This post should say it all, but I will repeat the main points after the link:
the tip is simply this, what should you, the patient, be asking your psychiatrist on the first visit? Yeah, you asking the doctor, that is a legitimate position, and I have been asked some if not all of these questions, so I can write it with legitimacy:
1. How long have you been practicing as a board certified psychiatrist?
2. Do you provide any other treatment interventions besides prescribing medication?
3. Do you have admitting privileges to any hospital that provides psychiatric care?
4. Can I (the patient) ask for other medication options besides what you offer?
5. What is your standard of prescribing medication, do you prefer to prescribe one medication at a time and do you believe in titrating and tapering medications?
6. What is your position on second opinions about my diagnosis and treatment options?
and the seventh, which got me some backlash,
7. Do you belong to the APA?
People think they are in the presence of a deity or authority figure, but my reply is “NO”, you are in the presence of a person with an expertise, and some ability to direct you to a path of healthy function and productivity, as well as mental stability, and I think those things may not come to full fruition concurrently as we might hope.
And you as the patient have the right to disagree with the expertise and treatment recommendations, but, you have no right to demand from the expert what you think you want if the provider does not agree with your interpretations. Because if it doesn’t fit the standard of care, well, the beauty of other opinions and options by separate providers.
I provide treatment recommendations that are based on what is right and responsible, not popular easy and convenient. I am sure there are plenty of providers out there who practice the popular easy and convenient treatment options. Good luck with them.
You might want to consider those above 7 questions before you proceed to the treatment part of the visit. Hey, just my opinion, I could be wrong. I am a psychiatrist, but also a human…
Tip #9: Beware of psychotropic-polypharmacology. Physicians who think that multiple medications will effectively treat mental health problems, well, let’s just start off with this image to reinforce the point:
I looked for an image of a physician holding a shotgun, but none really fit the bill, so this is my back up pic. And while this post is not specifically about Seroquel, which is quetiapine, I think it illustrates the point well when you see it combined with an antidepressant, an antimanic, anxiolytic, and then other meds for side effects these other psychotropics cause, well, get ready to duck?
I have these patients coming to me from colleagues who have basically dumped their prescription cocktails onto others, and quite frankly, I think it both hilarious and heinous simultaneously that people are being told taking 3 or more meds will make them better without consequences.
I have never been a fan of polypharmacy, and while I know there are times it probably is needed, I will reluctantly write for 3-4 meds at most if they are indicated and the patient is well educated to the risk/benefit profile of this combo plan, but I don’t like doing it. And these multiple meds in the same class, well, hasn’t this been dispelled by now, you don’t write for 2 SSRIs, or 2 benzos, and even the combo of 2 or more antiseizure meds for bipolar, I mean, really?
Don’t even get me started on these folks coming to me on 2 or more antipsychotics. That is NOT a misprint, there have been people coming to me on 3 antipsychotic meds, thinking 2 atypical and a first generation med like Haldol or Thorazine is going to calm the treatment resistant psychotic or manic. NOT!!!
Give it thought before you agree to take all these meds, as the side effect profile of many combinations rises logarithmically and just winds up making people more miserable than manageable.
Hey, you who are taking all these pills, tell me otherwise, I will respect your experience and opinion. Just say it honestly.
Sorry, this issue is not going to be discussed respectfully or therapeutically. I am sick and tired of these daily pot smokers coming in to see me for psychiatric care and saying in one breath “pot really helps me for my anxiety/mood/insomnia/other psychiatric problem, but I have problems still”, and then expect me to provide medication, a lot of these pot heads looking outright for controlled substances like benzos or stimulants (I mean, really, claiming ADD using a drug that impairs cognition, do these folks demand more diabetes meds while they suck on a regular soft drink in PCP offices???).
Find a lackey to do your bidding. I am not a lackey, and frankly, if people who smoke dope most days of the week struggle with anxiety, depression, cognitive impairments, and even some who get psychotic, well, is one that surprised that a mind altering substance is altering one’s mind in a negative way, at least after the high is over?
After all, what goes up will come down, is that too complex to understand?
And the Boomers who are still using illicit substances, there is only one thing to say to these folks: GROW UP! Who is responsible and a respectful member of the community getting high at 60 years old??
Sorry, to those who use marijuana for a legitimate medical need, I am not addressing you in this post. Nope, I am talking to the “turn on, tune out, and drop out” crowd that think the 60s mantra apply to life 40+ years later.
Hey, in those states that have legalized medical marijuana, I am sure you can find providers who passionately embrace your needs and wants. I am not enlisting in this cause, because for every legitimate person who might be able to defend the use of THC, the next 4-5 are just stoners looking for excuses to get high strictly for fun. And that is not a psychiatric need, but a recreational one.
a lovely image to leave you all with a smile:
Tip #6: read the banner again here at the top of the blog, “… but if you want to get it right, face the truth.”
With these blatant liars, cheats, and idiots we have masquerading as candidates for President of the U.S., who the hell really faces the truth these days?
I see people almost every day, whether it be at a CMHC or private practice office, who come in telling me about these psychosocioeconomic stressors, usually more than one mind you, and then in the next damn sentence want a pill for it. Where is the logic, the realism, the concept of problem solving, that a pill will get people a job, pay their legitimate bills, make their spouses be kind and supportive, make the home environment a place to rejuvenate, see family members love and care again, get the judge to not throw them in jail or order a hefty fine, see neighbors be respectful and cooperative, appreciate the others who are leaders or authority figures or just people of sizeable influence be appropriate and responsible, and go on and on with whatever specific stressor(s) are front and center for these folks who want a damn pill to feel better.
Yeah, there is the tie in to the beginning to the banner, “if you want to feel better, take a pill…”
And these people who come into the office, who think I am the ultimate magician, really expect me to hand them a piece of paper that will make them better.
It is quite astounding these days when I have these moments, and they aren’t just for controlled substances, that is what is so rich at times. I have to find the right antidepressant, or antimanic, anxiolytic, antipsychotic, or whatever other class of psychotropic that is the diagnosis du jour at times.
Anyway, my advice, not only read the banner and memorize it, really decide if it is right if not for you, the reader, but anyone else you hold dear and care much for this other’s welfare and health.
Tip #7: please tell me why people over the age of 50 years old should be on stimulant meds like Ritalin, Adderall, hell, I have inherited a 60+ year old on Dexedrine, are you ready, at 50mg a day, thanks to my predecessor who thinks that a 1/3 of CMHC patients have ADD?
Sorry, this is one provider who thinks that if you have gotten through life in some form to be still somewhat independent and autonomous at 50 years or older and to be thinking you have ADD and need to be on stimulants, especially at high dosages like over 60mg of Ritalin, or 40 of Adderall, or 20 of freakin’ Dexedrine, well, you need to tell that story to another provider, this guy here running this blog is done with these stories of woe, but more likely, SO?!
The reality here? Over a third if not close to 50% of these alleged “older ADD patients” have a history of substance abuse, a lot more often active, and these 50+ year old pot smokers claiming ADD, well, if the drug works, why are we talking???
Another Tip I will get to in a few days, sorry to jump the gun there…
To wrap up Tip #7, maximize the CBT techniques learned in current psychotherapy to have some impact on these alleged ADD symptoms, and then call me with your therapist’s seal of approval to legitimately talk about meds for ADD. Oh, and if not diagnosed by a legitimate mental health care source prior, also have that psych testing paperwork done in the past few months too. Otherwise, a very short conversation will follow, and no papers with drug names and a quantity of pills noted will be passed to you.
sheesh, the new cocaine epidemic, brought to you by Psychiatry…
Addendum this morning: I thought about what I wrote lying in bed, and the point to this post was I cannot just write for meds for the above issues. Stressors need problem solved, meds can help with that, but, what is the point to just taking a medication? As per stimulants, well, I am burnt out with the older ADD crowd, these older folks just don’t want to change at the end of the day, it really is about the quick fix.
The Boomer generation is now 50-70 years old, they are entrenched in their “living in the moment” for their last 30-50 years now. And let’s have a moment of candor, too many of them just want to turn on and tune out, which seems to contradict the point of honest treatment for ADD, eh?
People keep challenging me when I comment about personality disorders, or what I label characterological deficits. They say the comment is intended solely to be derogatory and punitive, but, if mental health was solely about Axis 1 disorders, as many providers want the focus solely on as that is the only FDA indications for most psychotropics (or some non clinician commenters want the attention directed away to avoid consideration), why are more people coming into mental health care and not getting better with meds?
Well, if it is complicating medical problems, then wouldn’t we see patients improve if they could have their medical issues more reliably diagnosed and treated? If it is simply substance abuse, then, while getting clean isn’t easy, once a person has some period of abstinence under one’s belt, wouldn’t we see psychiatric symptoms subside if a byproduct of intoxication and withdrawal?
But, having been traveling around three states these past almost 6 years now, I see the same things at every clinic, at every acute support program, and private practice. I see more and more people who are at the very least comorbidly Personality Disordered as much as dealing with any mood/anxiety/thought/cognitive disorder. And stop trying to frame this as my making it about Borderline Personality Disorder, frankly I think the term is just a synonym for what is actually Personality Disorder Not Otherwise Specified.
And even in presentations that are more likely Borderline P.D., why do you think these patients are going door to door between providers and not “getting better”? Yeah, those psych meds for personality disorder, haven’t quite been perfected yet, right?!
My noting the role of characterological disorders is pointing out the basic point of what defines Personality Disorder, and let’s once again note the definition per DSM 4, as the APA has decided unilaterally to ignore Axis 2 issues since meds can’t be peddled for it:
A. An enduring pattern of inner experience and behavior the deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
1. Cognition (i.e., ways of perceiving and interpreting self, other people and events)
2. Affectivity (i.e., the range, intensity, liability, and appropriateness of emotional response)
3. Interpersonal functioning
4. Impulse control
B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.
F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug abuse, a medication) or a general medical condition (e.g., head trauma).
From the following link that compares 4TR to 5:
My point is simply this, watching what the two primary political parties in America are pushing as their main candidates, a frank narcissist and an entrenched antisocial, this seems to be what the country wants and can identify with these days. Yep, Carlin again said it, “It’s not the politicians who suck, but, the public.” Because I know in my heart we have more narcissism and antisocial behaviors in this last decade and a half than we endured the prior 40 years, that I can comment on at least.
So, when narcissistic, antisocial, histrionic, dependent, avoidant and paranoid personality traits cannot function in a general society, well, it starts with identifying there is a problem and a need for change. Not seeing some patients able to come in and see what they bring to their psychosocioeconomic strife; imagine, for these people it is the rest of the world that is at fault. And yet, these patients want a pill to treat the rest of the planet?
Cue what Jim Jones offered to his cult at the end:
Just what is in the Kool Aid in America these days…
Wouldn’t surprise me in a moment of candor Hillary Clinton evoking this idea!
That seems to be the ongoing question at my current CMHC job, which I am not staying at past the end of the year, and quite frankly, I don’t get why people in administration seem to be clamoring we are treating customers or clients, and not patients. Yet, isn’t the premise to the process health care, not customer satisfaction? Would these same administrators be scolding surgeons for not providing surgery to every person who walked in the office???
Where is that part of the contract that every patient has to leave with a prescription, I don’t remember signing that!
Yep, that is my point, I am not here to make people happy just to give them what they want, albeit I think the patient and I want them to be healthy and functional, but, I am not here to appease their alleged chemical needs. Nope, sometimes the doctor has to say no, and often because the “need” the patient presents is just a “want”, and not a healthy or appropriate one at times.
But, administration doesn’t seem to understand that “No” is part of treatment, that “No” is almost always not a firm and absolute plan, and that “No” could direct to a later “Yes” as the patient progresses to that portion of the treatment plan.
And for me specifically, “No” is almost always to the patient who is pursuing controlled substances like benzos or stimulants, yet the patient’s background seems to indicate those meds will have more risks than benefits, at least at moment one of care. Funny, I bet if some of these administrators had the ability to prescribe, and then take on some liability for it, I think they would suddenly find the word “NO” in their vocabulary, and use it with some frequency.
Saying “No” is not mean nor denying care. It is about going from least to most invasive, you know, that part of the Hippocratic Oath doctors take in accepting the role of physician, and for me it is always starting with a respectful and well meaning explanation of why a request has to be denied at first.
But, some people just can’t hear the word “no”, hmm? And for me, the people who seem to react the loudest and persistently annoyed echo the same behaviors of those 5 year olds who don’t like hearing “no” as well. Helps me with the differential in considering Axis 2 factors to the presentation.
So, I’ll have to put up with patients and administrators who can’t hear the word “no” in my travels while I still practice psychiatry, and then I guess we’ll just have to see whether it is about me not being nice, or perhaps being right.
Because “no” is never right these days, eh?!
Cue Hillary Clinton and Donald Trump as exhibits A and B for that point…
Hey, just read anyone who does not have a partisan agenda to tell you how great Obamacare is, because those sources are obscenely profiting from this scum bag government intrusion into peoples’ lives, and what will you learn?
Yeah, the following link is a partisan person who hates Obama and this law, but, I personally agree with her, so this is what I forward first.
how about this link?
Getting tired yet? I am not… Make sure to read the ending!
So, to all you patients out there staring at the sides or back of your provider’s head much of that doctor’s visit, how’s that going for you?
By the way, I don’t go near the computer at temp jobs that have EMR until the end of the visit. EMR and psychiatry are like , well, Democraps and Repugnocants.
Nice way to tie it in to politics at the end there, eh?
My private practice? No EMR, ’cause I don’t take Deadforcare, er, Medicare.
Sorry to those negatively affected by that decision. Welcome to my world…
Tip #2: if you are referred to a therapist for psychotherapy before seeing a psychiatrist, and you are told in the first visit with this non physician provider you need to see a psychiatrist and go on medication, that should be kind of baffling, if not frightening if you are not suicidal, dysfunctionally manic, or psychotic, hmm?
After all, you are seeing a professional with an alleged expertise that can at least start to treat most psychiatric disorders that aren’t at risk for possible hospitalization or acute medicinal stabilization, and let’s be honest, at least 90% of people who are seeking out a therapist have psychosocial issues that are not going to be solely impacted by medication, believe that when you read it.
And yet, I don’t have an exact figure, but, I would hazard to guess that over 50% of therapists these days are telling patients to see a psychiatrist or other prescribing professional and consider medication on the first two visits with the therapist, tops. And why is that, when I think the percentage of patients who are erroneously sent to a therapist first for initiating mental health care services is no worse than 10-15%, again, tops.
I don’t have an easy answer to that either, but, sorry, some of it is just lazy and fearful providers who don’t know how to challenge patients, or perhaps even the therapists themselves, to know what to do with some of the chaos sitting in their offices. And then there it is, if these therapists don’t have an easy and quick answer to a problem at moment one of treatment, it must need medication to solve and cure, eh?
Think about it, especially if you have gone through this in recent times…
Tip #3: What is your experience, whether it be as a just a person, or as a provider, when you interact with a person who is on high dosages of prescribed controlled substances, like opiates, stimulants, or benzos as the top three sources of risks of abusable prescription drugs out there of late?
I’ll share with you mine: they more likely act and sound just like illicit drug abusers. Except at least one painful exception: because their dealers wear white coats and are sanctioned by the states they practice to provide these substances, there is no accountability or consequences, as far as these patients are concerned, to continue to pursue these drugs. Thus lies the most painful realization: provider sponsored addiction that tries to hide behind pathological denial, rationalization, and minimization when these patients cause disruption and havoc in their homes, businesses, and communities.
I’ll end with this gem I read this morning in the most recent issue of Psychiatric Annals, curiously and confusingly about Prescription Opioid Medications in a psychiatric journal, in the abstract from the first article about the topic, “Do Current Policies and Practices for Prescribing Opioid Medications Solve Chronic Pain Problems”: “Despite the widespread prescribing of opioid medications for the treatment of chronic pain, there is little of no evidence for its efficacy. In fact, the studies show that long term prescribing of opioid medications leads to significant morbidity and mortality.”
Same can be said, in my opinion, about a sizeable amount of prescriptions for stimulants and benzos for those who do not meet a stringent criteria for those medications to be prescribed, at least in the quantities that wind up in some patients’ bodies.
Again, think about it…
First, this comment from Dr Nardo at his site http://www.1boringoldman.com:
“Finally, one wonders if some of this almost reflexive drug treatment is continuing because people don’t know what else to do for their patients other than prescribe drugs [particularly after the thirty years we’ve just lived through]. And that’s not just about psychiatrists. Many practicing therapists make a referral for a med-consult during their first session. Physicians who receive these consults feel obligated to respond with a prescription. So this is a time when training programs, supervisors, and CME programs in multiple specialties would do well to focus on something like Back to Basics [meaning all sorts of forgotten or unlearned skills]. A strong reason for fighting for mental health parity is to give clinicians of all sorts the time to do their jobs [for the moment, I’ll forgo my recurrent ranting about Collaborative Care]. One can expect Managed Care to oppose any such a suggestion. In fact, when we talk about Conflicts of Interest, we ought to apply some of the indictment to the motives of Managed Care, who’ve had a field day chopping up mental health coverage…”
(from this post: http://1boringoldman.com/index.php/2015/10/14/reflections-on-a-doodle/ )
Then I advise anyone interested to read this latest post from Shrink Rap:
In there this reproduced comment to Dr Miller:
“My out of network reimbursements have come back recently because my health insurance (not medicaid or medicare) has switched to a computer program. The program can’t read the forms or recognize the information from my psychiatrist’s invoice if everything isn’t in the right place. I had to ask my therapist to switch her statement forms (i.e. create a new form) in order to meet the needs of the insurance. I offered to make one myself but she did it. You know how long it took? 3 minutes.
This is another post where you, the shrink, is demonstrating extreme selfishness and self-centeredness by thinking about the approximately one extra minute it would take to fill out the form as requested, and not bothering to consider the effect on the patient, which is what actually matters. Have you thought about how your post will make patients feel about how resentful and bitter their therapists feel about doing the work necessary for their patients to be reimbursed/get services in the first place?
Shame on you. Think about someone else for once. Or at least pretend to, in this public forum. “
Fascinating, isn’t it, when people think that we should have either taken a vow of poverty and treated the world for free, or, just sank into a corner or under a rock and just disappeared, so the predators among us in society could continue to go undetected and prey on those who fit the narcissistic and antisocial agendas, at great cost to such victims mind you.
Anyway, the point of this post is to introduce a brief and ending series of “Tips 101”, observations and accumulations of valuable points of view that might help some out there in need of honest and caring mental health services.
Tip 1: If you are seeking out psychiatric care, especially for the first time, I would advise you to be wary of three basic behaviors by psychiatrists who probably aren’t looking out for your best interests, but more likely the providers first:
1. If the provider interrupts you within the first ten minutes to discuss medication needs, how does such a provider come to such a quick conclusion?
2. If you are advised to take 3 or more meds from this first evaluation setting, how does such provider know what possible consequences could arise from poly pharmacy that more likely is over treatment?
3. If the provider uses the term “biochemical imbalance”, does not offer any suggestion of concurrent psychotherapy, and wants to see in you in 2 weeks or less following the beginning of a medication trial, what is that message for cause to your psychological struggles?
Hey, just my opinion, but, having seen at this point in my career hundreds of people who have come to see me after 1 or more of the above experiences, and most of these patients often very disappointed and jaded, what is the problem with those above scenarios? Seems like doing what is popular, easy, and convenient, and those concepts really don’t fit what is truly needed in psychiatric care, true, colleagues with a soul?
Anyway, I will be offering Tips 101 posts the next 6 weeks before I basically sign off at this blog, so if interested, please stop by for a lesson, or just sit in the back and see if the lecture is of value, or entertainment.
Hey, you can always find the nearest exit…