At the CMDS Conference there was a meeting arranged for psychiatrists to discuss the new euthanasia legislation. We had several practicing psychiatrists, retired psychiatrists, missionary doctors and a couple of new residents. Concern was expressed by all who noted that when people are suicidal they are most often not in their right mind to be making a life and death decision. Further if they are given the option of suicide then they can cling to that without consideration of alternative simply because it is a drastic permanent solution to what is most commonly a temporary problem. The residents stated that it was already being discussed with patients as a potential option.
The psychopharmacologists present, especially the older ones, listed countless cases of patients who presented suicidal because of untreated psychiatric illness whose suicidality stopped once their mental illness was addressed. It was such a common psychiatric practice and all had observed that a new medication could be literally life saving. Of those present several commented on observing this just recently with the latest of our medications for depression and anxiety, TRINTELLIX, PRISTIQ and ABILIFY. Patients who had previously had no relief experienced this with a change of medication and almost miraculously they stopped being suicidal. Their lease on life was restored.
Emotional pain was discussed as similar to physical pain. and Once the emotional pain was addressed hope was restored. There was further the idea that suicidal thoughts were common in the general practice and especially in the psychiatric practice but the obsession with suicide and suicidal behaviour could often represent psychotic thinking. Again once the psychosis was treated the obsession to suicide lifted. Everyone had seen such cases and expressed concern with the new almost beurocratic approach to death appearing to encouraging suicide.
There was also discussion of various psychotherapies which had worked to shift a patient from negative thinking to positive thinking. Cognitive behavioural therapy and paradoxical interventions and now dialectic therapies all have been shown again and again to cause a patient initially suicidal to simply rethink their options, choose life and move forward. The original psychoanalytic approaches still worked miracles. But every year there major advances in the potential psychotherapeutic approaches to the treatment of mental illness and especially suicidality.
Everyone present had known a suicidal patient and seen the devastation that suicides caused for the families and friends who felt helpless and seemed invariably to think that of it as the ‘wrong’ decision, ‘irrational’, or 'premature'. Yet the patient often presented 'as rational' and so often insisted they had really thought of or tried all options which we as psychiatrists most often saw was simply untrue.
There was a sense too that this paralleled the abortion issue which had similarly begun with extreme outlier examples and lots of mobilization of public support and moving quickly to the present state of the most lucrative abortion industry with its powerful financially invested lobby. How long would it take before psychiatrists might face being arrested for not encouraging euthanasia. Further given the financial realities of child rearing costs in Canada, increasingly abortion is forced on even the middle class. To call it ‘choice’ is a joke when in Toronto and Vancouver professionals with two incomes can’t afford a house and often barely manage to manage with prohibitive taxation. How long before the 'choice' of euthanasia is similarly forced on individuals. That certainly was the case in Holland where the older depressed patients were getting euthanasia rather than psychiatric care.
I especially liked the youngest person present who said , “I don’t like the euphemism, MAID. It’s euthanasia. I think my generation isn’t as stupid as the politicians think that they can candy coat a thing and eveyone won’t recognize it as euthanasia."
Personally I was thankful to be with other caring clinicians. I’ve been devastated by many suicides working in the highest risk populations. In this fentanyl crisis I’ve had several young patients overdose. Frankly I’m not sure if this wasn’t suicide given the increasingly callous disregard of the mentally ill and marginal by the privileged elite of our society. Increasingly I feel that my patients aren’t wanted. I am thankful for the Christian Medical and Dental Society because the clinicians, especially my colleagues in psychiatry, demonstrate such compassion.
We also discussed the pseudoscientific positions the increasingly aetheist authorities misuse and misrepresent science mostly to increase taxes and reduce services. There just aren't enough resources for the mentally ill, not enough acute or chronic beds and not enough psychiatrists or recovery options.
As clinicians working in the field of psychiatry in Canada most of us really feel we need spiritual solace in dark times. Being with these colleagues I remembered again that I must never forget that Jesus was a healer. I personally can solace in the Lord and comfort in the fellowship of faithful healers.
Praying with fellow psychiatrists was the highlight of my trip. Thank you Jesus.
Showing posts with label psychopharmacology. Show all posts
Showing posts with label psychopharmacology. Show all posts
Saturday, May 13, 2017
Friday, October 28, 2016
Dementia - Canadian Psychiatric Association Annual Conference 2016
I forget the names of these gentlemen but I checked and I still do a mean clock face. This was by far the best ‘academic’ presentation with far too much information for me to type down all the key points. The three brilliant and humble doctors who did the presentation really need to write a book for aging practitioners. I took a series of screen shots with my iPhone of their presentations hoping to ‘catch’ the essence of all the advances made in this area of psychiatry. Having been around a few years I’m fairly up to date with the general areas along with my own sub speciality interests. I keep abreast of traumatic brain injury and chemical brain assaults but chose to attend this lecture series because in creasing numbers of my patients are older and several are worried about dementing. I tell them that we used to say a patient didn’t have an alcohol problem unless they drank more than their physician. Today, just has addiction psychiatry has advanced with leaps and bounds rather than staggering forward I was thoroughly amazed at how much has developed in the fields of dementia. Every day there are breakthroughs with medications for rats which are indeed addressing plaques and making them more capable of mazes. We’re on the cusp of real human breakthroughs with already many psychological, sociological and biological approaches to something that was once thought to be ‘natural’ but now is more and more known to be more complex. I will find the program and list the names of these gentleman. They really were impressive. I hope the slides give some inkling of this. I captured those bits that I wanted to remember personally and share them here. There was a whole wealth of material. Great slides, great topics, great presentations and incredible research. Thank you so much.
Friday, February 22, 2013
Rate My Doctor
I was delighted to hear that Dr. Shane, one of the finest forensic psychiatrists in Canada, was working to limit the damage done by the Rate Your Doctor organization. As a forensic psychiatrist he is not supposed to be popular. I totally relate to him.
I just reviewed my rate my doctor site. I was mr popularity in school. I'm a psychiatrist and an addictionist. I've reported pedophiles who have had hundreds of victims. I've notified Transport Canada that their pilot is smoking crack or marijuana. A lot of my work is done on behalf of third parties where the person I'm seeing is being assessed for dangerous ness to society or whether they are a risk to others in the workplace. I'm a methadone doctor and I have had my prescriptions forged and have on several occasions discharged patients from the methadone program for illegal abuse of methadone or breaches of the protocols of the methadone program that require the physician to terminate the person's care.
I have been asked by the police to treat people for bestiality. Routinely I'm asked to sign forms for people in which they are lying and wanting me to lie on their behalf to get money falsely from insurance companies or the government. I say no and they hate me.
When I reviewed complaints I'd received 90% were because I'd 'diagnosed' a person as having a drug addicton or alcoholism and the person was being required to see me because of domestic violence or workplace safety issues or harm to children.
I am referred patients by doctors and commonly the doctor referring the patient doesn't advise me or may not know the patients history. I have refused to see several men because they tried to conceal from me their history of rape and violence against women. I have found out this information from collateral sources. I have refused to see them because I have a female assistant who I will not put at risk. I might have seen them if they had been honest with me. I refused to see a Nazi once. He was very threatening. My windows were shot out. I've changed my phone numbers on several occasions and I've lost a staff member because of the venomous rage poured out at her by a patient blacklisted by most psychiatrists for their damage to property in the office.
My own life has been threatened on many occasions simply because my correct and truthful assessment has resulted in a person losing their income because of dangerous drug addiction, because they were hearing voices telling them to kill their boss and I am required by law to report this to the person they are threatening, that they were under control of spirits that wanted them to violate children and I am required by law to report this to child protection service. When called by the RCMP regarding whether threatening and dangerous persons should be issued a firearms license I have had that person turn up at my office threatening me. One person sent to by police after an arson attempt tried to pour gas on me and set me on fire. The police accepted the person needed to be restrained.
A patient brought a gun to an interview demanding I give them valium.
I was a supervisor in the dangerously insane ward of the asylum. I did see patients in jail. I was a supervisor in the psychiatric emergency. I have been a supervisor in a detox unit. i have many times had to say no to people who felt entitled to services which they were not and they were not willing or could not pay for those services. I have had patients come to my office demanding an MRI saying they need one and their stupid gp won't give them one and if I don't do it they're make me wish I had. They want the MRI for free because they're involved in some litigation and hope that the MRI will help them get more money. However they don't meet the 'criteria' for MRI .
I have always worked in the areas of greatest need. When I was a country family physician and northern flyin doctor I was much loved and appreciated. When I was a psychoanalytic psychotherapist I was highly regarded. When I began working in areas where I was required by law to serve the state and the client or have to consider the rights of children as opposed to parents and doing occupational psychiatry where the issues of safety sensitive factors employment arise, suddenly I've got this filth on rate your doctor.
When I diagnose alcoholism the pilot is required to enter a treatment program. Their disease is so severe that they want to 'kill the messenger'. They are putting their co workers and others not to mention millions of dollars of company property at risk and they are very angry at everyone whose job it is to think of more than just them but consider the life of others.
There are 'feel good' psychiatrists. They are junior psychiatrists and they rarely have the responsibility for major decisions outside of the individual. They can remain 'popular'. They are not Forensic Psychaitrists. They are not Occupational Psychiatrists. They are not Addiction Psychiatrists. They are not Emergency Psychiatrists or Psychiatrists that work in the Asylum. They never say 'no' and their patients love them. I sometimes have the unhappy task of treating the patients of these doctors who have left their patients grossly addicted to a variety of medications that the patients are very angry to be having to stop when the 'good' doctor gave them this and they can't understand why he won't see them or why he can't prescribe to them anymore. Many of these 'good doctors' have lost their 'prescribing' priviledges. Not Ironically a couple of these psychiatrsts are called as the very best psychiatrists and I could just throttle them for the mess they made of their poor patients which we in addiction psychiatry are left to clean up.
I have one patient who is still angry with me because I stopped her from killing herself. She insists that if I didn't resuscitate her God would have saved her baby from dying. There's no reason outside her psychotic thinking to believe her death would have revived a dead baby but she wanted to try and I interfered with that. I know one schizophrenic patient that believes anyone who is treating him "nice' is just preparing to kill him. I have to be extremely 'neutral' with him. No medication has altered his underlying paranoia but he's not been chronically suicidal in my care.
I do use 'story telling' as a therapeutic tool. I do cognitive behavioural and supportive therapy. I do not let people venomously 'vent' about their ex-husbands or ex wives in my office. This is not 'good therapy'. It's highly lucrative but it only reinforces the injury and re traumatises the patient.
I'm not being paid to passively listen to patients. I'm first and foremost a medical psychaitric diagnostician. I have to be sure a patient doesn't have symptosn of anxiety or depression because of an undiagnosed cancer, brain tumor, thyroid disorder, or metabolic problem. In a therapeutic assessment I'm informing patients as I go along often answering questions and correcting misinformation they increasing come baggaged with by reading fear mongering web sites which are selling a diagnosis or treatment.
I have far more effective 'tools' for helping people than passive listening. I have done years of training in active 'listening' therapies but there are few who are specifically suited for these types of therapy. Less that 10 % of patient's referred to psychiatrists are appropriate for anything like the televison psychiatry models of therapy. Further the research says those types of therapy work best where patients are paying for that kind of care. Hence psychoanalysis is no longer covered by health care funding insurance programs. I am specifically trained in 'change' therapy. As an addiction specialist I'm trained in motivational therapy which implies that the person will 'change'. The state pays for psychiatrists to help people change for the better, not to make them feel good sick. The health care system isn't in place to perpetuate disease. (At least it's not supposed to be)
My obese patients want to 'talk' about their problems but are very angry when I say after a couple of sessions or so , "If you're not willing to do some thing about your problem then there's nothing further I can do". Based on a motivational assessment they aren't even in the 'contemplation' phase and are best advised to come back in 6 months to review what they're willing to do about their problem. All the 'life style' disease problems don't get better by having patients go on and on about 'why' they drink, gamble, over eat, shop, hoard, live on pornography sites. These people want to collude with you and talk about thier problems as a means to maintain their problems without actually doing anything about their problems. As a result of research findings we're not supposed to see these people and perpetuate their illness by enabling. They are angry because they get tremendous 'secondary gain' by seeing top specialists and showing that another doctor 'failed' to help them because their addiction is a really sick disease. It's considered a waste of tax payer money for specialists to persist in therapy where the patient only talks about change but doesn't make any actual change.
A large part of my therapy for some patients is 'educational' as is the case with all 'cognitive behavioural therapy'. Many of my patients however are referred because of behavioural problems.
Only 20 % of my present practice are relatively highly functional individuals with 'neurotic' concerns. When I had a psychotherapy practice this was about 80% of my patients. My present practice for the last 15 years has focused more on trauma and addiction: head injury, ptsd, personality disorder, and major medical illness. Most psychiatrists exclude personaliy disorder and addiction and head injury from their practice.
Because I've worked in areas of greatest need I've always had very sick patients as well as less sick patients but more I've had a higher per centage of really sick patients. Many of my patients have major medical and neurological illness. They are not likely to return to work but it is hoped that they can have a better health care outcome. Often there are a dozen other specialists involved in the care of these complex patients. No psychiatrist in the "business" of medicine would touch these patients because they are extremely costly, timely and sick. They're generally very unhappy with life and their medical care in general, frankly because they have had horrible events happen to them . As a psychiatrist I can't offer them a new life, or millions of compensation and often all I'm doing is trying to provide sometimes only 'palliative' care. Smart and popular psychiatrists send these patients back to gps, avoid them like the plague, and won't see them more than once for a consult. Dozens of my patients have been rejected dozens and dozens of times by 'cherry picking' psychiatrists. Sometimes like me, other psychiatrists are just overburdened and may not be able to take on another highly disturbed patient.
I have to move my patients around so that my waiting room isn't a nightmare of trauma for the patients. I don't want my active crack using patient to come before or after the lady I'm seeing for grief after losing her baby. I try to avoid having my rape patients sit next to the sex offenders I see. I have a lot of difficulty managing my booking schedule and it's a real hard time for new staff who sometimes wil book three severe borderline personality disorders in a row and wonder why I look like vampires have sucked my blood at the end of the day. I can't see two grieving patients back to back and I don't like seeing more than one manic in any day. I can see schizophrenics one after another. There's a reason for that. Most active addicts can not be seen for more than 15 minutes though for special reasons you may have to see them for an hour. That's usually far too stressful for them. The same goes with adolescents and people with early dementia. I can only do one family, group or couple in a day usually because the intensity of the complexity is so draining. Emergencies are always screwing up my schedule. Scheduling my office is like booking an operating theatre. It's a speciality in itself. Despite notices patients often arrive with reams of paper work and cavalierly 'expect' doctors to just get this done by a deadline arbitrarily set by someone who usually doesn't know anything about medicine. My schedule is booked 6 months in a advance. Now where is there going to be 'time' for this 'urgent' report thatn's never properly funded to be done. Patients get moved to accommodate emergencies. So every patient often thinks their particular 'need' (never want) is an 'emergency' and want you to just cancel or move all the other patients to accomodate them. Sometimes we don't leave the office till 8 or 9 pm and often on weekends I'm working.
Because I do truama I'm commonly having to do medical legal reports and suddenly because judges (who scheduling problems make mine look trivial ) free up courts, I'm scrambling to have a report done and to see a patient so that this can all be available for a court date that moved sometimes months ahead. I'm a treating clinician and as such I have to be willing to provide these reports if I am to be of help to my patients. I have much more control over independent medical examinations because I can simply not book these. They pay much more than regular psychiatry and most of my colleagues are doing these so they can continue to do the 'publicly funded' psychiatry. More and more psychiatrists are simply not doing 'public funded' psychiatry but rather working in administration, on salary or doing private work for companies and insurance. Private psychiatry has high overhead, no benefits, no pension, no cars, no lunches, no fixed hours, no overtime. My colleagues in 'salaried' positions are rich and luxurious in their slower paced much more highly rewarded positions often far from the maddening crowds.
There's no money where the most angry patients live and the risks are increasing every day as the cost of the complaint process sky rockets because of all the "time loss" for private clinicians. When a patient complained I wouldn't see them that day, I lost a full day of work, having to cancel patients and re book them so that I could accomodate this 'bully' who wanted to jump the queue and thought by threatening my secretary they could. When I reported staff office theft I had to cancel an afternoon of patients to meet with the police and go over all the damage this irate and violent person had caused.
Everyone likes to provide one time 'consults'. The doctors who do this are popular with patients and commonly disliked vehemently by family physicians who want someone whose going to share the burden. Familiarity breeds contempt. It's really easy to see a person, get in and get out and hope to never see the person again. A number of psychiatrists specialize in this approach. This is essential in other areas of medicine but the work of psychiatry is in the ongoing and chronic care and the 'acute management' of sick patients. The government expects the health care teams to take care of these patients and they do but more often than not the patients don't want this often 'factory' type care. They want to see a psychiatrist and not a counsellor with only 2 years of training and rarely the appropriate supervision. The psychiatrists in the teams rarely spend any real time actually meeting and talking to patients. They adjust medications maybe every 6 months. When I worked in mental health teams only a small portion of my time on salary was devoted to direct patient care. The majority of times I was going to committtee meetings, meeting with other staff, reviewing reports, making phone calls, doing lunch.
I talk to patients. I listen to patients. I am known by patients. I'm an open book. Most of the patients who chose to see me and want to see me want to 'change' and want more than a band aid. Many of my patients come in at a particularly low spot in their lives and leave restored. I joke about my practice saying "I overhaul ferraris or sometimes just tune up ferrari's:. The people I choose to work with are usually survivors or fighters. So often I feel priviledged to be a part of their journeys.
The majority of my colleagues who are practicing frontline clinical psychiatry are facing all the same systemic problems as I am. I see the addiction doctors and the occupational pscyhiatrists and forensic pscyhiatrists are often faced with similiar complaints as I have. I admire their work and feel sorry that so many of the people who I see doing a really tough job are the ones getting it in the neck becasue they're there. I don't respect those who are hiding somewhere far from the patients, smiling. I may envy them at times but I don't respect them. I also know I have some of the most amazing colleagues and some of those in other areas of subspecialization in psychiatry are my true heros. A couple of my favourite women psychiatrists are working all day long just like me but with injured children and a fundamental lack of resources in the community.
5 million Canadians can't find a family physician, 1 in 5 and of the people who need a psychiatrist maybe 1 in 10 at most actually get to see one once and one in a hundred actually get to see someone who will see them regularly. 20 years ago I could refer a patient to a colleague and they'd see that patient for consultation that week. Today I wait 2 years to get a patient into a pain clinic, 6 months for an MRI, a year to see a subspecialist neurologist, and thats just some of the wait list problems constipating the system and making all the patients who are often getting sicker and sicker while they wait incredibly angry. I don't blame them but it's not my fault personally that someone other than front line workers are getting the big bucks of health care. Whenever I hear of millions or billions of dollars going to health care I think of fat cats in committee meetings discussing how many 'meetings' they're going to have to discuss how they're going to spend the money. I don't see the resources translating into services that make my or my patients lives easier.
Many of my patients come to me because I respect their spiritual traditions so ironically for an overtly Christian psychiatrist I have a fair slice of patients from every other religion in the world as well as agnostics and atheists. I love that the atheists tell me that they like that they know where I stand. Freud was very Jewish. Jung was spiritualist. My Moslem patients say they want someone who has a faith and wont' disparage theres. My buddhist and hindu patients like that I support their mediation. Dozens of patients over the years have told me that they were discriminated against for their faith and that psychiatrists belittled their religion in countless ways they probably weren't even aware they were doing.
Patients are referred to me. Over the years I've accepted more patients from certain family physicians whose work I've admired. I am not accountable for the tremendous shortage of psychiatrists. I am not required to see all patients referred to me and turn away a dozen referrals a week because I'm overbooked or because the patient doesn't 'fit' my practice. My assistant tries to communicate with the receptionists in the gps office. Many referrals come from walk in clinics where receptionist turn over and many doctors results in my assistants responses not getting passed on. I am not required to communicate in this way. I am only responsible for patients once I've actually seen them. I am not required to see a person more than once for assessment.
If I choose to provide care I do so based on what is indicated for the particular condition. Many patients want them to see me daily, 2-3 times a week, weekly. I used to see patients 2 x a week and weekly. In response to the shortage and because there are no psychiatric resources I've reduced the frequency I see my patients to what isn't ideal but remains marginally okay. I't's much easier to see a few patient frequently or a lot of patients for assessments. It's very hard to see a lot of patients at 2 week, one, three, and six month intervals in terms of scheduling. I have patients coming back to see me who I first saw 25 years ago. What they had then was 'cured' but what they have now has come on with age and is a different kettle of fish. I try to see people I've seen before a s priority. I've seen thousands of patients over the years so there's more and more difficulty getting people in when they return or when the need to be seen.
Walk in clinics are a very mixed bag. 20 years ago I used to have referrals from a half dozen physicians who I communicated regularly with and who knew me and my work and didn't send patients to me that they hadn't already thoroughly screened. This is not the cases with walk in clinics. Commonly today I see patients who were seen by several psychiatrists that year or just got out of hospital and the referring family doctor doesnt' know this and hasn't communicated it. I am deeply saddened by how little walkin clinic doctors know their patients and then I know many patients are 'doctor shopping' and 'specialist shopping' and their's no system tracking patients to see whose doing this. One patient I knew was seeing three psychiatrists and I only learned when I wasn't paid for their visits to me, something I only found out a month later, having accomodated their 'emergency'.
I have been working without any of the resources I was promised in my training for nearly a decade. I am routinely handling emergencies in the office because there are no resources in the community. I am treating people who once were locked up for life without any of the resources they were promised when their hospital was closed. I had several head injured patients I was seeing every three months then had to see monthly and discuss weekly because the government closed their clubhouses and these poor tragic individuals were left in their rooms all day. Naturally their psychosis got work and their angry outbursts increased.
No one notifies me months in advance that they're going to suicide. When I had a psychotherapy practice like most private psychologists I was always on time and always on top of my schedule. If a patient had problems I could send them to the hospital and they got good psychiatric care. A few months back I witnessed my patient jump in front of a bus while my assistant tackled them to save their life and not have bus driver and passengers traumatized. I stopped my practice and spent an hour with patient the ambulance and finally got the patient to the hospital where they were discharged an hour later. So without any 'back up' the family physician and moved our schedules and patients around to see this incredibly sad and highly suicidal man several times a week until he was over his crisis. Office practice was never meant to serve this purpose but there are no hospital beds and none on the horizon.
The hospital emergency used to have a ward where psychiatric patients could stay a week, then if they needed longer they had a ward where they could stay a month and then if they needed longer they could go to a hospital where they could stay for 6 months or years. No body had figured out that all of this has gone and the money has been spent on 'planning' , 'administration' , 'talking' and 'politics' and 'ideas' and 'consultants' and 'business consultants'' and a whole lot of other things but the fact is there's no money and countless patients in dire need.
Some days my office is busier than a psychiatric emergency. Other days I think I'm back at the asylum. I start my day at 7 am. I'm required to review my emails. I've got a hundred a day. Most of it is spam and the government won't pass the appropriate legislation to stop these 'business bullies'. I am in direct patient contact often 10 to 12 hours a day. Some days I see 10 or 12 patients while others I see 50 or more. I get dozens of phone calls a day and dozens of f axes and dozens of lab work and other records I have to review. I rarely get lunch and drink coffee always on the run. I feel guilty but still take bathroom breaks. Sometimes I feel like not coming out of the cubicle. I routinely cancel lunches and miss all manner of engagements and have cancelled vacations many times to accomodate work demands. I have many colleagues who do far more than I do in this regard and there are all kinds of 'platitutes' out there about not working so hard but never do those spouting platitudes help with the heavy lifting or late night shifts.
When a person misses an appointment and doesn't notify us in 24 hours those dozens of people on the emergency wait list can't be called. Those others who are waiting six months to see a psychiatrist in the lower main land can't be seen earlier.
A lot of people sent to psychiatrists are incredibly angry long before the time they get to see us. This wasn't the case 25 years ago. Rarely was I referred an 'angry' person. Most of my patients were 'sad' or anxious. Now all the sad people seem to be creamed away by counsellors and psychologists whereas the angry and the angry/depressed/anxious are sent to us. My obstetrician colleague says the same. He's not had an easy delivery in years. Like us his fee schedule hasn't changed and the amount of time he has for a patient hasn't been adjusted to deal with the aging population and greater risk.
The government has been cutting my income since I started practice. I made the most money I ever made in my life working as a general practitioner in my first job. It's been down hill financially ever since. The government says they're going to cut doctors incomes again.
So I try not to read rate your doctor. I wouldn't recommend for anyone to be a specialist clinician in Vancouver today. I am really thankful for men of Dr. Shane's caliber who take the time to address the problem.
I see that there is a Rate My Judge site in the US but not in Canada. I really wonder if it's a good thing to have a criminal popularity poll against judges. I know I'm terrified when I see pedophiles and violent people and psychopaths and sociopaths. I'm afraid to do the right thing because I don't want to face the abuse that comes from those people who want to fly planes stoned, work drunk, beat up their wives, have sex with their children. 99% of my patients are fine human beings. I know it's their 'sickness' but that doesn't necessarily limit the damage they can do. Rate your doctor like rate your judge strikes me as likely to appeal most to people who are looking for a place to put their anger and carry out vendettas.
I noticed though that many people did rate my work positively and thanked me for my care. I am humbled by that and very thankful indeed. It's the highest praise when patients take the time to share the positive. I realize I personally must make a greater effort to be thankful to all those I often take for granted because I 'expect' them to do their job. I know I too tend to 'blame' the customs officer for the delay when the fact is he's there and a half dozen others didn't make their shift and they not him account for the back up.
I am more likely to be annoyed by the person who isn't doing their job according to my expectations too without realizing that my expectations of what they are supposed to be doing is not what their boss or the governnment or administration is telling that person to do. It was said that a paediatrician has 90 minutes of examinations and things to do with a child before they actually see the child and hear the child's complaint for the booked 15 minute appointment. Everyday I have a new and more absurd and utterly ridiculous demand put on me by some one who may never have seen a patient or have a clue about what a psychiatrist does. This is increasingly common with insurance companies and employers.
Patients get angry about confidentiality but they have signed away that confidentiality to their employer or to their insurer and if their insurer is with their employer I'm required by law to share my records 'regardless'. I'm now required by law to keep detailed records and produce those records for the courts as well. It is against the law for me to not 'lie' for patients yet I've been approached hundreds of times by patients demanding and expecting me to do just that.
Just as I teach my patients getting over major trauma or cancer or life threatening events to focus on the positives I have to do that myself.
Thank you all who have thanked me. I really appreciate it. And I'm sorry to those who I've somehow offended because I lacked the skill to serve you better despite the fact that I probably was not what you wanted. Somehow it's a shame the system results in such mismatches or it's just sad that people can't have what they want all the time.
I just reviewed my rate my doctor site. I was mr popularity in school. I'm a psychiatrist and an addictionist. I've reported pedophiles who have had hundreds of victims. I've notified Transport Canada that their pilot is smoking crack or marijuana. A lot of my work is done on behalf of third parties where the person I'm seeing is being assessed for dangerous ness to society or whether they are a risk to others in the workplace. I'm a methadone doctor and I have had my prescriptions forged and have on several occasions discharged patients from the methadone program for illegal abuse of methadone or breaches of the protocols of the methadone program that require the physician to terminate the person's care.
I have been asked by the police to treat people for bestiality. Routinely I'm asked to sign forms for people in which they are lying and wanting me to lie on their behalf to get money falsely from insurance companies or the government. I say no and they hate me.
When I reviewed complaints I'd received 90% were because I'd 'diagnosed' a person as having a drug addicton or alcoholism and the person was being required to see me because of domestic violence or workplace safety issues or harm to children.
I am referred patients by doctors and commonly the doctor referring the patient doesn't advise me or may not know the patients history. I have refused to see several men because they tried to conceal from me their history of rape and violence against women. I have found out this information from collateral sources. I have refused to see them because I have a female assistant who I will not put at risk. I might have seen them if they had been honest with me. I refused to see a Nazi once. He was very threatening. My windows were shot out. I've changed my phone numbers on several occasions and I've lost a staff member because of the venomous rage poured out at her by a patient blacklisted by most psychiatrists for their damage to property in the office.
My own life has been threatened on many occasions simply because my correct and truthful assessment has resulted in a person losing their income because of dangerous drug addiction, because they were hearing voices telling them to kill their boss and I am required by law to report this to the person they are threatening, that they were under control of spirits that wanted them to violate children and I am required by law to report this to child protection service. When called by the RCMP regarding whether threatening and dangerous persons should be issued a firearms license I have had that person turn up at my office threatening me. One person sent to by police after an arson attempt tried to pour gas on me and set me on fire. The police accepted the person needed to be restrained.
A patient brought a gun to an interview demanding I give them valium.
I was a supervisor in the dangerously insane ward of the asylum. I did see patients in jail. I was a supervisor in the psychiatric emergency. I have been a supervisor in a detox unit. i have many times had to say no to people who felt entitled to services which they were not and they were not willing or could not pay for those services. I have had patients come to my office demanding an MRI saying they need one and their stupid gp won't give them one and if I don't do it they're make me wish I had. They want the MRI for free because they're involved in some litigation and hope that the MRI will help them get more money. However they don't meet the 'criteria' for MRI .
I have always worked in the areas of greatest need. When I was a country family physician and northern flyin doctor I was much loved and appreciated. When I was a psychoanalytic psychotherapist I was highly regarded. When I began working in areas where I was required by law to serve the state and the client or have to consider the rights of children as opposed to parents and doing occupational psychiatry where the issues of safety sensitive factors employment arise, suddenly I've got this filth on rate your doctor.
When I diagnose alcoholism the pilot is required to enter a treatment program. Their disease is so severe that they want to 'kill the messenger'. They are putting their co workers and others not to mention millions of dollars of company property at risk and they are very angry at everyone whose job it is to think of more than just them but consider the life of others.
There are 'feel good' psychiatrists. They are junior psychiatrists and they rarely have the responsibility for major decisions outside of the individual. They can remain 'popular'. They are not Forensic Psychaitrists. They are not Occupational Psychiatrists. They are not Addiction Psychiatrists. They are not Emergency Psychiatrists or Psychiatrists that work in the Asylum. They never say 'no' and their patients love them. I sometimes have the unhappy task of treating the patients of these doctors who have left their patients grossly addicted to a variety of medications that the patients are very angry to be having to stop when the 'good' doctor gave them this and they can't understand why he won't see them or why he can't prescribe to them anymore. Many of these 'good doctors' have lost their 'prescribing' priviledges. Not Ironically a couple of these psychiatrsts are called as the very best psychiatrists and I could just throttle them for the mess they made of their poor patients which we in addiction psychiatry are left to clean up.
I have one patient who is still angry with me because I stopped her from killing herself. She insists that if I didn't resuscitate her God would have saved her baby from dying. There's no reason outside her psychotic thinking to believe her death would have revived a dead baby but she wanted to try and I interfered with that. I know one schizophrenic patient that believes anyone who is treating him "nice' is just preparing to kill him. I have to be extremely 'neutral' with him. No medication has altered his underlying paranoia but he's not been chronically suicidal in my care.
I do use 'story telling' as a therapeutic tool. I do cognitive behavioural and supportive therapy. I do not let people venomously 'vent' about their ex-husbands or ex wives in my office. This is not 'good therapy'. It's highly lucrative but it only reinforces the injury and re traumatises the patient.
I'm not being paid to passively listen to patients. I'm first and foremost a medical psychaitric diagnostician. I have to be sure a patient doesn't have symptosn of anxiety or depression because of an undiagnosed cancer, brain tumor, thyroid disorder, or metabolic problem. In a therapeutic assessment I'm informing patients as I go along often answering questions and correcting misinformation they increasing come baggaged with by reading fear mongering web sites which are selling a diagnosis or treatment.
I have far more effective 'tools' for helping people than passive listening. I have done years of training in active 'listening' therapies but there are few who are specifically suited for these types of therapy. Less that 10 % of patient's referred to psychiatrists are appropriate for anything like the televison psychiatry models of therapy. Further the research says those types of therapy work best where patients are paying for that kind of care. Hence psychoanalysis is no longer covered by health care funding insurance programs. I am specifically trained in 'change' therapy. As an addiction specialist I'm trained in motivational therapy which implies that the person will 'change'. The state pays for psychiatrists to help people change for the better, not to make them feel good sick. The health care system isn't in place to perpetuate disease. (At least it's not supposed to be)
My obese patients want to 'talk' about their problems but are very angry when I say after a couple of sessions or so , "If you're not willing to do some thing about your problem then there's nothing further I can do". Based on a motivational assessment they aren't even in the 'contemplation' phase and are best advised to come back in 6 months to review what they're willing to do about their problem. All the 'life style' disease problems don't get better by having patients go on and on about 'why' they drink, gamble, over eat, shop, hoard, live on pornography sites. These people want to collude with you and talk about thier problems as a means to maintain their problems without actually doing anything about their problems. As a result of research findings we're not supposed to see these people and perpetuate their illness by enabling. They are angry because they get tremendous 'secondary gain' by seeing top specialists and showing that another doctor 'failed' to help them because their addiction is a really sick disease. It's considered a waste of tax payer money for specialists to persist in therapy where the patient only talks about change but doesn't make any actual change.
A large part of my therapy for some patients is 'educational' as is the case with all 'cognitive behavioural therapy'. Many of my patients however are referred because of behavioural problems.
Only 20 % of my present practice are relatively highly functional individuals with 'neurotic' concerns. When I had a psychotherapy practice this was about 80% of my patients. My present practice for the last 15 years has focused more on trauma and addiction: head injury, ptsd, personality disorder, and major medical illness. Most psychiatrists exclude personaliy disorder and addiction and head injury from their practice.
Because I've worked in areas of greatest need I've always had very sick patients as well as less sick patients but more I've had a higher per centage of really sick patients. Many of my patients have major medical and neurological illness. They are not likely to return to work but it is hoped that they can have a better health care outcome. Often there are a dozen other specialists involved in the care of these complex patients. No psychiatrist in the "business" of medicine would touch these patients because they are extremely costly, timely and sick. They're generally very unhappy with life and their medical care in general, frankly because they have had horrible events happen to them . As a psychiatrist I can't offer them a new life, or millions of compensation and often all I'm doing is trying to provide sometimes only 'palliative' care. Smart and popular psychiatrists send these patients back to gps, avoid them like the plague, and won't see them more than once for a consult. Dozens of my patients have been rejected dozens and dozens of times by 'cherry picking' psychiatrists. Sometimes like me, other psychiatrists are just overburdened and may not be able to take on another highly disturbed patient.
I have to move my patients around so that my waiting room isn't a nightmare of trauma for the patients. I don't want my active crack using patient to come before or after the lady I'm seeing for grief after losing her baby. I try to avoid having my rape patients sit next to the sex offenders I see. I have a lot of difficulty managing my booking schedule and it's a real hard time for new staff who sometimes wil book three severe borderline personality disorders in a row and wonder why I look like vampires have sucked my blood at the end of the day. I can't see two grieving patients back to back and I don't like seeing more than one manic in any day. I can see schizophrenics one after another. There's a reason for that. Most active addicts can not be seen for more than 15 minutes though for special reasons you may have to see them for an hour. That's usually far too stressful for them. The same goes with adolescents and people with early dementia. I can only do one family, group or couple in a day usually because the intensity of the complexity is so draining. Emergencies are always screwing up my schedule. Scheduling my office is like booking an operating theatre. It's a speciality in itself. Despite notices patients often arrive with reams of paper work and cavalierly 'expect' doctors to just get this done by a deadline arbitrarily set by someone who usually doesn't know anything about medicine. My schedule is booked 6 months in a advance. Now where is there going to be 'time' for this 'urgent' report thatn's never properly funded to be done. Patients get moved to accommodate emergencies. So every patient often thinks their particular 'need' (never want) is an 'emergency' and want you to just cancel or move all the other patients to accomodate them. Sometimes we don't leave the office till 8 or 9 pm and often on weekends I'm working.
Because I do truama I'm commonly having to do medical legal reports and suddenly because judges (who scheduling problems make mine look trivial ) free up courts, I'm scrambling to have a report done and to see a patient so that this can all be available for a court date that moved sometimes months ahead. I'm a treating clinician and as such I have to be willing to provide these reports if I am to be of help to my patients. I have much more control over independent medical examinations because I can simply not book these. They pay much more than regular psychiatry and most of my colleagues are doing these so they can continue to do the 'publicly funded' psychiatry. More and more psychiatrists are simply not doing 'public funded' psychiatry but rather working in administration, on salary or doing private work for companies and insurance. Private psychiatry has high overhead, no benefits, no pension, no cars, no lunches, no fixed hours, no overtime. My colleagues in 'salaried' positions are rich and luxurious in their slower paced much more highly rewarded positions often far from the maddening crowds.
There's no money where the most angry patients live and the risks are increasing every day as the cost of the complaint process sky rockets because of all the "time loss" for private clinicians. When a patient complained I wouldn't see them that day, I lost a full day of work, having to cancel patients and re book them so that I could accomodate this 'bully' who wanted to jump the queue and thought by threatening my secretary they could. When I reported staff office theft I had to cancel an afternoon of patients to meet with the police and go over all the damage this irate and violent person had caused.
Everyone likes to provide one time 'consults'. The doctors who do this are popular with patients and commonly disliked vehemently by family physicians who want someone whose going to share the burden. Familiarity breeds contempt. It's really easy to see a person, get in and get out and hope to never see the person again. A number of psychiatrists specialize in this approach. This is essential in other areas of medicine but the work of psychiatry is in the ongoing and chronic care and the 'acute management' of sick patients. The government expects the health care teams to take care of these patients and they do but more often than not the patients don't want this often 'factory' type care. They want to see a psychiatrist and not a counsellor with only 2 years of training and rarely the appropriate supervision. The psychiatrists in the teams rarely spend any real time actually meeting and talking to patients. They adjust medications maybe every 6 months. When I worked in mental health teams only a small portion of my time on salary was devoted to direct patient care. The majority of times I was going to committtee meetings, meeting with other staff, reviewing reports, making phone calls, doing lunch.
I talk to patients. I listen to patients. I am known by patients. I'm an open book. Most of the patients who chose to see me and want to see me want to 'change' and want more than a band aid. Many of my patients come in at a particularly low spot in their lives and leave restored. I joke about my practice saying "I overhaul ferraris or sometimes just tune up ferrari's:. The people I choose to work with are usually survivors or fighters. So often I feel priviledged to be a part of their journeys.
The majority of my colleagues who are practicing frontline clinical psychiatry are facing all the same systemic problems as I am. I see the addiction doctors and the occupational pscyhiatrists and forensic pscyhiatrists are often faced with similiar complaints as I have. I admire their work and feel sorry that so many of the people who I see doing a really tough job are the ones getting it in the neck becasue they're there. I don't respect those who are hiding somewhere far from the patients, smiling. I may envy them at times but I don't respect them. I also know I have some of the most amazing colleagues and some of those in other areas of subspecialization in psychiatry are my true heros. A couple of my favourite women psychiatrists are working all day long just like me but with injured children and a fundamental lack of resources in the community.
5 million Canadians can't find a family physician, 1 in 5 and of the people who need a psychiatrist maybe 1 in 10 at most actually get to see one once and one in a hundred actually get to see someone who will see them regularly. 20 years ago I could refer a patient to a colleague and they'd see that patient for consultation that week. Today I wait 2 years to get a patient into a pain clinic, 6 months for an MRI, a year to see a subspecialist neurologist, and thats just some of the wait list problems constipating the system and making all the patients who are often getting sicker and sicker while they wait incredibly angry. I don't blame them but it's not my fault personally that someone other than front line workers are getting the big bucks of health care. Whenever I hear of millions or billions of dollars going to health care I think of fat cats in committee meetings discussing how many 'meetings' they're going to have to discuss how they're going to spend the money. I don't see the resources translating into services that make my or my patients lives easier.
Many of my patients come to me because I respect their spiritual traditions so ironically for an overtly Christian psychiatrist I have a fair slice of patients from every other religion in the world as well as agnostics and atheists. I love that the atheists tell me that they like that they know where I stand. Freud was very Jewish. Jung was spiritualist. My Moslem patients say they want someone who has a faith and wont' disparage theres. My buddhist and hindu patients like that I support their mediation. Dozens of patients over the years have told me that they were discriminated against for their faith and that psychiatrists belittled their religion in countless ways they probably weren't even aware they were doing.
Patients are referred to me. Over the years I've accepted more patients from certain family physicians whose work I've admired. I am not accountable for the tremendous shortage of psychiatrists. I am not required to see all patients referred to me and turn away a dozen referrals a week because I'm overbooked or because the patient doesn't 'fit' my practice. My assistant tries to communicate with the receptionists in the gps office. Many referrals come from walk in clinics where receptionist turn over and many doctors results in my assistants responses not getting passed on. I am not required to communicate in this way. I am only responsible for patients once I've actually seen them. I am not required to see a person more than once for assessment.
If I choose to provide care I do so based on what is indicated for the particular condition. Many patients want them to see me daily, 2-3 times a week, weekly. I used to see patients 2 x a week and weekly. In response to the shortage and because there are no psychiatric resources I've reduced the frequency I see my patients to what isn't ideal but remains marginally okay. I't's much easier to see a few patient frequently or a lot of patients for assessments. It's very hard to see a lot of patients at 2 week, one, three, and six month intervals in terms of scheduling. I have patients coming back to see me who I first saw 25 years ago. What they had then was 'cured' but what they have now has come on with age and is a different kettle of fish. I try to see people I've seen before a s priority. I've seen thousands of patients over the years so there's more and more difficulty getting people in when they return or when the need to be seen.
Walk in clinics are a very mixed bag. 20 years ago I used to have referrals from a half dozen physicians who I communicated regularly with and who knew me and my work and didn't send patients to me that they hadn't already thoroughly screened. This is not the cases with walk in clinics. Commonly today I see patients who were seen by several psychiatrists that year or just got out of hospital and the referring family doctor doesnt' know this and hasn't communicated it. I am deeply saddened by how little walkin clinic doctors know their patients and then I know many patients are 'doctor shopping' and 'specialist shopping' and their's no system tracking patients to see whose doing this. One patient I knew was seeing three psychiatrists and I only learned when I wasn't paid for their visits to me, something I only found out a month later, having accomodated their 'emergency'.
I have been working without any of the resources I was promised in my training for nearly a decade. I am routinely handling emergencies in the office because there are no resources in the community. I am treating people who once were locked up for life without any of the resources they were promised when their hospital was closed. I had several head injured patients I was seeing every three months then had to see monthly and discuss weekly because the government closed their clubhouses and these poor tragic individuals were left in their rooms all day. Naturally their psychosis got work and their angry outbursts increased.
No one notifies me months in advance that they're going to suicide. When I had a psychotherapy practice like most private psychologists I was always on time and always on top of my schedule. If a patient had problems I could send them to the hospital and they got good psychiatric care. A few months back I witnessed my patient jump in front of a bus while my assistant tackled them to save their life and not have bus driver and passengers traumatized. I stopped my practice and spent an hour with patient the ambulance and finally got the patient to the hospital where they were discharged an hour later. So without any 'back up' the family physician and moved our schedules and patients around to see this incredibly sad and highly suicidal man several times a week until he was over his crisis. Office practice was never meant to serve this purpose but there are no hospital beds and none on the horizon.
The hospital emergency used to have a ward where psychiatric patients could stay a week, then if they needed longer they had a ward where they could stay a month and then if they needed longer they could go to a hospital where they could stay for 6 months or years. No body had figured out that all of this has gone and the money has been spent on 'planning' , 'administration' , 'talking' and 'politics' and 'ideas' and 'consultants' and 'business consultants'' and a whole lot of other things but the fact is there's no money and countless patients in dire need.
Some days my office is busier than a psychiatric emergency. Other days I think I'm back at the asylum. I start my day at 7 am. I'm required to review my emails. I've got a hundred a day. Most of it is spam and the government won't pass the appropriate legislation to stop these 'business bullies'. I am in direct patient contact often 10 to 12 hours a day. Some days I see 10 or 12 patients while others I see 50 or more. I get dozens of phone calls a day and dozens of f axes and dozens of lab work and other records I have to review. I rarely get lunch and drink coffee always on the run. I feel guilty but still take bathroom breaks. Sometimes I feel like not coming out of the cubicle. I routinely cancel lunches and miss all manner of engagements and have cancelled vacations many times to accomodate work demands. I have many colleagues who do far more than I do in this regard and there are all kinds of 'platitutes' out there about not working so hard but never do those spouting platitudes help with the heavy lifting or late night shifts.
When a person misses an appointment and doesn't notify us in 24 hours those dozens of people on the emergency wait list can't be called. Those others who are waiting six months to see a psychiatrist in the lower main land can't be seen earlier.
A lot of people sent to psychiatrists are incredibly angry long before the time they get to see us. This wasn't the case 25 years ago. Rarely was I referred an 'angry' person. Most of my patients were 'sad' or anxious. Now all the sad people seem to be creamed away by counsellors and psychologists whereas the angry and the angry/depressed/anxious are sent to us. My obstetrician colleague says the same. He's not had an easy delivery in years. Like us his fee schedule hasn't changed and the amount of time he has for a patient hasn't been adjusted to deal with the aging population and greater risk.
The government has been cutting my income since I started practice. I made the most money I ever made in my life working as a general practitioner in my first job. It's been down hill financially ever since. The government says they're going to cut doctors incomes again.
So I try not to read rate your doctor. I wouldn't recommend for anyone to be a specialist clinician in Vancouver today. I am really thankful for men of Dr. Shane's caliber who take the time to address the problem.
I see that there is a Rate My Judge site in the US but not in Canada. I really wonder if it's a good thing to have a criminal popularity poll against judges. I know I'm terrified when I see pedophiles and violent people and psychopaths and sociopaths. I'm afraid to do the right thing because I don't want to face the abuse that comes from those people who want to fly planes stoned, work drunk, beat up their wives, have sex with their children. 99% of my patients are fine human beings. I know it's their 'sickness' but that doesn't necessarily limit the damage they can do. Rate your doctor like rate your judge strikes me as likely to appeal most to people who are looking for a place to put their anger and carry out vendettas.
I noticed though that many people did rate my work positively and thanked me for my care. I am humbled by that and very thankful indeed. It's the highest praise when patients take the time to share the positive. I realize I personally must make a greater effort to be thankful to all those I often take for granted because I 'expect' them to do their job. I know I too tend to 'blame' the customs officer for the delay when the fact is he's there and a half dozen others didn't make their shift and they not him account for the back up.
I am more likely to be annoyed by the person who isn't doing their job according to my expectations too without realizing that my expectations of what they are supposed to be doing is not what their boss or the governnment or administration is telling that person to do. It was said that a paediatrician has 90 minutes of examinations and things to do with a child before they actually see the child and hear the child's complaint for the booked 15 minute appointment. Everyday I have a new and more absurd and utterly ridiculous demand put on me by some one who may never have seen a patient or have a clue about what a psychiatrist does. This is increasingly common with insurance companies and employers.
Patients get angry about confidentiality but they have signed away that confidentiality to their employer or to their insurer and if their insurer is with their employer I'm required by law to share my records 'regardless'. I'm now required by law to keep detailed records and produce those records for the courts as well. It is against the law for me to not 'lie' for patients yet I've been approached hundreds of times by patients demanding and expecting me to do just that.
Just as I teach my patients getting over major trauma or cancer or life threatening events to focus on the positives I have to do that myself.
Thank you all who have thanked me. I really appreciate it. And I'm sorry to those who I've somehow offended because I lacked the skill to serve you better despite the fact that I probably was not what you wanted. Somehow it's a shame the system results in such mismatches or it's just sad that people can't have what they want all the time.
Wednesday, May 16, 2012
Cipralex - Escitalopram
I've been prescribing Lundbeck Pharmaceutical's, Cipralex, (Escitalopram) since it first became available in the last few years. Finally it's covered by our provincial formulary.
Prozac or fluoxetine, the first of the SSRI, Serotonin Specific Reuptake Inhibitors, was truly a break through in pharmaceutical therapeutics. Prior to it's introduction the tricyclics, such as Amitriptylline, were all that was available. I remember the horrors of seeing acutely suicidal patients and beginning them on one of the tricyclics knowing that the medications had unpleasant side effects. They would have to be titrated upwards slowly because of toxicity and would take at least 6 weeks to become psychoactive. The tricyclics further had a narrow window of benefit versus danger. A small amount of medication, usually less than a week or twos supply was all that was necessary to cause cardiac arrest if taken as an overdose. If the patient didn't die they had to be admitted to an intensive care units for days to protect against lethal arrythmias.
Having faced all of those risks as a clinician I was thankful for the SSRI"s. The first generation brought rapid onset of action, with patients experiencing benefits in as little as 2 weeks though the full benefits of the medication could still take 1-2 months. The side effects were far less and each generation has resulted in a medication with fewer and fewer side effects. Finally the risk of suicide by overdose is very little and much less with later generations of SSRI.
Cipralex is the latest of the SSRI generations. It's advantage over the previous SSRI"s is it's short action. Prozac could accumulated in the system because of it's long half life, half life being the length of time it took to remove half of a compound from the system. Cipralex clears out of the system in a day or two. This is important in case there are any reactions to the medication by itself or in combination with others. In comparison consider that alcohol clears in less time and marijuana is psychoactive for 6 weeks or sometimes more.
The second generation of SSRI"s included two I found very useful and beneficial. Zoloft or sertraline was specifically used for PTSD whereas Paxil or Paroxetine was an amazing anti anxiety medication for generalized anxiety disorders and panic attacks. Zoloft continues to be used extensive as does Prozac. The difficulty with paxil was that it was most likely to cause sexual side effects, delayed ejaculation, decreased desire and erectile failure in as many as 40 per cent of patients at higher dosages. This could be counteracted first with ginkgo biloba and secondly with viagra or cialis.
Trazadone anothe second generation SSRI still tends to be used more for an interesting side effect. It's extremely good for keeping people asleep so that it can be combined with most of the other antidepressants in those people who have difficulty with insomnia, a common sympton in depression.
Celexa , or citalopram, a third generation SSRI, was extremely useful in the elderly and in treatment of patients who had other medical conditions especially a history of myocardial infarction or cardiac concerns in general. It was a surprisingly safe medication with a very 'clean' profile in its being least likely to interact negatively with medications used in other specialities. It commonly was beneficial for patients with major medical illness and post surgical depressions without having any signficant down side. Celexa is essentially the closest precurser of Cipralex.
Cipralex in contrast to Celexa, while retaining it's benefits, had specific superiority in the treatment of anxious depression, anxiety disorders with panic attacks and interestingly Obsessive Compulsive Disorder.
Clomipramine the tricyclic antidepressant was shown before Prozac to be almost essential to the treatment of OCD. High dosage of medication was commonly needed too. Whereas a person with depression or general anxiety might benefit from 10 mg of prozac , the ocd patient would often need more than 60 mg to get the full benefit. Cipralex appears almost equally beneficial for OCD but again at higher dosage that presently recommended.
Both Celexa and Cipralex have another interesting clinical significance. Of all the antidepressants I've used treating head injured patients, patient with traumatic brain injury it's been these two and wellbutrin or buproprion that my patients have literally sworn by. I think it's interesting that these cipralex has benefit in brain injured patients and OCD because these are considered more 'biological' than what can be described as the more psychological depressions that tend to respond to a wide variety of therapies. That the patients and their families see the benefit so significantly is what is most exciting.
Cipralex is a good antidepressant and really shines as a long term anti anxiety medication. It's beneficial in TBI and in OCD. It's also beneficial in patients who have mood disorder but the diagnosis is Bipolar. Because of the safety and cleaness of it's pharmaceutical proflie and relatively short half life it's also one of the safest medication that can be used with patients who use drugs or alcohol but may well not be open about this with the doctor. It's been well tried in a street clinic I work at with much benefit and no serious side effects of concern. Safety is appreciated and the pharmaceutical companies are most concerned that their medications are safe simply because they pay the costs when things go wrong.
Prozac is the only antidepressant that is said to be acceptable for the treatment of childhood depression in Canada. The research on patients whose mother was on an SSRI when they were intrauterine is now in 30 year follow up with one of the safest profiles in the history of pharmaceutical treatment.
Depression is a life threatening disease. Anxiety is a horror to live with. It's not just something that goes away. OCD is wholly disabling for some patients. Suicide is a major cause of death and medications like Cipralex are truly beneficial adjuncts to the armentarium of ways we successfully and effectively treat cases mild to severe to save patients from hospitalization.
I thank Dr. Tsung, a colleague for 'picking my brain' and causing me to think of the thousands of prescriptions I've written over the years for SSRI and how I chose which medications. I do choose the latest medication which usually is the best in the way that the newest of cars incorporates the latest science and technology in those who have not responded or only had a partial response to previously available treatments. Further I will use the latest medication in those who are well off and can afford it and have moderate to severe symptons. I was very thankful when cipralex became part of the formulary, which means it was available to all patients on disability or pensions or even welfare. It's a recognition by the decision makers of the benefit of the medication and a testimony to the pharmaceutical company to bring in a new and very beneficial product at a price where most people can afford it and governments can see the benefit of providing coverage. It makes it that much easier for clinicians.
Prozac or fluoxetine, the first of the SSRI, Serotonin Specific Reuptake Inhibitors, was truly a break through in pharmaceutical therapeutics. Prior to it's introduction the tricyclics, such as Amitriptylline, were all that was available. I remember the horrors of seeing acutely suicidal patients and beginning them on one of the tricyclics knowing that the medications had unpleasant side effects. They would have to be titrated upwards slowly because of toxicity and would take at least 6 weeks to become psychoactive. The tricyclics further had a narrow window of benefit versus danger. A small amount of medication, usually less than a week or twos supply was all that was necessary to cause cardiac arrest if taken as an overdose. If the patient didn't die they had to be admitted to an intensive care units for days to protect against lethal arrythmias.
Having faced all of those risks as a clinician I was thankful for the SSRI"s. The first generation brought rapid onset of action, with patients experiencing benefits in as little as 2 weeks though the full benefits of the medication could still take 1-2 months. The side effects were far less and each generation has resulted in a medication with fewer and fewer side effects. Finally the risk of suicide by overdose is very little and much less with later generations of SSRI.
Cipralex is the latest of the SSRI generations. It's advantage over the previous SSRI"s is it's short action. Prozac could accumulated in the system because of it's long half life, half life being the length of time it took to remove half of a compound from the system. Cipralex clears out of the system in a day or two. This is important in case there are any reactions to the medication by itself or in combination with others. In comparison consider that alcohol clears in less time and marijuana is psychoactive for 6 weeks or sometimes more.
The second generation of SSRI"s included two I found very useful and beneficial. Zoloft or sertraline was specifically used for PTSD whereas Paxil or Paroxetine was an amazing anti anxiety medication for generalized anxiety disorders and panic attacks. Zoloft continues to be used extensive as does Prozac. The difficulty with paxil was that it was most likely to cause sexual side effects, delayed ejaculation, decreased desire and erectile failure in as many as 40 per cent of patients at higher dosages. This could be counteracted first with ginkgo biloba and secondly with viagra or cialis.
Trazadone anothe second generation SSRI still tends to be used more for an interesting side effect. It's extremely good for keeping people asleep so that it can be combined with most of the other antidepressants in those people who have difficulty with insomnia, a common sympton in depression.
Celexa , or citalopram, a third generation SSRI, was extremely useful in the elderly and in treatment of patients who had other medical conditions especially a history of myocardial infarction or cardiac concerns in general. It was a surprisingly safe medication with a very 'clean' profile in its being least likely to interact negatively with medications used in other specialities. It commonly was beneficial for patients with major medical illness and post surgical depressions without having any signficant down side. Celexa is essentially the closest precurser of Cipralex.
Cipralex in contrast to Celexa, while retaining it's benefits, had specific superiority in the treatment of anxious depression, anxiety disorders with panic attacks and interestingly Obsessive Compulsive Disorder.
Clomipramine the tricyclic antidepressant was shown before Prozac to be almost essential to the treatment of OCD. High dosage of medication was commonly needed too. Whereas a person with depression or general anxiety might benefit from 10 mg of prozac , the ocd patient would often need more than 60 mg to get the full benefit. Cipralex appears almost equally beneficial for OCD but again at higher dosage that presently recommended.
Both Celexa and Cipralex have another interesting clinical significance. Of all the antidepressants I've used treating head injured patients, patient with traumatic brain injury it's been these two and wellbutrin or buproprion that my patients have literally sworn by. I think it's interesting that these cipralex has benefit in brain injured patients and OCD because these are considered more 'biological' than what can be described as the more psychological depressions that tend to respond to a wide variety of therapies. That the patients and their families see the benefit so significantly is what is most exciting.
Cipralex is a good antidepressant and really shines as a long term anti anxiety medication. It's beneficial in TBI and in OCD. It's also beneficial in patients who have mood disorder but the diagnosis is Bipolar. Because of the safety and cleaness of it's pharmaceutical proflie and relatively short half life it's also one of the safest medication that can be used with patients who use drugs or alcohol but may well not be open about this with the doctor. It's been well tried in a street clinic I work at with much benefit and no serious side effects of concern. Safety is appreciated and the pharmaceutical companies are most concerned that their medications are safe simply because they pay the costs when things go wrong.
Prozac is the only antidepressant that is said to be acceptable for the treatment of childhood depression in Canada. The research on patients whose mother was on an SSRI when they were intrauterine is now in 30 year follow up with one of the safest profiles in the history of pharmaceutical treatment.
Depression is a life threatening disease. Anxiety is a horror to live with. It's not just something that goes away. OCD is wholly disabling for some patients. Suicide is a major cause of death and medications like Cipralex are truly beneficial adjuncts to the armentarium of ways we successfully and effectively treat cases mild to severe to save patients from hospitalization.
I thank Dr. Tsung, a colleague for 'picking my brain' and causing me to think of the thousands of prescriptions I've written over the years for SSRI and how I chose which medications. I do choose the latest medication which usually is the best in the way that the newest of cars incorporates the latest science and technology in those who have not responded or only had a partial response to previously available treatments. Further I will use the latest medication in those who are well off and can afford it and have moderate to severe symptons. I was very thankful when cipralex became part of the formulary, which means it was available to all patients on disability or pensions or even welfare. It's a recognition by the decision makers of the benefit of the medication and a testimony to the pharmaceutical company to bring in a new and very beneficial product at a price where most people can afford it and governments can see the benefit of providing coverage. It makes it that much easier for clinicians.
Thursday, April 26, 2012
Buprenophine and BuTrans Patches
Last night I attended a superb dinner presenation by Dr. Owen Williamson arranged by Chris Szado, the pharmacological representative for Bu Trans. Buprenorphine is a partial agonist opioid that has been extremely successful as an alternative to methadone in select populations for addiction therapy. It's also been used for moderate pain control with less concern for addiction. .One of the main advantages of patch technology like Bu Trans is that it can't be diverted. Pills like oxycontin were being crushed and injected by heroin users but this is not the case with Bu Trans. Indeed Oxycontin , dubbed Hillybilly Heroin, has been removed and replaced by OxyNeo, the exact same drug but in a formulation that does not allow the pill to be crushed and used for injection. Oxyneo in contrast to Oxycontin turns into an insoluble gel with crushing and heating so is a breakthrough development we can all be thankful to the pharmacology company for developing.
Bu Trans advantage pharmacologically especially for pain is that it results in slow steady release through skin absorption - and less fluctuations in dosage than oral preparation. Patches can be worn for a week at a time so the whole problem of missing dosage or taking too many pills at once is simply bypassed.
Dr. Owen Williamson is an Orthopedic Surgeon from Australia who specialized in spinal surgery then became a leader in pain medicine in Australia. He'd used buprenorphine there years and had 7 years experience with the buprenophine patches before coming to Canada where he works specifically as a Pain Specialist. Canada doesn't have a subspeciality of pain medicine yet so most of us there tonight were indeed Addiction Medicine specialists who were pain specialists as a consequence of our work with addiction.
Appropriate narcotic treatment of pain doesn't lead to addicition however addicts commonly had pain and presented with pain to address their addiction issues.. Indeed many of us were there tonight to ask Dr. Williamson's advise on how best to manage pain in our addicted patients. Often despite being on methadone and having their addiction controlled with methadone patients have pain and this needs to be addressed.
After the presentation during a lovely meal provided by the excellent Market Restaurant on Georgia we had ample time to discuss not just individual clinical strategies but community medicine and community psychiatry in general.
There is extensive evidence based scientific research in clinical management of addiction and the appropriate treatment of pain yet authorities with distinctly different agendas and apparently often political short sighted personal aims commonly intervene with such old saws as the 'war on drugs'. To date the only success in that multi billion dollar tax payer kerfuffle has been the recognition of the success of the socalled 'drug courts'. These divert addicts who committ crimes to support their addiction from jails into treatment.
All the efforts to 'police borders' or invade other countries has to date only escalated drug abuse. Filling jails with addicts has also demonstrably harmed society and created more criminality. Miami Vice as a television show probably did more to make cocaine sexy to kids than act as a deterrent to drug abuse. The glamor is in the 'context' and it's easy to get into the 'glamour' as a user than a cop.
Of course it's extremely difficult to unhorse the white knights who have a license to kill, often come from elite families,and get to ride roughshod over all civil rights and human rights claiming to protect a child who is likely to learn about addiction from his school mates and family especially if his family were jailed rather than treated for addiction. . Thanks to scientific research there are studies that seriously question use of the Hollywood cowboy police chase because police chases have caused more damage, maiming and killing. Thanks to better surveillance technology today than yesterday police can save themselves car damage and collect their suspects reasonably a day later. It's equally effective today but decidedly less glamorous. Treatment of addiction today is the gold standard. The hope is for as many options in the treatment of addicition as we as doctors have in the treatment of diabetes. Buprenorphine and Bu Trans are certainly welcome addictions. My psychiatrist and addiction medicine friends in the US who have had these tools swear by them.
Dr. Gary Horvath, the Addiction Medicine specialist, whose clinic Doc Side is in Downtown Eastside Vancouver is presently using buprenorphine on selected patients where he can assure clinical safety and is having significant success.
So it was enjoyable to learn of how buprenorphine can be used alone for addiction and/or pain or how to switch a person from other narcotics to buprenorphine and how it is used for tapering people off narcotics whether they are being used for pain or addiction management. There's real advantage to the Bu Trans patch being used when people are tapering off methadone and their dose is below 40 mg a day. This assists them in going through the final withdrawal phase.
Dr. Owen Williamson is a very bright and accomplished young man who has extensive experience in this field as well as being decidedly witty. I am only giving a taste of the presentation. I took notes and am including these here, just as more of a jist. I was eating the very fine Market Restaurant food while listening too the talk so will only apologise for any mistakes or mispelling. I would indeed suggest contacting either Chris Szado with Bu Trans or Dr. Owen Williamson directly for the 'facts'. My purpose in sharing this here is to save a reminder for myself and to essentially raise consciousness about advances in the incredibly rapidly developing speciality fields of addiction and pain management.
iphone 2 finger notes on notepad while eating scrumptuous food at end of long work day
Owen D Williamson
Bu Trans advantage pharmacologically especially for pain is that it results in slow steady release through skin absorption - and less fluctuations in dosage than oral preparation. Patches can be worn for a week at a time so the whole problem of missing dosage or taking too many pills at once is simply bypassed.
Dr. Owen Williamson is an Orthopedic Surgeon from Australia who specialized in spinal surgery then became a leader in pain medicine in Australia. He'd used buprenorphine there years and had 7 years experience with the buprenophine patches before coming to Canada where he works specifically as a Pain Specialist. Canada doesn't have a subspeciality of pain medicine yet so most of us there tonight were indeed Addiction Medicine specialists who were pain specialists as a consequence of our work with addiction.
Appropriate narcotic treatment of pain doesn't lead to addicition however addicts commonly had pain and presented with pain to address their addiction issues.. Indeed many of us were there tonight to ask Dr. Williamson's advise on how best to manage pain in our addicted patients. Often despite being on methadone and having their addiction controlled with methadone patients have pain and this needs to be addressed.
After the presentation during a lovely meal provided by the excellent Market Restaurant on Georgia we had ample time to discuss not just individual clinical strategies but community medicine and community psychiatry in general.
There is extensive evidence based scientific research in clinical management of addiction and the appropriate treatment of pain yet authorities with distinctly different agendas and apparently often political short sighted personal aims commonly intervene with such old saws as the 'war on drugs'. To date the only success in that multi billion dollar tax payer kerfuffle has been the recognition of the success of the socalled 'drug courts'. These divert addicts who committ crimes to support their addiction from jails into treatment.
All the efforts to 'police borders' or invade other countries has to date only escalated drug abuse. Filling jails with addicts has also demonstrably harmed society and created more criminality. Miami Vice as a television show probably did more to make cocaine sexy to kids than act as a deterrent to drug abuse. The glamor is in the 'context' and it's easy to get into the 'glamour' as a user than a cop.
Of course it's extremely difficult to unhorse the white knights who have a license to kill, often come from elite families,and get to ride roughshod over all civil rights and human rights claiming to protect a child who is likely to learn about addiction from his school mates and family especially if his family were jailed rather than treated for addiction. . Thanks to scientific research there are studies that seriously question use of the Hollywood cowboy police chase because police chases have caused more damage, maiming and killing. Thanks to better surveillance technology today than yesterday police can save themselves car damage and collect their suspects reasonably a day later. It's equally effective today but decidedly less glamorous. Treatment of addiction today is the gold standard. The hope is for as many options in the treatment of addicition as we as doctors have in the treatment of diabetes. Buprenorphine and Bu Trans are certainly welcome addictions. My psychiatrist and addiction medicine friends in the US who have had these tools swear by them.
Dr. Gary Horvath, the Addiction Medicine specialist, whose clinic Doc Side is in Downtown Eastside Vancouver is presently using buprenorphine on selected patients where he can assure clinical safety and is having significant success.
So it was enjoyable to learn of how buprenorphine can be used alone for addiction and/or pain or how to switch a person from other narcotics to buprenorphine and how it is used for tapering people off narcotics whether they are being used for pain or addiction management. There's real advantage to the Bu Trans patch being used when people are tapering off methadone and their dose is below 40 mg a day. This assists them in going through the final withdrawal phase.
Dr. Owen Williamson is a very bright and accomplished young man who has extensive experience in this field as well as being decidedly witty. I am only giving a taste of the presentation. I took notes and am including these here, just as more of a jist. I was eating the very fine Market Restaurant food while listening too the talk so will only apologise for any mistakes or mispelling. I would indeed suggest contacting either Chris Szado with Bu Trans or Dr. Owen Williamson directly for the 'facts'. My purpose in sharing this here is to save a reminder for myself and to essentially raise consciousness about advances in the incredibly rapidly developing speciality fields of addiction and pain management.
iphone 2 finger notes on notepad while eating scrumptuous food at end of long work day
Owen D Williamson
Originally orthopedic surgery then spine surgery then public health
Melbourne 3 years later pain - biggest predictor mental health
Chronic pain and addiction
National Pain Summit yesterday
Addiction - 10%
Chronic Pain - 30%
OxyContin attraction was predictability - cost of 1 80 mg oxycontin on street same cost as 2 days heroin
67% high school students get their opioids of abuse from home
Need for use of "drug safe"1 in 5' Canadians have chronic pain
Diverters - industrial dosages of pain medicine - street value of example patients -$650,000 a year
Inquest into death of Donna Marie Bertrand
- suicide - antidepressants
- jury 32/48 recommendations related to opioids
- pharmanet - "every patient I see I get pharmanet"
BC - suboxone very good for pain and addiction
Suboxone can be used in BC if methadone contraindication
Detox and maintenance
Detox maintenance and taper
-fast
- slow
If you taper over 12 weeks twice as good as any faster regarding relapse and least relapse if taper over year
Transdermal buprenorphine - transition people from methadone to buprenorphine
Maintenance alone on heroin - Naomi study
Cochrane reviews - more relapse on buprenorphine
30% Persisting pain after trauma
Butrans - persisting pain
Max recommended dose 20 mcg/hr every 7 days
In aust dose is 40
In Europe dose is 70
Buprenorphine
U receptor partial agonist
K receptor antagonist
Chronic pain doubles risk of suicide
Buprenorphine
Binds to alpha and b globulins not albumin
Hepatic not renal metabolism
Side effects of patch
Nausea
Priorities
Don't confuse fetanyl or durogesic patch with bu-trans patches - can lead to death
Opioid induced hyperalgesia - this is done because of effect on glial cells
Allodynia - painful response to something not normally painful
Pain Medicine
- opioid rotation - webster
Meth to TDB conversion
- reduce meth to 40
- apply patch 12 hr later - 35 mcg/hr
- hospital
- nosyk b et al Addiction 2012 (ePub)
Wednesday, December 1, 2010
Suicide is an Autoimmune Disease
The title of this article is, "Suicide is an autoimmune disease". In truth I can't say for sure if 'Suicide' is a disease or the principal symptom of the underlying auto immune disease. What is imminently clear is that is an autoimmune phenomena.
It is seen in a wide variety of mental illness and mental illness associated with physical illness. Suicide has been reported with Thought Disorders like Schizophrenia, Addictive Disorders like Alcoholism, Mood Disorders, both unipolar and bipolar, personality disorders, especially borderline and sometimes in adjustment disorders.
What is clear is that it is not conceptualized as an autoimmune disease phenomena in general yet it is imminently clear that it is highly consistent with autoimmune phenomena seen in genetic and acquired immune disorder.
To this end I would propose that psychological, sociological and especially pharmacalogical therapies be developed along these lines. With respect to the latter there has been use of prednisone in the treatment of mental illness but not specifically looking at suicidal behaviour, thought and speech. Certainly the increasing variety of medications used in the treatment of autoimmune disease warrant a trial of therapy along the lines of Star D trials as adjunctive medications in relationship to suicidally as it arises in mental illness.
- Posted using BlogPress from my iPad
It is seen in a wide variety of mental illness and mental illness associated with physical illness. Suicide has been reported with Thought Disorders like Schizophrenia, Addictive Disorders like Alcoholism, Mood Disorders, both unipolar and bipolar, personality disorders, especially borderline and sometimes in adjustment disorders.
What is clear is that it is not conceptualized as an autoimmune disease phenomena in general yet it is imminently clear that it is highly consistent with autoimmune phenomena seen in genetic and acquired immune disorder.
To this end I would propose that psychological, sociological and especially pharmacalogical therapies be developed along these lines. With respect to the latter there has been use of prednisone in the treatment of mental illness but not specifically looking at suicidal behaviour, thought and speech. Certainly the increasing variety of medications used in the treatment of autoimmune disease warrant a trial of therapy along the lines of Star D trials as adjunctive medications in relationship to suicidally as it arises in mental illness.
- Posted using BlogPress from my iPad
Wednesday, April 28, 2010
Lithium Carbonate
Lithium Carbonate is a mainstay medication in psychiatry. It's been tried and proven in the treatment of Bipolar Disease.
Historically there was only one bipolar disease, that which was called Manic Depressive disorder. This was a horrible disease with Mania so severe that it could last untreated and lead to death from hyperactivity, grandiose delusional thinking and angry outbursts. Later the cyclothymic disturbance of mood swings, a very attenuated form of the classic illness was called Bipolar II.
Lithium Carbonate was and probably still is the drug of choice for Bipolar I especially the Manic episode. It's also an amazing 'preventative medication'.
The story goes that Lithium Carbonate's special capacity for modulating mood was found when it was used for heart patients as Lithium Salt instead of normal table salt, Sodium Salt. People were noted to be 'mellow' and from this 'observational' history the medication use developed.
Lithium Carbonate's pharmacological 'raison d'etre' isn't clearly known. It's thought that somehow it stabilizes membranes. Empirically it works and it works very well.
It's also relatively safe at low dosage used most commonly in the community. With increasing dosage there is increasing toxicity.
When LithiumCarbonate is started it's standard to check the blood work. Lithium can be toxic to the thyroid gland so TSH (Thyroid Stimulating Hormone) is ordered to measure baseline activity in case there is any change while on Lithium. The other organ which can be involved are the Kidneys so Creatinine is measured along with the Glomerular Filtration Rate, tests that assess the filtering function. If the Creatinine were to increase it would indicate that the filtering function of the kidneys were impaired. Sometimes an Electrocardiogram is taken if there is any concern about heart function as Lithium can cause arrythmias. Once a person is established on the best Lithium dosage for the individual these tests are repeated initially at 3 -6 months and then annually while the person is on Lithium.
Lithium is usually begun in the 300 mg three times a day dosage. The blood level of Lithium is then measured since each person's metabolism is different. Acceptable blood levels for Lithium treatment of bipolar disorder are in the range of .6 to 1.2 mEq/litre. By adding or subtracting 300 mg of Lithium roughly in the range 600 to 1500 mg a day, the desired lithium level is achieved. Lithium equilibriates such that drug test for Lithium level can be done 1-2 weeks after altering the dosage. The idea is to have the level at the lower end when a person is relatively stable and at the higher end when a person is more manic. In hospital for mania acute treatment it's not uncommon to aim for a lithium level just short of toxicity in the 1.5 mEq/litre range.
Once stable Lithium levels, Na. K. CBC Cr and TSH and urinalysis are done with decreasing frequency to annually in a person stable on Lithium.
Because dehydration can affect the lithium level, when people are sick with fever or diarrhea it's good to check the lithium level. Lithium toxicity is usually noted subjectively first as an increasing tremor or trembling.
There is a common expression in clinical medicine that goes, treat the person, not the lab. This refers to the fact that many people individually benefit from medication dosage that doesn't quite go with what the textbooks would say. This is often true with Lithium Carbonate where maintenance dosages do not necessarily have to be strictly in the 'drug level' range as patients may remain stable on a lower dosage with the potential for a greater safety. The key here is that if a person is already on Lithium and develops mania and or depression the optimum dosage can be reached more easily than if a person were started from scratch or with no lithium on board. To this end I was interested to note that Lithium Carbonate was used as an adjunctive medication in the Star D Protocols for chronic depressions clearly indicating the potency of the medication as an adjunctive. Many patients benefit from 300 to 600 mg a day as prevention and for stabilization in maintenance. For treatment however this not adequate and the standard textbooks mirror clinical practice where often much higher dosages are needed to stabilize the Bipolar Disorder.
Sleep disorder increasingly is seen to be part of the Bipolar Disorder with insomnia associated with mania and hypersomnia associated with some depressions of the Bipolar class.
Lithium Carbonate may well affect the sleep cycle and thereby help with the mood disorder. It's commonly used with antidepressants especially SSRI's when a person is in the depressed phase and it's safely used with other mood stabilizers when a person is having manic symptons.
That said, it's an amazing medication that has allowed many people to live essentially normal lives with excellent long term work and stable intimate and conventional relationships. Without lithium these very same people might well have spent inordinate time in hospital and certainly would have not had the same success in the community. Fortunately too there are new medications which combine with Lithium to provide even better finer tuned care for patients with Bipolar disorder.
Historically there was only one bipolar disease, that which was called Manic Depressive disorder. This was a horrible disease with Mania so severe that it could last untreated and lead to death from hyperactivity, grandiose delusional thinking and angry outbursts. Later the cyclothymic disturbance of mood swings, a very attenuated form of the classic illness was called Bipolar II.
Lithium Carbonate was and probably still is the drug of choice for Bipolar I especially the Manic episode. It's also an amazing 'preventative medication'.
The story goes that Lithium Carbonate's special capacity for modulating mood was found when it was used for heart patients as Lithium Salt instead of normal table salt, Sodium Salt. People were noted to be 'mellow' and from this 'observational' history the medication use developed.
Lithium Carbonate's pharmacological 'raison d'etre' isn't clearly known. It's thought that somehow it stabilizes membranes. Empirically it works and it works very well.
It's also relatively safe at low dosage used most commonly in the community. With increasing dosage there is increasing toxicity.
When LithiumCarbonate is started it's standard to check the blood work. Lithium can be toxic to the thyroid gland so TSH (Thyroid Stimulating Hormone) is ordered to measure baseline activity in case there is any change while on Lithium. The other organ which can be involved are the Kidneys so Creatinine is measured along with the Glomerular Filtration Rate, tests that assess the filtering function. If the Creatinine were to increase it would indicate that the filtering function of the kidneys were impaired. Sometimes an Electrocardiogram is taken if there is any concern about heart function as Lithium can cause arrythmias. Once a person is established on the best Lithium dosage for the individual these tests are repeated initially at 3 -6 months and then annually while the person is on Lithium.
Lithium is usually begun in the 300 mg three times a day dosage. The blood level of Lithium is then measured since each person's metabolism is different. Acceptable blood levels for Lithium treatment of bipolar disorder are in the range of .6 to 1.2 mEq/litre. By adding or subtracting 300 mg of Lithium roughly in the range 600 to 1500 mg a day, the desired lithium level is achieved. Lithium equilibriates such that drug test for Lithium level can be done 1-2 weeks after altering the dosage. The idea is to have the level at the lower end when a person is relatively stable and at the higher end when a person is more manic. In hospital for mania acute treatment it's not uncommon to aim for a lithium level just short of toxicity in the 1.5 mEq/litre range.
Once stable Lithium levels, Na. K. CBC Cr and TSH and urinalysis are done with decreasing frequency to annually in a person stable on Lithium.
Because dehydration can affect the lithium level, when people are sick with fever or diarrhea it's good to check the lithium level. Lithium toxicity is usually noted subjectively first as an increasing tremor or trembling.
There is a common expression in clinical medicine that goes, treat the person, not the lab. This refers to the fact that many people individually benefit from medication dosage that doesn't quite go with what the textbooks would say. This is often true with Lithium Carbonate where maintenance dosages do not necessarily have to be strictly in the 'drug level' range as patients may remain stable on a lower dosage with the potential for a greater safety. The key here is that if a person is already on Lithium and develops mania and or depression the optimum dosage can be reached more easily than if a person were started from scratch or with no lithium on board. To this end I was interested to note that Lithium Carbonate was used as an adjunctive medication in the Star D Protocols for chronic depressions clearly indicating the potency of the medication as an adjunctive. Many patients benefit from 300 to 600 mg a day as prevention and for stabilization in maintenance. For treatment however this not adequate and the standard textbooks mirror clinical practice where often much higher dosages are needed to stabilize the Bipolar Disorder.
Sleep disorder increasingly is seen to be part of the Bipolar Disorder with insomnia associated with mania and hypersomnia associated with some depressions of the Bipolar class.
Lithium Carbonate may well affect the sleep cycle and thereby help with the mood disorder. It's commonly used with antidepressants especially SSRI's when a person is in the depressed phase and it's safely used with other mood stabilizers when a person is having manic symptons.
That said, it's an amazing medication that has allowed many people to live essentially normal lives with excellent long term work and stable intimate and conventional relationships. Without lithium these very same people might well have spent inordinate time in hospital and certainly would have not had the same success in the community. Fortunately too there are new medications which combine with Lithium to provide even better finer tuned care for patients with Bipolar disorder.
Sunday, March 21, 2010
Methadone and Psychiatric Medication Interactions
Methadone as discussed here is related to 'methadone maintenance treatment' for substance, usually heroin or opiate, addiction. Methodone can be used for pain management but there the further confounding factor of what the primary pain inducing illness make that a potentially very different discussion.
Because methadone has a long half life (length of time it takes for half the methadone to be metabolize) it's breakdown can be affected by other medications which are metabolized at the p4Because methadone has a long half life (length of time it takes for half the methadone to be metabolize) it's breakdown can be affected by other medications which are metabolized at the p450 site. Medications can 'compete' for this site and slow down the metabolism increasing the risk of overdose and respiratory failure. Methadone can further prolong the QT interval and cause cardiac arrhythmias.
Contraindications and cautions regarding concommittant drug use are not wholly inflexible rules but advise clinicians to be very aware of the risk benefit ratio and to consider alternative medications where possible. In methadone maintenance however it's always a "risky" business because the person for whom treatment is being initiated is already using dangerous street drugs of highly questionable origin and dosage. In addition they are not uncommonly using street clinics, sharing prescriptions and despite best intentions not necessarily being totally honest with the addiction doctor. Further, when a medication is listed under 'contraindications or cautions' it may be related to the dosages of medication used. A medication safe at lower dose in combination with another low dose medication may be associated with increased risk at increasing dosage.
Those psychiatric drugs which are contraindicated in combination with methadone are as follows:
- Ziprasidone – zeldox – can cause constipation/paralytic ileus, CNS depression, psychomotor impairment and QT prolongation,and cardiac arrythmias
- Phenothiazines – antipsychotics – thoridazine, fluphenazine, perphenazine, chlorpromazine, - can cause constipation/paralytic ileus, CNS depression, prolongation of QT interval, and cardiac arrhythmias. Here the consideration is most concerning if a methadone patient were given a long acting depot injection such as 'modecate'. The phenothiazines are not as commonly used to day but loxapine is and it's closely related to thorazine and chlorpromazine.
- Pimozide – antipsychotic – may cause cardiac arrhythmias – this is not a commonly used antipsychotic. It still has a special place for 'monosymptomatic delusional disorder' and has been used most recently when other antipsychotics have not been effective.
- MAOI's – atypical antidepressants – may increase risk of serotonin syndrome. These are rarely used these days and usually only after other antidepressant medications have been tried. It would be unlikely for a methadone patient to be started on an MAOI but it is possible for a person on MAOI's to seek methadone treatment.
Caution should be used with these psychiatric medications:
Buprenorphine – naloxone – revia – it may precipitate withdrawal in opioid-dependent persons increasing the risk of CNS depression and psychomotor depression. Naloxone is used as an opiod antagonist in the emergency but emergency doctors are well versed in the various scenarios where this might be problematic and the emergency is equipped to handle the consequences. The only community based place where this might arise is the use of Naloxone for treatment of Alcohol or Cocaine dependence.
Clozapine – this is an atypical antipsychotic - it may increased the risk of paralytic ileus, CNS depression, QT prolongation, cardiac arrhythmia and hypotension. It's not unlikely that a person using clozapine might seek methadone treatment, however clozapine treatment is most often closely monitored and the patients on clozapine are mostly managed by teams with greater likelihood of awareness and prevention.
Haloperidol – antipsychotic – commonly used especially in psychiatric emergencies – orally and IM routes of administration – it may increase risk of severe constipation/paralytic ileus, CNS depression, psychomotor impairment, hypotension, QT prolongation, and cardiac arrhythmias.
Quetiapine – a commonly used antipsychotic , also used at low dose for sleep, became increasingly popular because it is one of least likely to cause tardive dyskinesia. It may increase risk of QT prolongation, cardiac arrhythmias, hypotension, CNS depression and psychomotor impairment. This is dosage related.
Tricyclic antidepressants – these were the most commonly used antidepressants before the advent of the SSRI's, ie Prozac. The most commonly used are amitriptylline, desipramine and clomipramine. They've had a resurgence as a number of patients aren't responsive to the newer antidepressants and the tricyclics have shown benefit in pain disorders and depressions with psychosomatic aspects. The combination can cause severe constipation/paralytic ileus, CNS depression, psychomotorc impairment, hypotension, QT prolongation, and cardiac arrhythmias. This occurs as a result of additive effects.
Venlafaxine – effexor – this is a very popular effective broad spectrum antidepressant which has been called 'side effexor' only because of it's tendency to have increasing side effects at higher dosage. It's use in combination with methadone can due to additive effects increase the risk for QT prolongation, cardiac arrhythmias, serotonin syndrome, and neuroleptic malignant syndrome.
Other psychiatric medications which should be monitored include:
Carbamezapine – this is an anti seizure medication which has been used for manic depressive disorder, bipolar mood disorders, impulse dyscontrol syndromes and for violence. It is the drug of choice for rage attacks especially those triggered by alcohol. It can decrease methadone levels and precipitate opioid withdrawal symptons.
St. John's Wart – this is an effective antidepressant that has been demonstrated in evidence based studies in Europe. It's available here from over the counter health food stores with questionable dosage and quality of preparation. It is however used commonly in winter months here as an adjunctive treatment or alternative treatment and for those who are more sensitive to seasonal affective disorder. It may decrease methadone levels and precipitate opioid withdrawal because it induces hepatic metabolism.
Acetominophen – Tylenol – pain killer – may increase risk of CNS and respiratory depression, profound sedation, and hypotension. Problems are a result of the additive effects and dosage related.
Anticholinergics—atropine, benztropine, scopolamine - these can be used in parkinson's disorder and in combinations with antipsychotics to treat the side effects of antipsychotics. They may increase risk of severe constipation/paralytic ileus and other anticholinergic adverse effects as a result of the additive impact.
Antihistamines – used for allergies, over the counter, and sometimes used for sleep – combination with methadone can increase constipation/ CNS depression, and psychomotor impairment – dose related additive effects.
Benzodiazepines – ativan, clonazepam, diazepam, valium – may cause vasodilatation, severe hypotension, CNS and respiratory depression, psychomotor impairment – additive, dosage related response in combination with methadone.
Cannabinoids – pot, hash, marijuana –also medicinal dronabinol - when combined with methadone can increase risk of CNS depression, psychomotor impairment , dosage related and additive
Ethanol – alcohol – may increase risk of CNS and respiratory depression, and psychomotor impairment, effect is dosage related.
Citalopram – commonly used and relatively safe SSRI – may increase risk of serotonin syndrome.
Fluoxetine – Prozac – commonly used antidepressant - may increase methadone levels and increase risk of QT prolongation, cardiac arrhythmias, serotonin syndrome, and neuroleptic malignant syndrome.
Ginseng – may increase risk of sedation – additive
Loxapine – may increase risk of severe constipation/paralytic ileus, CNS depression, hypotension, and psychomotor impairment – additive effects
Mirtazepaine – may increase risk of CNS depression and psychomotor impairment.
Olanzepine – zyprexia – may increase riks of severe constipation/paralytic ileus, CNS depression, psychomotor impairment, hypotension – additive effects.
Paroxetine – paxil – may increase risk of serotonin syndrome and neuroleptic malignant syndrome
Pregabulin – used for pain disorders - may increase risk of CNS depression – additive effects
Rispiridone – very commonly used atypical antipsychotic – may increase risk of CNS depression, and hypotension
Sertraline – antidepressant – may increase risk of serotonin syndrome and neuroleptic malignant syndrome – additive effects
Trazadone –antidepressants and also used as sleep aid - may increase risk of CNS depression, psychomotor impairment, - additive effects
Valerian – used as an anti anxiety tea – risk of CNS depressants - has additive effects.
Valproic Acid –Divalproex – increased risk of CNS depression and psychomotor impairment.- additive effects.
These are just the psychiatric medications interactions known to date and he cautions associated. Mostly the effects are dosage related.
There are countless other medications that have be be monitored carefully espec ially in the antibiotic and cardiac and respiratory medications.
As some drug user 'sample' the drug cabinets of places they visit without consideration of the dire consequences that might occur the initial phase of methadone maintenance therapy is one of potential high benefit combined with increased risk. Patients often want dosage increases to be rapid but the standard recommendation is to start methadone at 20 mg daily witnessed use then increase by 5 and at most 10 mg a day. This allows for increased safety during the period of stabilization. It 's also a time of education and a time when clinicians and patients get to know each other and establish a therapeutic relationship with the inherent trust and increased disclosure and cooperation associated.
Friday, February 5, 2010
Exchanging Psychiatric Medications
Exchanging psychiatric medications was one of the principal reasons for overnight and two day admissions to hospitals in the past when hospital beds were available. It's still the safest way for complicated cases.
In the community if a patient is only on one medication such as a SSRI, say Fluoxetine, (Prozac) it's rather easy to switch to another newer SSRI, escitalopram (Cipralex). There's a rough equivalence between 10 mg of Prozac and 10 mg of Cipralex. However, because Fluoxetine as a long half life (the length of time before the medication is half metabolized) 10 mg may in fact represent more like 15 or 20 mg. At the same time over time there is a natural resistance to medication that occurrs at the cellular level requiring increasing dosage of medication to achieve the same effect. There are various names and explanations for this, such as 'tolerance' etc but the fact remains a patient commonly on a very good antidepressant will present saying the 'medication isn't working'anymore. Most commonly the 'stress' in the patients life has quadroupled but sometimes really , nothing has changed but over time the medications' efficacy has reduced.
At this point the first strategy is to increase the medication and this may go on to when the benefits of a medication are outweighed by it's side effects. Prozac is commonly 'topped' by 80 to 100 mg with the consideration that as the dosage of a medication is increased outside the manufacturers specifications the liability of the clinician increases exponentially. The Prozac manufacturer says the medication is safe to 60 mg for instance but some of us have used it to even 120 mg though the risk of 'serontonin syndrome' is considerable.
Hence, the usual need for a change of a medication is when the one medication is 'topped out'. However, the way a medication works at 'high dosage' is different than it's working at low dosage so again there is little 'equivalence'.
In practice in the community, I titrate down a medication dropping by increments, in this example of 10 to 20 mg while increasing the other medication by 10 to 20 medications until I've replaced one with the other. Each change is given a few days or a week sometimes simply because that's the length of time it takes to see the effectiveness or likelihood of side effects or because practically that 's the scheduling of the clinic.
Fortunately in antidepressants the newer antidepressant is perceptually more potent because of the lack of tolerance. Hence 100 mg Prozac could be replaced by 40 mg of Cipralex. That's the advantage of the shift.
Often though the original medication has been 'augmented' with alternative medications which increase the efficacy of the medication. Examples of augmentation for SSRI medications include low dose lithium, low dose thyroid medication, low dose ritalin, and low dose mood stabilizers, anti anxiety or antidepressant medications. Each of these medications has a differential response to the old medication and the new medications.
None of the text books or pharmaceutical references address the complexity of this so that not uncommonly the augmenting medications are cut first. Cutting a medication is often extremely frightening and disruptive to the patient who not only is physiologically committed to the medication (like stopping chocoloate, tea or coffee) but psychologically is committed (it was oncea life saving addition). This 'withdrawal' experience is itself difficult and consequently generalists are quick to add medications but commonly refer the case to specialists when all the 'fixes' are used up and the patient needs to have essentially an 'overhaul'.
The university hospital is a treat because invariably they suggest a 'wash out' , stopping all medication for 1 - 2 weeks and then starting the new medications. This is when the community based colleagues look at their academic associates and ask who is more psychotic the patient or the doctor, simply because such resources are rarely available, the cost is extraordinary and the rest of us out of academia including patients have to work for a living. Patients are only willing to go through 'wash outs' as last resorts because effectively they're going to experience all the terror and depression and even hallucinations during that time. They will have nurses and doctors 24 hours present but they're be 'feeling' the raw sensations themselves.
So in the community we practice the 'art' of medication. Today with an aging population the patients are not only on the 2,3 or 4 psychiatric medications but not unusually a similiar set of medications from two or three other specialists as it often takes a 'team' to keep these marvellous sports car bodies of ours doing the amazing laps we continue to do into the 80's in the rat race of life when we should all be dead or off fishing and golfing by the age of 50 with street urchins, childrens and slaves of any country holding the fans so we don't have to exert ourselves and then don't have to see doctors, rest, sun and good diet with lots of sex with young athletes and spiritual exercises for half the days utilizing our time.
Each of the medications affect another medication. So my patients on methadone can be killed quite easily by my increasing the seizure medication Tegretol or adding clonazepam to the mix to help with sleep. Methadone has a small window of safety in terms of respiratory function and any medication that effects this can cause asphyxia. Alcohol and marijunania and a number of over the counter preparations such as antihistamines are as likely to create death as any of the pharmaceuticals. The same goes with a variety of the arrhythmia stabilizing medications used in the treatment of heart disease especially after a myocardial infarction.
The greatest problems arise when doctors don't know what the patient is taking. This includes illicit drugs and 'herbs'. Herbal medications counteract the effect of antibiotics and until scientists discovered this no one could understand why certain patients were dying from otherwise treatable infectious diseases.
That said, there are references. As physicians we study these references and frankly wish that the drug dealers, and sometimes the alternative health care providers would study the subject as well given they are commonly making a lot more money than we are and only have a limitted training requirement to ours while presenting themselves as 'authorities ' and commonly telling patietns they don't 'need' something or that 'it will be okay' if you add a bottle of whisky to your psychiatric medications and your heart medications.
The Michael Jackson case was a tragedy that thankfully has culminated in the Hollywood doctor being tried for malpractice. Sadly he probably was trying to work 'with' the rather egocentric and demanding superstar who like so many patients is often 'non compliant' or 'non adherent' to medical advice.
As a person who has had tickets for speeding and know that speeding is one of the principal causes of death in traffic accidents and I'm flossing resistant as well, despite the best efforts of my terrific dentist and his wonderful dental hygeinists, I don't judge Michael Jackson, his doctor, or the patients who don't do what they are 'supposed to do'. Mostly we all get away with it. The retrospectoscopy is send in medicine to be an adaptation of the proctoscope for use by the same.
It's just that this factor needs to be introduced to the equation because non compliance results in a deviation from the ideal usage of medication by anywhere from 10 to 30% some of which is compensated for by the safety designs of the medications.
In the end, patients are living longer fuller healthier lives and science has not only cured countless diseases, extended life and put men in space it continues to come up with ways to assist us in dealing with the complex interactions of medications and factors of medicine. For the last decade I've used computer programs that are good for 2 or 3 medications and while they don't deal with the 'soup' they do help me mostly with not interfering with medications used for the treatment of cancer, arthritis, or other systemic diseases which are commonly associated with life preserving medications. Several of the medications I use specifically affect diabetes and insulin efficacy and I have at least a dozen diabetics in my psychaitric practice.
I can check Mirtazepine interaction with insulin by punching in some names on my Epocrates program on my iphone. Unfortunately it takes time. All the advances in medicine take time. The greater the complexity and this is true with aging populations and sicker patients the greater time required and the greater trained individuals but the fact remains that its usually unsupported. So each day I make an ethical struggle with looking up something or explaining something or cross referencing something and every week or two I see a patient who says,
"You don't seem to know very much. My other doctors don't ever look things up. They don't explain things and talk like you do. They listen and then give me a prescription. They don't waste my time. I can get in and out of seeing them in 5 minutes and I don't get a parking ticket. You not only don't know what you're doing but can't do it fast at all. I'm fed up with doctors like you. They should teach you something at those schools that gave you all those fancy pieces of paper."
Yes, you're right. That's what I tell the licensing bodies, the auditors, the lawyers, and everyone else. I wish somebody had taught me something. But then, I had the best teachers and a whole lot of my patients wouldn't have been alive today or more importantly enjoying good lives if all we did and knew was what I learned 25 years ago in school. Every year I'm doing 2 to 4 weeks of upgrading and it's still not enough. Only the computer scientists in my practice grasp the significance of the advances in the pharmaceutical industry. We commiserate about viruses and anti viruses and 'fixes' and 'beta' systems.
It's the best we can do and when I really sit back and think of it, what I'm a part of is miraculous. I'm really thankful to all the people involved in the process of helping me and the patients have the tools to address their illness.
Wednesday, January 13, 2010
Personality Disorder
Psychiatry is a hodge podge collection of venn diagram interconnecting overlapping diagnosis. The DSM Axial diagnostic system was an attempt to look at the various dimensions of a disorder and chart their biological psychological and sociological sources.
Axis I refers to the current and major focus of therapy whereas axis II refers to the personality traits or disorder, axis III any predominantly physical concern, axis IV social or environmental factors and Axis V the global assessment of functioning for the individual based on a scale that shows 100 as exceptionally well, below 50 as failing and lower requiring chronic social and psychological assistance or institutionalization.
Axis II, the personality disorder scale is generally speaking the least competently completed. There are many reasons but mostly 'personality' and 'character' are poorer understood today by average psychiatrists and unfortunately for the diagnostic class there are no pharmaceutical solutions to the treatment of personality. Personality disorders bring to the awareness of all that medications really predominantly manage 'symptons' and personality disorders are decidedly at greater risk for all the symptons of psychiatry but the treatment of choice is medication and psychotherapy not just medication alone.
Increasingly psychiatrists are little trained in psychotherapy, lack psychological mindedness and rely predominantly on medications for their income. There are even those psychiatrists who hold the medication pad like a cross between them and their patients.
Personality is considered to be a play of genetics and environment. The collection of coping skills that an individual leaves adolescence with were considered necessary for the individual to survive their family and early environments. They were adaptive to an extent but become decreasingly 'adaptive' over time till these habits of interaction finally fail to serve the individual in their interaction with society and they end up in the psychiatrists office with some evidence of 'dis-ease'.
Personality disorders don't just appear late in life otherwise a good clinician will consider 'organic personality disorder' which is a 'personality change' secondary to brain injury or other physically disturbing event. Generally speaking personality disorders are a "pattern of dysfunction" which can be seen in adolescence and continuing through adulthood until it culminates in need for treatment.
Usually personality disorders are more identifiable by others than by themselves. Many of the personality disorders "get under the skin" of others because it's obvious that their chronic 'coping' patterns are at the basis of the recurrent failures to achieve their ends.
Personality disorders derive mostly from the work of Dr. Carl Jung, Reich, Adler and others who looked at the complexity of the relationship of individual and society and how culture and individuals interacted.
Dr. Carl Jung made a major contribution by identifying the major division between the introvert and the extrovert. The DSM classifies these two types of personality as Cluster B for extrovert and Cluster C for introvert. Cluster A in the DSM is best described as "odd". They're the true eccentrics, the adult autistics and slightly schizophrenic sorts who muddle along without being really crazy but seem 'off' to most by their peculiar habits.
Cluster B is where the Antisocial Personality Disorder, Narcissistic Personality Disorder, Histrionic and Borderline Personality disorders are gathered. Much of the research that has helped us understand personality disorders in general has derived from the well funded research that has gone into the study of the Antisocial Personality Disorders.
The key here is 'context' and 'adaptation'. A person with the traits of 'antisocial personality disorder' might well use these positively by joining a police force or military rather than becoming a 'gang' member. Similiarly it's been said that to be a good criminal lawyer you have to have a fair measure of narcissistic personality disorder. The histrionic naturally makes a very good actress but might not be very good as a space shuttle pilot. The borderline is often similiarly described as a 'b' movie actress or actor because of the chaos that permeates their lives. They are the proverbial drama queens who become suicidal over a broken fingernail.
Cluster C personality disorders include the dependent, those who are constantly parasitically attaching themselves to others and abdicating from responsibility but then are dissatisfied by the eventual abuse that comes when the idealizations turn to devaluations. Obsessive compulsive personality disorders fit this category . Naturally if you are an accountant and obsessive compulsive your concern for detail and perfection might benefit your clients. The trouble is that the obsessive can't live with themselves worrying about their mistakes all night long.
The passive aggressive personality disorder is probably the most significant and least diagnosed of the cluster c category despite its commoness as a 'trait'. Indeed one of the ironies of psychiatry is that this field attracts more introverts than extroverts and specifically cluster c passive aggressives are forever 'punishing' extrover patients by 'punatively' labelling them as 'cluster b' personality disorders. Cluster B personality disorder in turn more commonly label cluster c personality disorders as 'those assholes". There's considerable black humor in the field of personality research and when one understands personality traits one can't help but see them in everyone and see why so commonly it's over emphasis or dependence on a 'trait' (coping mechanism) that is creating the 'problem' not so much the situation as the person in the situation will more commonly insist to all and sundry.
Now consider the paranoid. They might make a very good political or theological writer denouncing the evils and threats "out there' while never ever considering their own perceptual biases. The key thing is that this is a stable trait and that these individuals are generally functional but they're on the edge and like all the personality disorders the very characteristics that they have can cause them to 'go over the edge".
Tabloid newspapers make a heyday out of these times in these individuals lives. The histrionic 'flirting' with everyone suddenly is 'raped' and 'she/he' never saw it coming but everyone else would have described that person as a 'train wreck waiting to happen'. The obsessive compulsive one night 'break's' and finds themselves having gone from deep anxiety to chronic depression and now suicidal can't see why their life lead them to the psychiatric hospital yet those around always knew this person was 'wound too tight'.
The personality disorders have benefitted most from group therapies where their interactions with many people can be interpreted back to them. Too often in one to one therapy they simply 'discount' the 'opinion' of the therapist yet in a group it's harder to ignore a dozen others giving the same feedback.
Medications commonly are used symptomatically to help a person be able to hear advise and take in information without so much defensiveness. Anti anxiety medications, antidepressant medications and even anti psychotic medications are commonly the place where therapy begins because in crisis personality disorders are not 'open' to change. Indeed the very coping mechanisms that usually get them into the difficulties in the first place are the ways they hope to get out of the difficulty.
Hence the anxious antisocial personality disorder can't hear the 'recommendations' of the police officer because they're trying to figure out how to 'lie' their way out of this situation or 'fight' their way out. Medications can be used to reduce the anxiety and violence potential and give the person time to 'reflect' on their need to change if they don't want the same thing happening over and over again.
Increasingly the 'medicalization' of psychiatry has resulted in the 'fast food' approach to psychiatric problem solving. Hence, rather than looking at the 'why' the person has been in three relationships in which they've been beaten up or why they can't keep a job or have any long term friends, the medication approach is often solely a 'band aid' with the need for changing 'band aids' frequently or sometimes wrapping the patient up in metaphoric guaze. This is fine for 'crisis' management but the problem is that there is a need for much more.
Politically though, funding, and the approach to disease management is commonly based on addressing the 'crisis' and forgetting about the 'meaning' or the 'long term management' of whatever the 'crisis' was about. Crisis management is 'sexy'. The politicians love this sort of 'stop gap' measure but what is most commonly needed is the kind of thinking that is used in "rehabilitation medicine". Yet there is nothing 'sexy' about 'rehabilitation' or 'chronic care'.
So commonly in the present day system people were personality disorders are the most poorly treated and yet often have the greatest potential.
In the past there was great frustration in treating personality disorders for many because they didn't treat the addictions that commonly are part of the maladaptive coping armamentarium. Today it's recognized that treatment of addictions needs to precede the therapy for the personality disorders because the latter therapies of change are commonly 'anxiety' provoking and "uncovering" and encourage 'new, unknown," behaviours that increase the sense of 'vulnerability" and throw a person back to the addictive 'self soothing' behaviours if these aren't addressed first and in combination with the subsequent treatments, group and individual for the personality disorders.
Borderline personality disorder is commonly now understood to be untreated PTSD until proven otherwise. Anti social personality disorders are commonly understood today to be usually part of a 'context' where the behaviours which don't work in the 'greater society' are the very traits that permit 'survival' in the person's immediate environment. The movie, Clockwork Orange did a marvellous job of addressing the difficulties of treating an anti social individual without also treating the anti social individuals immediate 'group' and 'environment'. Passive aggressive only persist when they are not held accountable etc.
The successes in this field are so often the most gratifying for the therapists. These are usually the 'success stories' we read about where a person 'found themselves' or their 'life turned around'. It's one of the most exciting areas of psychiatry and tragically one that is often so poorly understood.
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