I just read an article on Oprah.com entitled Chill Pills about the use of medication for stress symptoms. I am struck by the sharp contrast between the article and the talks I gave yesterday in College Station, Texas (home of the Aggies).
The biggest problem I see is our “experts” are frequently those who are entrepreneurial enough to write a book OR who have climbed the ladder of academia and achieved professor status in the department of psychiatry at one of our medical schools.
They may be gifted writers but they may not be perceptive/engaged clinicians. Do they have the strong curiosity and discipline required to keep current with our rapidly growing understanding of the science of the mind? Are they empathic, i.e., can they tell their stories from their patient’s point of view? Do they listen and learn from each of their patients – what is it like to have a panic attack, be depressed, or not be able to pay attention? Do they learn the nuances of each of our treatments by doing one thing at a time? Do they work in a joint effort with their patients who they have empowered to actively participate in the treatment process? Maybe, but maybe not.
Some of our highest ranked professors are so busy they hardly have time to see real patients. If they do it’s often a one time consultation where they pronounce a diagnosis and make recommendations for treatment (many times they sound really good). The only problem is the recommendations often don’t work, but the expert never actually sees the outcome of their sage counsel.
A great example of the problem:
The treatment guidelines for managing panic disorder represent the consensus of our leading organization’s experts (American Psychiatric Association). As noted on Oprah.com, they recommend SSRI’s (selective serotonin reuptake inhibitors) like Paxil, Zoloft, Lexapro, Prozac, be used first line. Benzodiazepines (Xanax, Niravam, Klonopin, and Ativan) can be used in acute or pressing situations but must be used with great caution, especially because of sedation and addictive potential.
A recent analysis of prescribing habits of over 7,000 physicians, including primary care physicians, psychiatrists and other specialties, found alprazolam (Xanax, Niravam) to be by far the most prescribed medication for stress disorders. Could it be because these medications work well and have few side-effects?
A 12 year study (at Harvard) in 11 specialty clinics of real patients with panic disorder looked at how they were actually being treated and with what success. One of the good things about the study is these patients weren’t excluded if they also had other problems like depression. Studies the FDA requires for approval of medication are limited to those with only one disorder and many times this selects for patients with lesser degrees of difficulty. How did the clinicians do relative to the APA’s recommendation? Not very well.
- 10% were treated just with SSRI’s
- Combining SSRI’s with benzodiazepines gradually increased from 10% to 20%
- Benzodiazepines alone continued as the common treatment at 50%
Unfortunately, the treatment success outcomes were shamefully low with only about 25% getting well and staying well. The same was basically true for social anxiety and generalized anxiety disorder. The biggest problem I could see was the low doses of benzos that were used. I suspect the cognitive behavioral component of treatment was also very inadequate. The main point is the “in the trenches” the wisdom of the APA’s experts doesn’t represent the real world.
What’s the solution?
Unfortunately, I don’t see light at the end of the tunnel. Entrepreneurial doctors will keep writing books, professors of psychiatry will be looked to as the “experts,” and clinicians will continue seeing patients and studying to keep current.
The clinicians may say to themselves I should write a book, especially when they read or hear things through the media that do not reflect the reality they live everyday. But who has time to write a book? I can barely find the time to write 1-2 blogs a month.
4 thoughts on “Ivory Towers and Publishing Houses: Where to find the experts”
I think it’s very true that the dose of benzos is often inadequate. I’ve found this to be the case with every doctor I have visited, including psychiatrists. In fact, the psychiatrist I see right now has a 1.5mg per day ceiling for Xanax with ALL his patients. Hmmmm… I didn’t think patients should be generalized; I was always under the impression that each patient should be individualized and treated accordingly (as an individual with different needs than Joe Schmoe that the Dr. just had an appt. with). My GF went to a new psychiatrist a few months ago because of insurance reasons, and took her Niravam with her to show the Dr. what she was on. The psychiatrist not only told her not to take them because they were “addictive drugs,” but she took them from her! She did pay for them! They were helping her! Why? Why is there such an “anti-benzo” mentality amongst a lot of the “younger” physicians fresh out of med school? Xanax has been the only medicine that has provided me any relief, at all, for my anxiety, and I can’t even get the Dr. to increase my dose after 2 years! UGH!
Regena Carter Pelham…..I read your valuable story and comments and know the words of a kindred spirit. You said it all: just how many are out there “suffering in silence”…..and even “going silent” (taking their life), when it just hurts so badly that they feel they can no longer endure it? -Keith Bass-
Hi Dr. Jones, remember me? Panic attacks, avoidance behavior since early childhood, then completely housebound w/ severe agoraphobia for years & years. That daily would have me on the floor, clinging to the carpet so that I could feel some form of stability to grab on to and hang on to until my racing mind could get somewhat calm & deal with the reality of existance. To be alive and helpless to escape such mental, emotional and physical torture is truly the closest to what ‘hell on earth’ must be like. I was your willing to work with my much trusted psychologist, Dr. Bob Mandell (that actually made home visits to ME) that help peel me off the floor, eventually be able to work my way to your office with Bob in the car, leading to my ability to drive myself to your office and ALSO the blessing of being to endure leaving my home at other times. It was your willingness to ‘listen’ to me and treatment me with a combination of meds that met & ‘worked’ for my ‘individual’ needs. I had go to atleast 15-20 docs for help, took the every med that the FDA and DSM publications recommended. BUT, I got NO RELIEF. And I never got the feeling that the docs (this started in 1982) even really ‘understood’ or ‘got it’ when I would tell them relentlessly of what I was suffering. Thank you, Dr. Jones, for your commitment to think and step ‘outside the box’ in treating me. Maybe, these people need to hear the voice of the patient, the ‘victim’, the one who utimately is paying the price due to all of this ignorance. I will gladly tell my story, not only to hopefully wake up the ‘sleeping righteous’, but to help get the TRUTH out and expedite better medical treatment to all of the helpless that are forced to suffer in silence, wreck havoc on their families, give up hope, and God knows how many have ended their
lives to finally get relief. I have such empathy for the children that I KNOW are out there suffering from this. Their resulting behavior is not understood by parents, schools or physicians and they are NEVER diagnosed & treated properly. A LOST childhood is horrible and the colateral damage as you continue to live (or manage) thru life is massive. I don’t need to research this…. I have lived it!
Finally figured out how to use the comments page.
I agree. In our long Dr / patient relationship it was a trial and retrial to perfect my medication results. Tried Paxil, Zoloft, Prozac and but I was more depressed over sexual dysfunction than my original symptoms. The last few years have been on Wellbutron and Xanax. Increasing the levels to relieve panic and extreme anxiety (within guidelines) ’till they worked was the best advice I think I received from you. Too little did not work with other Drs. Don’t write a book so you could not keep paying close attention to your long term patients who you keep healthy. Oprah is in the entertainment business, and the “expert writers” are often in it for the ego trip and to sell books. It is hard to find a Dr. Jones.