What’s the Diagnosis?

The other day I met a new patient who described a long history of anxiety and depression that recently became severe. She had been to two other psychiatrists in the past year, and was seeing me because she was not getting any better; in fact if anything she was getting worse. She described symptoms that changed from anxiety and mild depression to severe panic attacks and social withdrawal; symptoms that were almost certainly the consequence of her being prescribed large doses of alprazolam (Xanax). She described a pattern that I have seen very often; a person has relatively mild, manageable anxiety, and is prescribed a benzodiazepine. After a few weeks the ‘benzo’ is no longer effective because of a process called ‘tolerance,’ and worse, if the person misses a dose, the discontinuation symptoms FEEL like severe anxiety and panic– leading the person to take more of the benzo. The dose must be increased to get a response, and then the discontinuation symptoms become even greater… leading to a spiral of increasing anxiety and medication use. This is a difficult pattern to break, because the patient must reduce and taper off the medication that once was providing relief– all the while tolerating a certain amount of anxiety and insomnia.

I feel bad for patients in this situation, because they would be better off had they never gone to a doctor for their anxiety in the first place. But the situation in my new patient was even worse– and what had happened to her was not uncommon. As her ‘anxiety’ worsened, the psychiatrist treating her piled on more and more medications. She was prescribed Depakote without relief. Then whe was prescribed risperidone. Then lamotrigine. These medications are all somewhat sedating, and when she complained of being too drowsy she was prescribed the stimulant Adderall, and then modafanil. The stimulants made her shaky, and so the original benzo was increased.

Medications like Depakote generic price, lamotrigine, and risperidone have a place in psychiatry; all three are mood stabilizers, and are used to treat bipolar disorder among a few other conditions. In order to qualify for a diagnosis of bipolar I (the more serious form of bipolar disorder) a person must have a history of ‘mania’– a period of 7 days (shorter if the person is hospitalized) when the person is ‘revved up,’ with less need for sleep, increased risk-taking, racing thoughts, and other specific criteria. There is some credible evidence that the diagnosis of bipolar has been overdone in recent years, particularly in children. Over-diagnosis of depression would not be a horrible thing, given that the medications primarily used to treat depression, a class of medication called ‘SSRIs’, are relatively benign. But the same cannot be said of over-diagnosis of bipolar disorder; medications used to treat bipolar have a number of significant side effects ranging from sedation and tremor to weight gain and diabetes!

When I asked the patient about her diagnosis, she was confused. She was not told that she had bipolar disorder, and so she was not certain why she was taking so many medications. She had no idea that some of the medications were prescribed only to treat side effects from other medications. And she had no idea that the medications had the potential to cause a wide range of systemic illnesses and conditions.

I don’t know what to make of THAT kind of psychiatry. I talk often on my radio show about the need for patients and psychiatrists to spend TIME with each other; time to get the diagnosis right, or in this case to at least come to SOME diagnosis! Too often, medications seem to be prescribed out of desperation; an overly-busy, short-on-time prescriber adding medication not according to a sound treatment plan for a careful diagnosis, but rather using medications to blunt symptoms like firefighters in a helicopter dropping water on a fire.

Not all psychiatric conditions require medications, but sometimes, medications are useful and even necessary. When medications ARE used, I encourage all patients to demand to know the diagnosis that is being treated, the options in medication and non-medication treatments, and the effects and side effects of anything that is prescribed. That understanding will probably take some time– but that time should be a basic part of every psychiatric relationship.