Is Your Neighborhood Drug Dealer Your Family Doctor?

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KAJA WHITEHOUSE, IS YOUR NEIGHBORHOOD DRUG DEALER YOUR FAMILY DOCTOR

Your family physician could be a drug dealer

A drug dealer is everywhere. Heroin may be the current drug menace du jour, but some experts think there should be much greater concern about something else as it relates to our mental and, possibly, physical health, and it’s not bought on the street from a dealer. The family physician, untrained in diagnosing or treating psychiatric disorders, may be the person who is providing powerful drugs to you and your kids.

You probably marched right into your doc’s office and asked for them — no muss, no fuss, and you left with the script for an antipsychotic, antidepressant, anxiolytic or even a Schedule II narcotic/stimulant for your kids. Sure, everyone in the family can be on psychotropic meds if you want. After all, you shouldn’t have a blue day and there’s so much more waiting for you. All you have to do is ask for that wonderful little pill that will lift that weight and allow you to run free.

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The allusions of untold freedom from worry and of an incredibly bright new existence are all over the magazines, on your computer screen and your friendly TV set. Escape is not possible, my friends. The ads have been bought and paid for, and you will experience each and every impression that has been promised on the rate cards.

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It should be mentioned, however, that not all psychoactive meds are taken for approved disorders because the “off-label” use can be for anything a physician wishes. In fact, some of the meds go from treating foot pain or seizure disorder to antidepressant in just a few steps. As one psychiatrist told me, “I can write a prescription for anything I want. I’m a doctor.” Pomposity of that level makes one wonder if he’d write a script for strychnine to treat whatever he deemed needed his ministering. There’s just one problem, and it’s his liability insurance that may be the ultimate deterrent.

The scenario vis-à-vis psychotropics is all too familiar in the United States where the Centers for Disease Control and Prevention indicates that the periods “from 1988-1994 through 2005-2008 (saw) the rate of antidepressant use in the United States among all ages increased nearly 400%.” (1)

Who prescribed all those medications for the latest clutch of psychiatric disorders that the American Psychiatric Association has deemed are “abnormal?” Yes, you guessed it. It’s your friendly primary care provider, pediatrician or even OB/GYN. And, once again, the CDC indicated that “less than one-third of Americans taking one antidepressant medication and less than one-half of those taking multiple antidepressants have seen a mental health professional in the past year.”

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It’s fortunate that the most recent edition of the psychiatric bible, The Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition (2), decided not to include normal grieving as a disorder. Grieving, after all, is natural and not a psychiatric disorder, but its addition would have bumped up those stats significantly.

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The DSM-5 covers a lot of psychiatric territory and is being translated into 18 languages. Should we wonder whether all of these cultures should be subsumed into one manual of psychopathology based on decisions by an American group of psychiatrists? You have to ask that very relevant question.

Again, not everyone in the psychiatric profession subscribes to loose prescriptioning, and some question how things could have gotten to this point and just where psychiatry and psychiatric meds are headed. Responses for this article have largely been positive as it relates to the reality of psychiatric disorders and people needing medications for them, but just who needs meds, what they may do (especially in the case of kids) and who should be prescribing are points of contention our interviewees addressed.

Consider the potential adverse side effects. A quick peek at serious reactions of psych meds include suicidal thoughts, weight gain, uncontrollable muscle movements (TD), memory impairment, inability to orgasm, death in the elderly, life-threatening serotonin syndrome, agitation, blackouts, seizures, nightmares, hallucinations and stroke in kids with heart problems. Not a pretty picture, but also not found in all cases. (3)

A truly unique perspective to psychiatric practice and prescribing was provided by New York City psychiatrist, Dr. Rami Kaminski, the president and medical director of The Institute for Integrative Psychiatry and a former commissioner/medical director for N.Y. State Office of Mental Health and psychiatrist at Mount Sinai School of Medicine at NYU. Impressive as his resume is, Kaminski is devoid of the “God Syndrome” often found in persons of his stature.

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Simply, he says, the first question you must ask yourself is, “Who do you serve? And if your first and utmost responsibility is to the patient, we have to protect our patients from society, not protect society from our patients. But with the insurance reimburse and so many issues that converge, you forget who it is that you are serving.” Once you find you are serving insurance companies rather than your patients, Kaminski believes, “Then you are going wrong. Something is going wrong.”

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It is Kaminski’s orientation that, “You must know that you are serving someone, and that’s the person you are beholding to, and you are their servant. You may be elegant, highly educated and well dressed, but you’re still their servant. I tell my patients that I am working for you. You are the reason I come to this office. You are the reason I sit here.” He makes no attempt to hide the fact that he loves his work.

Too often, he believes, the public isn’t being adequately educated about disorders and medications, and that is one of the major mandates for a psychiatrist. “There’s never a perfect solution, but if I put it out there, and they choose to ignore it, that’s fine. I’m not in charge of people.”

The patient, ultimately, is the leader and “the whole idea about medication is that you have to bring it up, and it has to be individualized and discussed in every respect.” But you can’t do what’s needed in a 15-minute session. “Each of my patients gets a full hour for each appointment, and I am available 24/7 for them.” Patient education is key. “If you are better educated about medications, you actually make me a better doctor by the questions you bring up.”

He doesn’t believe that psychotropic medications, properly prescribed and monitored, cause severe side effects like tardive dyskinesia (a potentially permanent movement disorder) or anorgasmia but he does believe you can’t subscribe to the mind-body duality any longer.

Kaminski eschews this separation. “It isn’t two halves of one person. It’s all one, and it’s seamless. All my patients now have to go on MyFitnessPal, a free application that allows them to track honestly what they eat.” In part, this addresses the problem of metabolic syndrome (excessive weight gain) found with a number of medications. Also, part of his treatment plan is the coordination of his efforts with a team of relevant medical specialists.

What has always been Kaminski’s goal since the age of 5? “To be a good doctor, and that can be taught. I give talks on how to be a good doctor to psychiatric residents.’”

On the West Coast, another psychopharmocologist/psychiatrist, Dr. Steve Balt, a consultant with the Mhttps://www.theblot.com/girl-rapunzel-syndrome-massive-hair-ball-7766054ind-Body Clinic and a researcher at Stanford, provides a sanguine, incredibly frank look at psychiatric practice. Currently, he is involved in efforts to help people who want to wean themselves off psychotropic medications and to initiate a safer, less costly and more effective treatment plan.

Addressing the concerns about side effects, Balt states, “My first reaction is that the side-effect issues are in many ways overblown.” He did concede, however, that “most psychiatric medications can cause side effects which can cause distress.” But while the meds are widely prescribed by psychiatrists and others, “the side effects don’t seem to appear in quite the numbers that we might predict.”

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The problem appears to lie, according to Balt, in a selection bias seen in the lay press and published literature where people with adverse experiences talk about them and this generates enough attention to skew the view of them. Balt admits he is no apologist for the pharmaceutical industry and sees the problem as one of physicians being ill-informed about side effects.

“The issues,” he says, “are two-fold, and there are bigger issues. One issue is that the medications we use can be horribly ineffective and data confirms this.” This he sees is a function of who gets into clinical trials and “the patients sitting in front of me would never qualify for any trial.”

In addition to the difficulties with medications, Balt believes that too many prescribers “just don’t know what we’re treating,” and this may be due to failure to do complete diagnostic interviews as well as the inadequacy of psychiatric knowledge. “When the medications work, we have no knowledge as to why they work or whether, in fact, it was the medication that had the effect we’re seeing.” Efficacy remains the primary mystery and “medications do not work more often than they do. We don’t acknowledghttps://www.theblot.com/panama-papers-sensation-idiotic-insult-eight-million-americans-expatriates-7721065e our mistakes or our failures, and we just move on to the next drug,” Balt says.

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Reflecting the realities of current practices, Balt also saw that a contributing factor in care is where side-effect information is left to package inserts and advertisements. The belief, he says, is that patients are more informed because of the Internet, and prescribers don’t need to spend too much time going over side effects. “All of this shields us from wondering why we’re using a drug in the first place.”

Time, in fact, plays a major role in the total picture. “Some practices, like my own, I take an hour or more with a patient. Most of the time is spent learning about the patient and their needs without reference to medication. Then we come to some conclusions as to what medication approach might be best, if anything. This is psychodynamic psychopharmacology where we educate patients about side effects.

“When patients know about side effects, they are more alert and tend not to experience them,” he adds. Patient empowerment is key. “They also know about alternative medications, and they recognize what is happening to them and know the workable solutions. Of course, they also have full permission not to take any medication.”

Current practice in many settings saddle the psychiatrist with filling out forms, with no time for full disclosure and a resulting diagnosis and treatment plan formulated after 30 minutes. The patient is then told to return in four months. “That to me,” Balt continues, “is not treatment, and it never works.”

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Who is instrumental in maintaining this approach to mental health disorders? “It’s not the pharmaceutical firms necessarily,” Balt says, “but the academics who decide treatment protocols and the rank-and-file physicians who line up right behind them.” The failure is that they don’t employ a critical mindset to the whole patient experience and the treatment plan. He didn’t use the term, but lockstep adherence would seem appropriate here.

An unhealthy reliance on medications and reimbursement issues that value payment over patients also plays a role in Balt’s opinion. “It’s become even more seductive,” he says. “There are very few settings I’ve seen where psychiatric care looks at the relationship and values and respects the human being.”

Reimbursement may indeed underlie the impressive statistics regarding psychotropic medications in one professional article (4). In 2010, Americans spent more than $15 billion on “antipsychotics, $11 billion on antidepressants and $7 billion…to treat attention-deficit-hyperactivity disorder (ADHD).” Is there truly a sharp increase in the number of patients, or is it overly-eager prescription writing that is at the heart of the matter? Remember, if a physician agrees to write the script, they will come.

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The question of time constraints and its effects on establishing therapeutic relationships, gathering information and working on a treatment plan is foremost in the mind of another well-known psychiatrist/advocate. Dr. Daniel Carlat, Associate Clinical Professor at The Tufts School of Medicine and Director, Prescription Project, The Pew Charitable Trusts, believes that time constraints do play a role in treatment planning. “The 15-minute window available for appointments in many settings may mean the psychiatrist is using a simple checklist and doesn’t have time to fully explore side effects or patient concerns,” he states. He, as his colleagues have stated, also views the question of who prescribes, and what their training is remain matters of concern for all.

“On the subject of side effects, patients may be hesitant to bring up sexual problems, and the prescriber will not address this in terms of changes in medications,” Carlat says. Even when told of the possibility of this particular problem, he indicates that patients would rather fight their depression and live with the side effect.

Regarding the most serious side effects of antipsychotic medications that are now used along with antidepressants, Carlat believes that the new antipsychotics have a far lower incidence of tardive dyskinesia, an involuntary movement disorder which may become permanent. “While this is a consideration, it is rarely seen,” he explains. However, how many non-psychiatrists know the specific test to use in-office to check for tardive? It’s called the A.I.M.S. test and stands for the Abnormal Involuntary Movement Scale. The scale checks for specific physical behaviors that usually begin with worm-like tongue movements or a puffing of the cheeks.

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Carlat is most concerned about prescribing psychotropics to children. “We don’t seem to have, in my opinion, sufficient research to support their widespread use in this population, and I am concerned about their long-term effects,” he says. Specifically, he feels that the major concern is that the developing brain in children may, in some way, be adversely affected. The MIT Young Adult Development Project has set the age of full maturity of the brain at about the age of 25.(6) The brain’s formative years, therefore, last for quite a long time and with the brain changes come changes and challenges in behavior. Should these behaviors be seen as psychopathology requiring medication?

One of the most vocal psychiatrists willing to speak out on the question of diagnosis and treatment with medications is Dr. Allen Frances, professor emeritus at Duke University and former chair of the DSM-IV Task Force. A prolific and renowned author of books and articles on psychiatric diagnosis and treatment, Frances is unhesitatingly outspoken in his concerns about these issues.

“Side effects,” he says, “are a huge problem. First off, the fact that the drug companies can advertise directly to consumers at all is a national disgrace.” Frances points out that the only other country that allows this practice is New Zealand. “In Europe, they are aghast that we allow this, and the only reason that we have allowed this is because of the huge lobbying power of pharmaceutical companies in Washington. I’ve been told they are the second most powerful lobbying group after military contractors.”

Viewing this as concomitant to a national disaster, Frances opines that these lobbying and direct-to-consumer efforts have “led to the marked overuse of medication. If a patient walks into a doctor’s office and asks for a specific medicine, they’re 17 times more likely to get medication.” Continuing with his grasp of the statistics, he stated, “Eighty percent of the psychotropic medications are prescribed by GPs, 90 percent of the anti-anxiety agents, 80 percent for antidepressants, 60 percent for stimulants and 50 percent for antipsychotics.”

The GPs, therefore, not the psychiatrists, are the prime movers of psychiatric meds. Perhaps this practice emerged as marketing specialists realized that “there are 10 times more primary care doctors than there are psychiatrists,” and the saturation campaign aimed at these physicians began.

Returning to the issue of side effects of these meds, Frances says, “I think the issue isn’t that we need to have better advertising of side effects. The real issue is that there’s no reason in the world that they should be allowed to mislead consumers.” Advertising was the fundamental problem that meant “anyone can be seen and diagnosed as having a disorder,” and that is “of concern, and the side effects are tertiary.

“They shouldn’t be allowed to be misleading in the promotion of the positive effect while side effects are underemphasized,” Frances says. But he believes there is a far more serious problem here and went on to describe how he views it.

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“Let’s talk about kids,” he says. “The biggest upsurge in drug company success has been in saturating kids with medication. And for kids, we don’t have any long-term studies to indicate what the effects will be in 10, 20 or 30 years. Even beyond that is what they’re recommending for children without any information about these long-term effects.“

Next, Frances turns his attention to the burgeoning diagnoses for children. The latest diagnosis to receive media attention is the disorder known as Sluggish Cognitive Tempo (SCT). The symptoms of the disorder include daytime sleepiness, hypoactivity, lethargy and slow movement. One wonders if those doing the diagnosing consider the 11-hour school day many kids have where they get up just after dawn and don’t return home until after 4 p.m. The authors of a professional article described the diagnosis as “an exciting new frontier in psychiatry.”(5) Does that translate into yet more meds for kids?

“We’re seeing childhood behavior as a disease. I hope this is the tipping point where people see how absurd it is, and they begin to realize that this has become a farce.” Continuing on this point, Frances says, “The experts in the field in child psychiatry and psychology are just out of control. We should be doing something regarding the loose diagnosis of things like ADHD. In some instances, it is an appropriate diagnosis, but we now have the desire to extend the diagnosis to two million more kids.”

Parental responsibility in this regard needs to be considered. “I’m hoping that, past a certain degree of recklessness, it no longer meets the laugh test, and parents see their job is to protect their children from reckless medicating,” Frances states, adding that “when 20 percent of high school boys are diagnosed with ADHD and on medication, I fear we’ve crossed the line, and something needs to be done about this.”

Clearly stating that he isn’t against appropriately medicating a patient when needed, Frances turns his attention to those who need it and are not being treated. “There are people with serious depression who don’t get to see a clinician. Our services for the severely mentally ill are disgraceful and barbaric. Mostly the care is provided in prisons rather than in the community. So there are people who desperately do need medicine and don’t get it. At the same time, there’s this frivolous creation of new diagnoses that will do much more harm than good.” Frances indicates that he hopes children’s advocacy groups would be as concerned about this issue as he.

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The psychiatric landscape is still undergoing seismic changes as the still-nascent science of brain pathology and psychopathology remains as exploration of
the final frontier between our ears. Little in the way of biological tests exist for any of the disorders listed in the DSM and yet, with this simplistic understanding of an incredibly complex system, medication is ordered. As our interviewees have stated, the use of one med may be right or it may be wrong or medication may not be needed at all. The only way to know is still the archaic trial-and-error method and, as it always has been, the phrase caveat emptor (let the buyer beware) is still appropriate here.

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1. NCHS Data Brief, No. 76, October 2011 http://www.nimh.nih.gov/about/director/2011/antidepressants-a-complicated-picture.shtml

2. Diagnostic & Statistical Manual of Mental Disorders http://www.appi.org/pages/dsm.aspx

3. Physician’s Desk Reference http://www.pdr.net

4. Inappropriate prescribing. American Psychological Association, June 2012, vol. 43(6), print version: p.36
http://www.apa.org/monitor/2012/06/prescribing.aspx Retrieved April 21, 2014

5. Sluggish Cognitive Tempo a Distinct Attention Disorder? http://www.medscape.com/viewarticle/819838 Retrieved April 25, 2014.

6. The MIT Young Adult Development Project: The Brain http://hrweb.mit.edu/worklife/youngadult/brain.html Retrieved April 25, 2014

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