Undermedicated

A patient I see for psychotherapy, without medications except for an occasional lorazepam (tranquilizer of the benzodiazepine class), told me his prior psychiatrist declared him grossly undermedicated in one of their early sessions, and had quickly prescribed two or three daily drugs for depression and anxiety.  He shared this story with a smile, as we've never discussed adding medication to his productive weekly sessions that focus on anxiety and interpersonal conflicts.  Indeed, the lorazepam is left over from his prior doctor.  I doubt I would have ordered it myself, although I don't particularly object that he still uses it now and then. Of course, there's a completely innocuous way to explain this difference between his prior psychiatrist and me.  My patient could have looked much worse back then, in dire need of pharmaceutical relief.  However, he didn't relate it to me that way, and I have no reason to doubt him.  There's also the possibility that I'm missing serious pathology in my patient — that I too would urge him to take medication if only I recognized what I'm now overlooking.  But... I don't think so.  I'm left to conclude that his prior psychiatrist and I evaluated essentially the same presentation rather differently.

In particular, I'm struck by the term "undermedicated" (more often spelled without the hyphen, according to my Google search).  This judgment most often comes up in speaking about populations, as in the debate over whether antidepressants are over-prescribed or under-prescribed in society at large, or whether children are diagnosed with ADHD and prescribed stimulants too often, or not often enough.  Under- and overmedication are also commonly mentioned when describing medication management of pain, a thyroid condition, mania, or chronic psychosis in an individual.  Here the terms express disagreement with a particular dosage, where the benefits of treatment and adverse side-effects or risks are deemed out of balance one way or the other.

"Undermedicated" also implies that adding medication is the preferred or only sensible treatment approach.  While this may always be true in hypothyroidism, it clearly isn't with regard to physical or emotional pain.  The term rhetorically denies non-medication alternatives.  I would also add that, to my ear, "overmedicated" and especially "undermedicated" sound dehumanizing, as though referring to a machine that is out of adjustment, or a chemical solution being titrated on a lab bench.  Since the natural state of human beings is not to be medicated at all, it sounds a bit odd to hear someone — as opposed to one's disease — assessed this way.  Perhaps I am especially sensitized to this after reading a controversial article by Moncrieff and Cohen that highlights the "altered state" induced by psychotropics and their lack of known, specific mechanisms of action.  There is often a supposition that medication dosage correlates with symptom relief.  This is not always true of subjective states, underscoring that the complexity of human experience often belies simple "over/under" judgments.

My patient's mood and anxiety vary with his interpersonal situation.  It wouldn't occur to me to turn his "thermostat" up or down in general, even if drugs reliably could do this.  Yet I know colleagues who'd argue that one, two, or even three daily medications could help him overcome his everyday challenges of dealing with people.  These approaches point to different fundamental viewpoints in psychiatry.  Does the patient have a disease, an as-yet-undiscovered chemical (or electrical, viral, inflammatory, etc) imbalance in the brain that is best remedied by a medical intervention, accurately dosed neither "over" nor "under"?  In acute mania or florid psychosis, as in hypothyroidism, it seems to me the answer may be yes, although this is unproven and time will tell.  Perhaps, too, in severe melancholic depression.  But in social anxiety?  Self-consciousness?  Feeling discouraged about one's career?  The field's perspective on these has shifted in recent decades, such that now a hidden biological cause is assumed by default, or at least held out as a rationale for treatment.  It is only by making this dubious assumption that one can speak of undermedicating such complaints, or the people who have them.

Polypharmacy — Sloppy thinking in psychiatry 2

My second post in this series on sloppy thinking in psychiatry is devoted to polypharmacy, the medical term for prescribing multiple medications at once, especially for the same problem.  Polypharmacy is at best a risk thoughtfully taken because nothing simpler and safer will do.  At worst it's a dangerous error, exposing patients to unnecessary hazards purely as a result of laziness and sloppy thinking by their doctors.  Unfortunately, the latter is all too common in psychiatry.  Let's look at why. It has been said that the less we know about an illness, the more treatments we have for it.  Instead of one definitive cure that attacks the root of the problem, various remedies ease symptoms — not the cause — often via different mechanisms.  A good example of a definitive cure is a specific antibiotic to treat a bladder infection.  We know how bacterial infections work, and we have antibiotics to attack the root of the problem.  Ancillary treatments for fever or pain are sometimes used, but they are clearly secondary, and often optional.  In contrast, the pathogenesis of psychiatric disorders is not known, thus we have no treatments to attack the roots of these problems.  For example, antidepressants affect neurotransmitters that appear implicated in depression, but the exact way these neurotransmitters relate to the syndrome of depression is unknown.  Thanks to our ignorance, we have medications that affect serotonin, and others that affect norepinephrine and/or dopamine.  In recent years atypical neuroleptics (antipsychotics) have been approved as add-ons for treating depression, a worrisome development given their risks.

Since we don't have a definitive cure for depression, many patients report partial (or minimal) improvement from any one medication.  The prescriber may then add another on the theory that it may help via a different chemical mechanism — a theory that is difficult to confirm or refute, as we don't know the mechanism in the first place.  The original medication is not stopped: If the patient improves, why disrupt a winning combination?  And if the patient doesn't improve, we wouldn't want to withhold an antidepressant from a depressed person, would we?  Sloppy thinking all around, yet sadly common.

Similar arguments can be made for the treatment of bipolar disorder and schizophrenia.  Lacking a true understanding of pathogenesis, we treat empirically.  And empiric treatment, while often compassionate and necessary and helpful, invites the shaky logic of adding more medications hoping for more empiric benefit.

Compounding and worsening this situation is psychiatry's abandonment of parsimony in diagnosis and clinical assessment over the past 30 years.  Prior to the publication of DSM-III in 1980, psychiatric evaluation was an attempt to explain a patient's seemingly unrelated complaints using a single theory (often psychoanalytic, but possibly biological or even behavioral).  The introduction of phenomenological diagnosis in DSM-III encouraged multiple diagnoses in the same patient, say Major Depression and PTSD on Axis I, and a personality disorder on Axis II.  There was no longer any attempt to tie it all together.  This has encouraged a piecemeal approach to treatment: a medication for depression, a different one for PTSD, maybe something for sleep, and something else again for agitation due to the personality disorder.  That's four different psychiatric medications already, and we've hardly even started.  Patients with personality disorders often complain of "mood swings," so let's add a mood stabilizer like lithium or Depakote.  And they're anxious, so we could add a benzodiazepine tranquilizer like Ativan, or a beta-blocker like propranolol, or an atypical neuroleptic.  Or what the hell, all three!  We're up to seven or eight medications now, and we haven't even considered a stimulant for their ADHD — because, after all, the patient is having trouble concentrating... funny how it was never diagnosed before.  And we haven't augmented the antidepressant with thyroid supplementation, nor have we added a second antidepressant...

While 10+ psychiatric medications is clearly over top, I've evaluated a number of patients who arrive on six, often an (1) antidepressant, (2) mood stabilizer, (3) tranquilizer, (4) sleep aid, (5) stimulant, and (6) another antidepressant or mood stabilizer.  Almost without exception, I've been able to cut this list in half, and in some cases down to zero, or more often, one medication.  It's less a matter of expert medication choice, and more an aversion to sloppy thinking.  According to one study, antipsychotic polypharmacy can be simplified without harm 2/3 of the time.

Psychiatric polypharmacy is often intellectually lazy.  Needless to say, there are far more drug combinations than there are studies assessing the risks and benefits of these combinations.  Polypharmacy is nearly always an educated guess, not "evidence based medicine."  It's not even good single-case research, where one would ideally change a single variable at a time.  All too often, medications are added to treat the side-effects of other medications, as with "ADHD" in the case above, a tail-chasing exercise that only gets worse over time.  With every added medication there are added side-effects, and sometimes adverse interactions that can be more harmful than the original problem.  In my experience, generic side-effects such as weight gain and cloudy thinking are more the rule than the exception in patients taking multiple psychiatric medications.  It should happen a lot less than it does.

Once again, photo courtesy of Petr Kratochvil.

Diagnostic alphabet soup

Earlier this year a reader asked me: "I would be very interested to hear your thoughts on patients becoming too focused on diagnoses. [...] While I was in an RTC as a teenager, and recently in the hospital as an adult, I have found that people almost treat their diagnoses as a competition. I was calling it the alphabet olympics. I also have a friend who will rattle off a bunch of abbreviations for his diagnoses. There is always something new popping up too. Sometimes I wonder if over diagnosing is a mistake some psychiatrists make."

I've seen this too.  Here's my take on the alphabet soup of diagnosis, and whether it's good for patients to focus on it.  First, a little history...

Prior to 1980, before the revolutionary 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), psychiatry tended to lump disorders into a few broad categories.  Schizophrenia covered a wide range of presentations, from relatively minor symptoms to devastatingly severe ones.  Depression could be brief, prolonged, triggered by obvious stressors or losses, or appear out of nowhere.  Neurosis referred to any presumed unconscious conflicts that interfered with life.

DSM-III changed all that.  (An excellent historical review article, in pdf format, is available here.)  This was the first effort by the American Psychiatric Association (APA) to publish an atheoretical, phenomenological psychiatric nosology.  What do these $10 words mean?  The idea was to create diagnoses that could be used regardless of one's school of thought or theory.  For example, some psychiatrists thought depression was biological, others considered it psychological.  Either way, if a patient had a low mood for two weeks, along with poor sleep, appetite, concentration, and libido, he or she had Major Depressive Disorder according to DSM-III.  It didn't matter why.

This scheme encouraged multiple diagnoses.  A given patient could fulfill criteria for Major Depressive Disorder, an Anxiety Disorder, a Personality Disorder, and other disorders, all at the same time.  This reflects a drawback of atheoretical diagnosis.  An underlying theory, such as Freudian psychoanalytic theory, or a systematic biological or learning theory, can pull together apparently disparate symptoms into a coherent diagnostic formulation.  Without such a theory to guide diagnosis, each set of symptoms stands on its own.  While some DSM diagnoses had exclusion criteria — they could not be listed in the presence of other diagnoses — this still left plenty of opportunity to list multiple disorders in the same person.

Each edition of the DSM grows in size.  One reason is that scientists can't stand to leave a good category alone — if it can be turned into two good categories.  Thus, anorexia and bulimia, which used to be one disorder, are now divided.  Depression is divided into major depression, dysthymia, seasonal affective disorder, adjustment disorder with depressed mood, and so forth.  Bipolar disorder comes in Type I and Type II, as well as lesser versions.  I am not against making these distinctions when there is good reason to do so, and there often is.  But one consequence is diagnostic alphabet soup: a growing set of arcane labels usually shortened to three- or four-letter abbreviations.  And the nature of atheoretical diagnosis means that any given patient may qualify for several.

Many psychiatrists feel they "understand" a patient better if they can establish one or more DSM diagnoses — although, being atheoretical,  such diagnoses don't actually explain anything.  They do, however, point reassuringly to recommended treatments, usually pharmaceutical.  Moreover, medications are FDA-approved for each of these indications separately.  This has marketing advantages for drug manufacturers.  Shyness doesn't sound like a psychiatric problem to be treated with medication, but "Social Anxiety Disorder," essentially a synonym for shyness, does.  Dividing anxiety into Generalized Anxiety Disorder, Social Anxiety Disorder, and many other types created markets for various medications.  In a parallel fashion, health insurers demanded more specific diagnoses in order to pay for psychiatric treatments.  There is money, and therefore politics, behind dividing human misery in these particular ways.

Perhaps the most interesting part of my reader's question is why some patients are attracted to these labels.  Her experience with teens and young adults may, in part, reflect embracing these labels in an ironic or mocking way:  "Now I have MDD, OCD, and PTSD.  Isn't that a kick?"  Probably more relevant is the concrete way a diagnosis seems to account for one's frightening instability.  Better to be "ADHD" than merely a scattered teen who can't study.  The former confers scientific legitimacy, promises specific treatments, and even justifies entitlements such as extra testing time in school.  These labels can also ease personal responsibility and humiliation, as when outrageous social behavior can later be attributed to Bipolar Affective Disorder or some other "chemical imbalance."  Despite the persistent stigma of psychiatric diagnosis, these labels have enough psychological and practical advantages that some patients wear them proudly.

The downside to all of this is that individuals can become known, even to themselves, by impersonal diagnostic labels.  Knowing oneself as PTSD, ADHD, and/or OCD can dehumanize.  It can prematurely close off inquiry and self-reflection.  And DSM diagnoses do not actually explain anything; they are better conceptualized as statistical categories.  Such diagnoses are useful tools, but like all tools they can be misused.

Politics, religion, and ADHD meds

Cross-posted from Technorati with permission.

At a dinner meeting a couple of weeks ago I met two psychiatrists who work at Kaiser Permanente, the large HMO system that boasts a 24% health insurance market share in California.  (This has nothing to do with my story really.  I just think it's amazing that a quarter of all insured Californians are Kaiser patients.)  As we described our practices, I mentioned that I recently helped a patient stop his Adderall, the amphetamine combination drug given for Attention Deficit Hyperactivity Disorder or ADHD.  The patient had come to me on a very high dose and was complaining of many side-effects: anxiety, muscle twitching, severe insomnia, weight loss.  I gradually tapered and eventually discontinued the stimulant over several weeks, with resolution of most of these symptoms.  He thanked me and said he felt much better.  I related this story with some pride, and mentioned to my dinner companions that I've had more success stopping high-dose medication, especially for ADHD, than I've had starting ADHD medication.  Moreover, I opined that ADHD is too readily diagnosed in adults, resulting in a lot of unnecessary amphetamine being prescribed.

I had not anticipated how odd these statements sounded coming from a psychiatrist.  One of the Kaiser docs, a child psychiatrist, quickly noted how many kids she'd helped by identifying and treating their ADHD.  It's an under-recognized problem, she assured me.  The other psychiatrist only saw adults, yet he too underscored how Adderall, Ritalin, and other stimulants helped his patients.  Someone mercifully changed the subject, and we let the matter drop.

It got me thinking though.  First, could we all be correct?  I have no reason to doubt the experience of child psychiatrists who see their young patients perform better, achieve more, and get along better with others when treated for ADHD.  I don't see children myself, and am basically a bystander in the debates over medicating children for ADHD and behavioral problems.  Moreover, even in adult psychiatry I believe that prescribed stimulants can sometimes help, not only for ADHD but also for depression in the severely medically ill, and in some other situations.

But my own experience has led me to be cautious.  "Adult ADHD" is a fad.  Its rate of diagnosis and treatment have skyrocketed in recent years, for no good scientific reason.  I get calls all the time from people who have diagnosed themselves using a simple online checklist and are seeking an MD to rubber-stamp an amphetamine prescription.  Since amphetamines are performance-enhancing even in normals and have street value as drugs of abuse, these potential patients put me in the uncomfortable position of second-guessing their request.  I'm not saying adult ADHD doesn't exist — in fact, I'm sure it does — but this isn't the kind of relationship I want with patients.  So I tell callers I don't do ADHD evaluations, leaving me with lingering regrets about thwarting the subset — I don't know how big it is — who have a legitimate need for this treatment.

And frankly, I've seen these medications over- or mis-prescribed by my fellow psychiatrists on a number of occasions.  In addition to the patient mentioned above, for nearly a decade I've seen a distinguished senior academic for medication treatment of anxiety and depression.  He's never had an ADHD diagnosis.  Nonetheless, he asked his psychiatrist back in 1993 to add Ritalin because a relative with ADHD benefited by it.  He's been on it ever since, 16 years.  I tapered the dose down by more than half, but my patient resists using less, even though it likely worsens his anxiety and he needs medication for sleep.  At this point I expect he's on it for life.  Another patient of mine, a young woman without an ADHD diagnosis but with a history of anorexia, had been prescribed 40 mg of Ritalin daily by her prior psychiatrist.  It helped her concentrate, but also suppressed her appetite, which was a major psychological issue for her.  We tapered down the Ritalin and discontinued it over about a year and a half, at which point she was doing well and reconciling with her mother — who, my patient said, had abused Ritalin herself for a long time.

Well, you get the idea.  I'm not opposed to psychostimulants, honest.  And I do believe ADHD is a serious problem and that it responds well to medication, along with other treatment.  However, I also believe that, in adults anyway, inattention and hyperactivity can mean lots of things.  I believe stimulant medications that cause anxiety, insomnia, loss of appetite, teeth grinding, high blood pressure, and other side-effects ought to be used judiciously.  (And I also believe that a patient needs to have had symptoms by age 7 to fulfill DSM-IV diagnostic criteria for ADHD.)

Some of the most contentious, polarized arguments in psychiatry revolve around ADHD and its treatment.  Are we poisoning our children with stimulants?  Or leaving thousands to suffer unnecessarily?  So far, these arguments still generate more heat than light.   The main thing I learned at the dinner meeting I attended is that, like politics and religion, ADHD and its treatment remains a touchy topic in polite conversation.

My post on Technorati

Technorati.com, the popular blog portal, recently invited bloggers to contribute to their newly revamped site. I signed up and submitted an article there, on ADHD medication. I'm happy to say it appeared on their site this morning, as the leading post in their "lifestyle" section. (I'm sure it will rotate out of the leading position soon.) We contributors agreed to submit content appearing first on Technorati. I'll re-post the piece here once I learn how long they'd like me to wait. For now, head over to their site and take a look, and feel free to comment there, here, or both.