO and he announced, "My sole concern right now is that we still exist in five years and that it's our name on the door." I realized we were NOT on the same page because of how little I cared about that. They lured people in with big two year salary guarantees and transferred to a 100% production model after that time with assurances that no one ever made less. Well, I did. I was doing 100% outpatient, helping with horrific access issues, I couldn't get the volume to maintain the salary. And I was busy. But they wanted me to keep doing what I was doing because they needed what I was doing more than they needed what I could have made more money doing. They said they'd work with me on it. And made some adjustments to the algorithm so while I still made a lot less it wasn't AS less and were shocked when I wasn't ecstatic about it. There were all these meetings over lunch that were required and not compensated. They had just signed on a whole panel of capitated Medicaid patients with no solid plan about how we would accommodate that. The message always seemed to be, "Do more with less." Again, not from my department. From the organization. When I said I didn't feel appreciated, the response I got was "we should make an effort to tell you so more." Call was required and unpaid beyond whatever RVU credit you got.

They weren't ALL bad. They listened to and liked some of my ideas for improving access and wanted to support them. But their model didn't allow them to in the most effective way. I burned out. That's why I stopped coming around here. I wanted nothing to do with the entire field of medicine. I attended a SEAK conference. I worked on my LinkedIN profile. I almost stopped caring about people. They were productivity numbers and obstacles preventing me from going home.

It was awful.

My new place is different. The salary is lowish (50K less than my guarantee at the other place, but functionally really only 20-30K less since that's what it fell to when I went on production), my cost of living is about 75% higher, but I'm salaried. And I work for an organization now that is actually actively seeking partnerships with other entities without really caring whose name is on the door. They're really genuinely into population health. And on days we have a lunch meeting, I get to leave an hour earlier.

The burn out resolved with the two months off (it started getting better as soon as I decided I was leaving). And I hope it doesn't come back. This is home for me so hopefully my personal life will be better here too. (That was another issue in the Midwest). Plus there is more of a variety of things I can do here, more support, better access to resources. So I hope it doesn't come back.

I have to say though that I miss Epic. The community assignment I'm at is using paper charts. And that just has its own set of hassles. Starting with, "Where's the chart?"


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[doctorpilgrim]

I work in rural community, so everyday witness the limitations and inadequacy of my knowledge but also see the limitations of medicine.

Why is irrational polypharmacy common.

Is it hard for others on the forum for advising a patient to have a trial of ssri for 6 weeks for anxiety, when psychiatrist can only see them every 2 to 3 months for 20 minutes. How about advising a patient that one doesn't need stimulant to watch tv and do grocery shopping. In most cases the patient has already tried stimulant/benzos for few days either from a physician or a friend and has seen the short term benefit. Usually after a long discussion the patient goes to another psychiatrist. To practice good psychiatry, one needs time to convince the patient and a team approach to follow the patient. IMHO the main challenge is keeping the patient committed to the plan.

Not to blame the victim, but irrational pharmacy be due to multiple reasons like patient pressure to treat emotional distress with medication only, failure to invest in therapy or change behavior, non compliance, treatment resistance and only one of which is psychiatrist being incompetent.

My view is more accommodative as I am also guilty as inpatient psychiatrist of starting patients on 2 antipsychotics but with express understanding and documentation that outpatient psychiatrist should try to wean off.

 

[shan564]

I work in rural community, so everyday witness the limitations and inadequacy of my knowledge but also see the limitations of medicine.

Why is irrational polypharmacy common.

Is it hard for others on the forum for advising a patient to have a trial of ssri for 6 weeks for anxiety, when psychiatrist can only see them every 2 to 3 months for 20 minutes. How about advising a patient that one doesn't need stimulant to watch tv and do grocery shopping. In most cases the patient has already tried stimulant/benzos for few days either from a physician or a friend and has seen the short term benefit. Usually after a long discussion the patient goes to another psychiatrist. To practice good psychiatry, one needs time to convince the patient and a team approach to follow the patient. IMHO the main challenge is keeping the patient committed to the plan.

Not to blame the victim, but irrational pharmacy be due to multiple reasons like patient pressure to treat emotional distress with medication only, failure to invest in therapy or change behavior, non compliance, treatment resistance and only one of which is psychiatrist being incompetent.

My view is more accommodative as I am also guilty as inpatient psychiatrist of starting patients on 2 antipsychotics but with express understanding and documentation that outpatient psychiatrist should try to wean off.

Yeah, I think it takes 15 minutes just to properly explain to the patient why they shouldn't be on a benzo. I've noticed that patients are much more amenable to taper the benzo if I spend a lot of time explaining the problem from scratch, but it would be hard to find time to do that if I only had 20 minutes with each patient...

 

[Therapist4Chnge]

I would totally make that plaque and display it as a joke. I'm serious. Why not, I already proudly display my Sigmund Freud action figure.

In my office I have a certificate from a trapeze class I took ~20yr ago. My dad found it in a box and framed it for me as a joke. I put it on a random shelf in my office bc it makes me laugh. So far only 1pt has noticed it.

 

[smalltownpsych]

Wait, what? She is blue and Seroquel is warm? Who makes that sh** up? That's a new one.

There was a psychiatrist at my old place who left precipitously under mysterious circumstances and I inherited some of her folks. They loved her. One person "needed" her 8mg of Xanax per day. And when I asked her why she was also on 60mg of adderall, she said "because the Xanax makes me too sleepy." I clarified that she'd never been diagnosed with ADHD. And she said, "yeah, she said I had that." What did she base that on? "Well, sometimes it's hard for me to read a book." There were a few people like this on high dose benzos and stimulants. And they all told some version of the same story, "Dr. So-and-so explained it so well. It's just like a car. One's the brake and the other's the accelerator." They loved her and hated me as soon as I started doing tapers. "My doctor said I needed to be on this! My body needs it! I saw her for years and you're going to decide to stop these meds after just talking to me for an hour??" And well, yes. But super gently. Still lots of complaints. And then I left them too shortly thereafter. But wit three months notice and lots of transparency.

And wow. That's a huge pay cut. You're to be commended for that. In leaving my last place I took around a 40K one to move to a higher cost of living area. I liked the docs I worked with there, that one aside. But I didn't like the organization's business model. I realized this when I went to a required meeting with the CEO and he announced, "My sole concern right now is that we still exist in five years and that it's our name on the door." I realized we were NOT on the same page because of how little I cared about that. They lured people in with big two year salary guarantees and transferred to a 100% production model after that time with assurances that no one ever made less. Well, I did. I was doing 100% outpatient, helping with horrific access issues, I couldn't get the volume to maintain the salary. And I was busy. But they wanted me to keep doing what I was doing because they needed what I was doing more than they needed what I could have made more money doing. They said they'd work with me on it. And made some adjustments to the algorithm so while I still made a lot less it wasn't AS less and were shocked when I wasn't ecstatic about it. There were all these meetings over lunch that were required and not compensated. They had just signed on a whole panel of capitated Medicaid patients with no solid plan about how we would accommodate that. The message always seemed to be, "Do more with less." Again, not from my department. From the organization. When I said I didn't feel appreciated, the response I got was "we should make an effort to tell you so more." Call was required and unpaid beyond whatever RVU credit you got.

They weren't ALL bad. They listened to and liked some of my ideas for improving access and wanted to support them. But their model didn't allow them to in the most effective way. I burned out. That's why I stopped coming around here. I wanted nothing to do with the entire field of medicine. I attended a SEAK conference. I worked on my LinkedIN profile. I almost stopped caring about people. They were productivity numbers and obstacles preventing me from going home.

It was awful.

My new place is different. The salary is lowish (50K less than my guarantee at the other place, but functionally really only 20-30K less since that's what it fell to when I went on production), my cost of living is about 75% higher, but I'm salaried. And I work for an organization now that is actually actively seeking partnerships with other entities without really caring whose name is on the door. They're really genuinely into population health. And on days we have a lunch meeting, I get to leave an hour earlier.

The burn out resolved with the two months off (it started getting better as soon as I decided I was leaving). And I hope it doesn't come back. This is home for me so hopefully my personal life will be better here too. (That was another issue in the Midwest). Plus there is more of a variety of things I can do here, more support, better access to resources. So I hope it doesn't come back.

I have to say though that I miss Epic. The community assignment I'm at is using paper charts. And that just has its own set of hassles. Starting with, "Where's the chart?"


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Sounds incredibly similar to the organization where I am working. End result being that now we have no psychiatrist. 🙁

 

[strangeglove]

The title of this thread makes me think of this: https://m.youtube.com/channel/UC2bbMmLXhQtITdRiqRvy-yQ?

 

[Doctor Bagel]

You know, sometimes I think I'm a bad doc who doesn't know what she's doing. But then I read threads like this and well .... I might still not be that great. But there are a lot of people WAY WORSE. Scary.

At my old place, there was a PCP who'd write for a lot of benzos, but then he'd refer to us to continue prescribing. Like Xanax 2mg TID, but you have to be seen by psychiatry and they'll continue it. I didn't. I didn't even offer a taper because we're in the same system and I'm not cleaning up his mess. Patients got pissed. I told them to take it up with him. I don't think he liked me very much.

Oh. And then there was the time I had a patient who was .... I don't remember. Bipolar depressed? I think I was ramping up lamictal and he still felt like crap. His therapist decided he needed to be on celexa. He told her he couldn't be on that kind of med because it gave him erectile dysfunction. She tells him "celexa never does that". So he reluctantly agreed. She gets PCP to rx celexa and d/c lamictal. I don't know about it. He shows up at his next visit to tell me this, feeling worse and with a non functional dick. Yeah. "No-sex-uh" NEVER does that. I was pissed. And so was he. We had to start lamictal all over again.


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So the therapist who isn't a physician or NP tells a patient what medications they should be on and what side effects they do or don't have? Isn't that practicing outside the scope of their license? Seems almost reportable.