The worst polypharmacy

[nitemagi]

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I may have a winner for worst polypharm ever. Young (early 20's) individual comes in after being hospitalized several times out of state after being hospitalized multiple times for anxiety and "ADD." He brought in his discharge paperwork that had his d/c meds, which included, Get this --

2 Atypical AP's (I bet you can guess what one of them is)
Strattera
Adderall
An SNRI
Xanax
Restoril
Valium,
and Tramadol "for pain" -- without any actual physical health conditions.

 

[OldPsychDoc]

I may have a winner for worst polypharm ever. Young (early 20's) individual comes in after being hospitalized several times out of state after being hospitalized multiple times for anxiety and "ADD." He brought in his discharge paperwork that had his d/c meds, which included, Get this --

2 Atypical AP's (I bet you can guess what one of them is)
Strattera
Adderall
An SNRI
Xanax
Restoril
Valium,
and Tramadol "for pain" -- without any actual physical health conditions.

What? No TCA for sleep? 😱

And, well--it must be quetiapine and aripiprazole, of course. You need the contrasting action in someone with both anxiety and ADD!

(I love the short/medium/long approach to benzo prescribing, though!)

Since you're in CA, I hope you just stopped it all and gave him a prescription for cannabis!

 

[sunlioness]

I need to go wash out my eyes now.

Sigh.

 

[vistaril]

I may have a winner for worst polypharm ever. Young (early 20's) individual comes in after being hospitalized several times out of state after being hospitalized multiple times for anxiety and "ADD." He brought in his discharge paperwork that had his d/c meds, which included, Get this --

2 Atypical AP's (I bet you can guess what one of them is)
Strattera
Adderall
An SNRI
Xanax
Restoril
Valium,
and Tramadol "for pain" -- without any actual physical health conditions.

the problem is rather obvious- he considers his prescribing psychiatrist to be (insert last inpt psychiatrist)....my guess is he's been given prescriptions far more times leaving the hospital recently than leaving any office.....

highly likely all those meds originated from 3 different providers...with the 2nd and 3rd providers(ie the 2nd and 3rd admissions) just adding their favorite drug in each class whole not removing the previous ones.....

if that pt strolled in my office with that med list, I'd read the dc paperwork first, interview the pt next, and go into the interview thinking it's a mood d/o vs pd......I'd likely end up dc'ing all the above meds and starting an SSRI(depending of course).....

 

[nitemagi]

likely end up dc'ing all the above meds and starting an SSRI(depending of course).....

👍

 

[OldPsychDoc]

...
if that pt strolled in my office with that med list, I'd read the dc paperwork first, interview the pt next, and go into the interview thinking it's a mood d/o vs pd......I'd likely end up dc'ing all the above meds and starting an SSRI(depending of course).....

..on whether or not he wanted Suboxone and an admission to prevent him from cutting himself. 😉

 

[DebDynamite]

And, well--it must be quetiapine and aripiprazole, of course.

Seroquel for everyone!
It treats everything!!!!👍

 

[vistaril]

Seroquel for everyone!
It treats everything!!!!👍

we joke, but it's a tremendous indictment of our field and psychiatrists........a large amount(most?) of off label low dose seroquel is prescribed by psychiatrists. Oftentimes an internist just continues what the psychiatrist already started previously...so I think the blame in that case goes(at least partly) to psychiatry.

I'm embaressed when internists come to me with some of these regimens psychiatrist put their pts on.....it's no surprise that many of them think we just mindlessly shift meds around.....

 

[watto]

We did this fake Seroquel ad as a gag in residency where we had it "Now approved for absolutely everything" including:

Bipolar Disorder
Generalized Anxiety Disorder
Psychotic Disorder
Brain Freeze
Amputated Leg / Gangrenous Stump
Tinea Cruris
Dehydration
Dropsy
Albinism
"Jerk of a husband"
Fever and Ague
Paine in ye Eare
Elephantiasis of the Nuts
Disability Paperwork Diagnosis NOS

 

[whopper]

I just discharged a patient yesterday who fainted due to her polypharmacy, was brought to the ER, and hospitalized.

She told me her psychiatrist put her on a med, it didn't work, so she put her on another and just kept the previous ones on. The med regimen was similar to the one above but no stimulant.

I sometimes wonder just what these people are thinking. This is basic basic knowledge.

I just discharged a lady today, diagnosed by her outpatient doctor as having CHF, diabetes, and bipolar depression.

There was no CHF, no diabetes, and she as on 5 meds for bipolar disorder, told me none of them worked except for lithium, got her off everything except the lithium, and she felt fine.

 

[Daedra22]

Even as a third year med student that list offends my sensibilities.

 

[freaker]

2 Atypical AP's (I bet you can guess what one of them is)
Strattera
Adderall
An SNRI
Xanax
Restoril
Valium,
and Tramadol "for pain" -- without any actual physical health conditions.

Dare I ask if xanax was the only one at a truly therepeutic dosage?

(We can leave it open for a debate whether there is actually such a thing as a therepeutic dosage of xanax outside of feeding the belly of the devil incarnate.)

 

[DebDynamite]

We did this fake Seroquel ad as a gag in residency where we had it "Now approved for absolutely everything" including:

Bipolar Disorder
Generalized Anxiety Disorder
Psychotic Disorder
Brain Freeze
Amputated Leg / Gangrenous Stump
Tinea Cruris
Dehydration
Dropsy
Albinism
"Jerk of a husband"
Fever and Ague
Paine in ye Eare
Elephantiasis of the Nuts
Disability Paperwork Diagnosis NOS

This is an excellent list. I am curious, how could you forget: insomnia!!

 

[toothless rufus]

dont remember the exact details, but had a pt come in on 3 antipsychotics, 2 benzos, ambien, SSRI, depakote and wellbutrin, and nothing even maxed out. I just could not believe it.

 

[snarfer]

dont remember the exact details, but had a pt come in on 3 antipsychotics, 2 benzos, ambien, SSRI, depakote and wellbutrin, and nothing even maxed out. I just could not believe it.

Sounds scary. In my experience, this tends to occur more often with pts being managed by NPs. My patients would say doctor so and so gave me remeron 45, fluoxetine 40, sertraline 200, buspar 20, but when I look him/her up for collateral information, I would see the NP initial.

 

[zenman]

Sounds scary. In my experience, this tends to occur more often with pts being managed by NPs. My patients would say doctor so and so gave me remeron 45, fluoxetine 40, sertraline 200, buspar 20, but when I look him/her up for collateral information, I would see the NP initial.

You won't find that crap with me, but unfortunately an NP at another place near me has a polypharm mindset. After his patients wind up at our place...the only inpatient unit around...many of his patients jump ship. But I also see the same with psychiatrists...and PCP's.

And to the psychiatrist who saw a patient for 15 minutes and diagnosed her with Bipolar Disorder...wtf? I realize you couldn't schedule her for another visit till August but couldn't you refer her elsewhere or at least dc her Prozac and put her on a mood stabilizer? I had to admit her today...and I copied you with the H & P.

 

[whopper]

From my experience this is not a problem solely with NPs but also with some psychiatrists. I've noticed this problem in several areas across the country.

I've noticed there's an idiotic polypharm prescriber, a prescriber that gives out benzos and opioids out the wazoo, and a prescriber that tries an antidepressant at the lowest dosage for about one year, the patient doesn't get better, then doc doesn't know what to do and leaves them on it, freaking out with the SSRI as if it's a nuclear warhead.

The only time I haven't noticed this polypharmacy problem all around me as much is since I worked with the university and the private psychiatric facility where the overall quality of the doctors are much higher and I can actually engage in a level of intellectual and reasonable discussion of treatment with most of the doctors I work with. I still know these people are out there, but at least I don't have to deal with them as much.

 

[RookieRoo]

Solution: Reimbursement for an hours worth of Med Man visits = Reimbursement for an hours worth of Therapy.

 

[whopper]

I don't know how much that'll fix it though it'll fix it some. Even if I hardly knew anything about a person and was doing med-checks where I only spent a few minutes with them, I would like to think I'd still have enough common sense to at least ask if the med they were on provided any benefit, document it, and if it didn't after an appropriate time frame, then taper them off of it.

The idiots from my experience aren't such because of lack of time but because they're idiots. A buddy of mine who is good is working at a community mental health center where one of the psychiatrists died and he took over her patients and they're all on large amounts of Xanax. That place gave the doctors 1/2 hour per session, paid the docs well (200K+ for 40 hours a week, plus they treated you like royalty with nurses doing all the grunt-work), and you had good time to really talk to the patients, yet she still loaded them all up on Xanax. I used to work at this place and I felt very comfortable with how much time they gave me with patients, and had to spend my first 6 months tapering most of the patients off of a benzo.

And the Xanax was not profit-motivated. This was a community mental health center, not private practice. When I first worked there, they asked me how long I needed with a brand-new patient and I told them at least 40 minutes. They told me most of the doctors wanted 1.5 hours and got it.

 

[GladifImakeit]

.

 

[splik]

Xanax is an awesome drug. Really great stuff.

so is cocaine, doesn't mean I'd ever prescribe it.

 

[RookieRoo]

That's a good point. Lazy people, even when given the time, may still do the easy thing and write for controlled substances. However, I still think that parity btwn meds and therapy will help push the trend the other way. It will make therapy more accessible to those who would prefer it, but can't afford the out of pocket costs which may range btwn $100-250 hr. A copayment for a med check on the other hand, would be much, much less.

 

[vistaril]

Solution: Reimbursement for an hours worth of Med Man visits = Reimbursement for an hours worth of Therapy.

ummm....you do realize if this happens it would be bad for psychiatry because it would mean med mgt reimb has decreased right?

 

[whopper]

I could see it being bad in this sense.

Most places don't have a shortage of psychotherapists, but only a shortage of psychiatrists. For that reason, to get to the most amount of patients, I've referred people out for psychotherapy. I still did psychotherapy on my patients, but it was more along the lines of brief supportive therapy instead of extended long sessions, and then relied on other psychotherapists to handle really heavy stuff like get in-depth data on everything that happened in childhood, exposure therapy, cry-out sessions, etc, and then they could call me up so we could touch base.

I've worked in counties where literally I was one of only maybe 3-4 psychiatrists and there were dozens calling every day begging to be seen by a psychiatrist. That's why I did it. I wanted to get to as many patients as I could, not for profit but to help more people. I even told good patients I liked that only needed refills because they were stabilized to consider going to their PCP instead of me so I could spend more time with the patients needing to be stabilized.

Paying someone the same for long-sessions vs. med management hurts the above model that can get a psychiatrist spread out helping more people.

The problem with the model I used was some of the therapists I worked with were terrible, but some were truly excellent and overall I do think I was able to get to more people and help them more.

A problem with almost every model is there's a way to abuse it and a way to use it better depending on your own personal style. I do think RookieRoo's suggestion would fix some problems with some docs but not with others.

I might do my own private practice sometime in the future and if so, I would want to work with non-psychiatric psychotherapists again. Frankly some are better in some aspects of it than I such as DBT, doing MMPIs, or other specialized services, and I could get to more people. The more people working with me under one roof, the less the maintenance expenses. Where I'm at the state hospital is down 3 doctors, all the local counties are almost out of psychiatrists in their community mental health centers, and this is even with a residency program in the area churning out docs each year. I've gotten at least a job offer a month with each place telling me how screwed they are because they have no psychiatrist.

 

[digitlnoize]

ummm....you do realize if this happens it would be bad for psychiatry because it would mean med mgt reimb has decreased right?

ummm...or therapy reimb has increased...

How about I just get paid for my time. I charge $200/hour. If I see a patient for 15 minutes of med mgt, I get $50. If I see them for 1 hour therapy I get $200. $200 per hour. Period. Problem solved.

 

[billypilgrim37]

This might beat it: 20yo F transferred to me on Seroquel XR 800mg, Seroquel 150mg, Latuda 80mg, Klonopin 4-6 mg, Inderal 80mg, Lamictal 25mg, Synthroid 125mcg (no hx hypothyroid).

 

[OldPsychDoc]

This might beat it: 20yo F transferred to me on Seroquel XR 800mg, Seroquel 150mg, Latuda 80mg, Klonopin 4-6 mg, Inderal 80mg, Lamictal 25mg, Synthroid 125mcg (no hx hypothyroid).

Only ONE benzo, no antidepressants, and no stimulant?
You should be ashamed of yourself! 🙄

 

[zenman]

This might beat it: 20yo F transferred to me on Seroquel XR 800mg, Seroquel 150mg, Latuda 80mg, Klonopin 4-6 mg, Inderal 80mg, Lamictal 25mg, Synthroid 125mcg (no hx hypothyroid).

So how's he doing?

 

[hamstergang]

Resurrecting this thread for a recent patient I sort of had: Rexulti, Risperdal, Lamictal, Topamax, Neurontin, Lithium, Pristiq, Viibryd, Vyvanse, and Ativan. Some of these are over the recommended doses and some way under. I can't even comprehend it.

 

[Echo Three]

Probably for a new thread: so when you inherit a patient on one of these meds lists, and for added fun, you cannot NOT see them, where do you begin?

 

[Shikima]

Probably for a new thread: so when you inherit a patient on one of these meds lists, and for added fun, you cannot NOT see them, where do you begin?

Take away controlled substances. They're controlled for a reason and have the biggest impact on neurobiology.

 

[Therapist4Chnge]

Only ONE benzo, no antidepressants, and no stimulant?
You should be ashamed of yourself! 🙄

lol. To be in the ballpark I'd expect two to three anti-psychotics and/or anti-ep, a benzo or two, a stimulant , a couple of "sleep aides", at least one SSRI/SNRI/etc. and then obviously some pain meds. Sad, but true.

 

[smalltownpsych]

Take away controlled substances. They're controlled for a reason and have the biggest impact on neurobiology.

Or you could go the opposite tack and get rid of all the less abusable medications. Probably meet with a lot less resistance that way.

On a more serious note, how did the OP have a patient with multiple hospitalizations for anxiety and ADHD? Combine that history with the polypharmacy and you get...(I almost want to do a poll to see how many can guess it right) Borderline Personality Disorder as the most likely dx. If the countertransference reaction from male staff is exceptionally strong and aggressive, then that would be like the diagnostic gold standard. 😉

 

[PistolPete]

Resurrecting this thread for a recent patient I sort of had: Rexulti, Risperdal, Lamictal, Topamax, Neurontin, Lithium, Pristiq, Viibryd, Vyvanse, and Ativan. Some of these are over the recommended doses and some way under. I can't even comprehend it.

Damn. These cases I'm quite afraid of in private practice since the likelihood of an adverse outcome is huge, liability is huge, and changing the medication regimen will undoubtedly be met with strong resistance. Good luck. Oh, and by the way, what happened in the visit? Did you change the regimen at all?

 

[SeniorWrangler]

Resurrecting this thread for a recent patient I sort of had: Rexulti, Risperdal, Lamictal, Topamax, Neurontin, Lithium, Pristiq, Viibryd, Vyvanse, and Ativan. Some of these are over the recommended doses and some way under. I can't even comprehend it.

I like the Viibryd-Vyvanse combo. Fun to say, fun to prescribe, probably fun to take.

 

[hamstergang]

Probably for a new thread: so when you inherit a patient on one of these meds lists, and for added fun, you cannot NOT see them, where do you begin?

My plan would be:
1) Empathize with the pain/distress they must be in to end up on so many medications.
2) Observe that they still aren't well, and that's why they're seeing you.
3) Comment that the medications likely aren't the answer, but may in fact being making things worse by messing with brain chemistry.
4) Suggest plan of lots of therapy and slowly bring down 1 medication at a time.
5) Take the afternoon off since the patient will never see you again.

Damn. These cases I'm quite afraid of in private practice since the likelihood of an adverse outcome is huge, liability is huge, and changing the medication regimen will undoubtedly be met with strong resistance. Good luck. Oh, and by the way, what happened in the visit? Did you change the regimen at all?

I only had the patient by phone call as the patient was getting admitted. So overnight, I continued things. It's up to the inpatient attending to fix it.

 

[YumIsPeople]

Resurrecting this thread for a recent patient I sort of had: Rexulti, Risperdal, Lamictal, Topamax, Neurontin, Lithium, Pristiq, Viibryd, Vyvanse, and Ativan. Some of these are over the recommended doses and some way under. I can't even comprehend it.

Rexulti, Vyvanse, and Viibryd are all brand-name drugs, and the generic desvenlafaxine ER is expensive for a generic, so this is quite an expensive mix of medications as well. Hopefully, the patient is at least getting some serious relief from it.

 

[hamstergang]

Hopefully, the patient is at least getting some serious relief from it.

Well,

the patient was getting admitted

so...

 

[AnnoyedByFreud]

My plan would be:
1) Empathize with the pain/distress they must be in to end up on so many medications.
2) Observe that they still aren't well, and that's why they're seeing you.
3) Comment that the medications likely aren't the answer, but may in fact being making things worse by messing with brain chemistry.
4) Suggest plan of lots of therapy and slowly bring down 1 medication at a time.
5) Take the afternoon off since the patient will never see you again.

oh god this is depressingly and hilariously accurate...

 

[NickNaylor]

My plan would be:
1) Empathize with the pain/distress they must be in to end up on so many medications.
2) Observe that they still aren't well, and that's why they're seeing you.
3) Comment that the medications likely aren't the answer, but may in fact being making things worse by messing with brain chemistry.
4) Suggest plan of lots of therapy and slowly bring down 1 medication at a time.
5) Take the afternoon off since the patient will never see you again.

Lost it at #5. So depressingly true.

 

[masterofmonkeys]

600mg of Lamictal
2500mg of VPA
900mg of lithium

Seen in the PES.

Lost my crap, cried, had a panic attack, held the patient while he cried, we both had panic attacks, and then his wife slapped some sense back into me, and then sent him for liver w/u.

 

[nancysinatra]

This thread was revived from 2012. And yet the problem of polypharmacy has probably only gotten worse since then. Since graduating from residency in 2013, I've definitely seen some patients in the community who were on 10+ psych meds. On a more national scale, in over four years, has anything improved on the psychopharm side of things? I'm asking - I actually don't know. But if not, why not, and what can we do about it?

 

[nancysinatra]

600mg of Lamictal
2500mg of VPA
900mg of lithium

Seen in the PES.

Lost my crap, cried, had a panic attack, held the patient while he cried, we both had panic attacks, and then his wife slapped some sense back into me, and then sent him for liver w/u.

What is a liver work up? Do you mean an ultrasound? A CT? A biopsy? Why, in this case? Also why did you have a panic attack?

 

[masterofmonkeys]

35mg/kg of VPA plus 600mg of LTG = hyperammonemia. I said liver workup, I meant a CMP and ammonia. Probably should have mentioned the confusion and asterixis huh.