Saturday, December 29, 2012

Violence In General - Medications

We see a lot of mis-prescribing among our admissions.  Every week we have at least one where we ask “Who the hell thought she should be prescribed Adderall? Now she’s manic and lost her job!” Or “I can see why they were giving her Celexa, because she’s depressed and the delusions have an obsessive quality.  But that’s just not cutting it.  She needs an antipsychotic.”  Thus I am at one level sympathetic to the the idea of meds being the problem.  I see lots of it.

We like things to be neat and tidy.  Sometimes they are.  The sign says STOP.  The customer has ordered chicken tenders. To get a refund you have to mail in the slip. I’m betting your job isn’t always that simple, and ours certainly isn’t.  The usual criticisms of prescribing are that the doctor only sees people for a a few minutes, that they are too ready to see certain conditions and are not aware of others, that they have been fooled by a patient who is intentionally or unintentionally lying, or that drug reps influence them too much.  All rather true, but misleading.  Personalities are complicated, and presentations are complicated.

Hell, you can’t even tell in yourself, can you?  Am I depressed? Coming down with something? Not eating right?  Refusing to acknowledge my real situation? Constipated?  Actually anxious, or OCD, or histrionic?  Spiritually dead? Reacting normally to hard times? Too busy?  More traumatised than I thought? How’s my thyroid?

If you can’t tell, living inside your own head, do you think ten minutes more with the doctor is going to make everything come clear for her?  This is doubly complicated with the young, or uncommunicative, because then we have to get our information from others – usually mom – whose input can range from brilliant to pathological.  We all present differently at different times, and this is magnified when we are uncomfortable.  We put in energy to look good, or to describe precisely how it’s not good at all, or to resolve in out own minds how both things are true.

Psychoactive medications do have side effects, or unexpected effects.  Are antidepressants for kids being overprescribed?  It’s a great newsy sort of item.  But some kids are getting them that shouldn’t, and some aren’t getting them that should.  We know that no matter what the general average is.  See also pain meds, ADD meds, anti-anxiety agents, OCD medications.  What is happening as a general narrative is useful only in whether it red-flags the treatment for a particular patient.  People arrive at the doctor’s office in distress.  Sometimes they don’t clearly meet criteria for anything, but have two or three things that they might be suffering from.  And they are miserable – or they are disquietingly dangerous in their thoughts – or they are not doing well in school. What’s the best thing to do?

In the national discussion, this gets further complicated by people with agendas.  They are sold on organics and hate Big Pharma, so they seize on every problem, refusing to acknowledge benefit.  Or their theology says you shouldn’t need medications (not only Scientology or Christian Science – there are Christian groups, particularly those influenced by chiropractic, natural healing, or promise-driven readings that can get you to the same place.  A lot of the Oral Roberts/Kenneth Hagin theology is pretty cultish, though I don’t know who their current successors are).  Or they just need to know more than everyone present.  Whenever there is a general narrative about psychiatric meds being peddled in the wake of a tragedy, I assume that an agenda-driven group is behind it.  Rahm Emanuel is not the only one who remembers Alinsky’s dictum of never letting a crisis go to waste. It’s hard not to see them as vultures, actually.  I can squint and see that maybe they want to ease another’s suffering, but no.  9 times out of 10 that’s the rationalisation, not the reason.


Dubbahdee said...

OK -- it's all much more complex than it seems, awash in hidden forces and currents difficult to discern. That's all a given. I too am prone to pass anything pronouncement of doom (or victory) through a grid of "it's not that simple."

But it's also not that easy to dismiss by saying it's not that simple.

Take your one example of the time with the doctor. If you take your argument to it's logical extreme -- we should reduce our time with the doctor to ZERO. Just mail in the payment and skip the appointment. Our results would be the same. You point rather assumes that the extra ten minutes would be spent with you and the doctor simply sitting in chairs looking at each other. Certainly in a less hurried conversation other questions might be asked. Other answers might be given. Causes heretofore hidden might be revealed. I think that is a very reasonable assumption IF one also assumes that the physician is actually trying to do her job.

And granted -- some kids get meds who should and vice versa. My question is more along the lines of how endemic is the prescription of meds to children under 18 and how much as it grown in the past 30 years? If we have an entire age-based swathe of our population awash in psychoactive substances that are NOT tested for safety within that age cohort, is that not worth looking at? My understanding is that clinical tests on many of these drugs involved primarily the affects on adult brains. They affect young brains differently.

I could be completely wrong. Probably am. I don't know.

Texan99 said...

I'm skeptical of most psychoactive drugs myself, but if I were miserable enough to consider using them, I'd want someone as thoughtful as you to help me decide which ones.

My poor bipolar nephew has tried many medications, none of which seem to help. He's just in and out of the hospital all the time.

Assistant Village Idiot said...

The safety is certainly worth knowing about - for someone. I don't know how to measure that, and I'm betting most of the people who write about it don't either. That doesn't mean it's not valuable to know about, just that I have nothing to contribute other than suspicions of all parties.

The larger issues of "what are we medicating?" are worth looking at. The kids can't sit still long enough, keep disrupting class? Why do we ask them to sit for that long? We reward the calmer, not necessarily the brighter or more capable, side of the bell curve.

Or we hate to see sad kids. Of course we do. So we figure something that fixes the feeling fixes the problem. To a point, that's true.

Yet perhaps even the negatives are a net gain. We see all sorts of things wrong that we think we can help kids with - conditions we just ignored and told them to leave us alone in past generations. When we know at some level there is nothing we can do, we just point the kid in directions where we hope they will find some way in the world. Once we suspect we might help, we do stuff, even if we do it badly.

I'm not sure that just because we are doing it badly means we should stop. It still may be a net gain.