Shirah Vollmer MD

The Musings of Dr. Vollmer

Psychopharmacology Ranting

Posted by Dr. Vollmer on August 9, 2011

The word on the street is that psychotropics are being prescribed for people who do not have mental disorders, implying that primary care doctors are overprescribing SSRIs, the class of medications most commonly used to treat anxiety disorders and depression. http://content.healthaffairs.org/content/30/8/1434.abstract. Here comes the rant. In point of fact, SSRIs are underprescribed by primary care doctors because in general, primary care physicians do not take the time to inquire about their patients’ mood state. The problem with this article, which has been picked up by the popular press, is that are diagnostic system is imprecise, such that it is appropriate to prescribe SSRIs to people who do not meet criteria for a mental disorder, but still have disabling symptoms which significantly impair their quality of life. Clearly, the problem is that primary care physicians are not documenting the indications for the SSRI, making it look like they are overprescribing them. The adage ‘if it is not written, it did not happen’ applies here. Primary care physicians, in general, are not trained to document the symptom which triggers the prescription for psychotropic medication. They are trained to document a diagnosis, such that when the patient does not fit in the category of a mental illness, then the physician prescribes the medication but does not communicate in the chart the basis of that prescription. This then becomes a problem of documentation, not a problem of overprescribing. This is also a problem of training. Primary care physicians need to be trained by psychiatrists to prescribe SSRIs, not by other primary care physicians, which is what is most commonly done now. Psychiatrists who work with psychotropics every day are more skilled at the important nuances of treatment, so they should be the ones coaching the primary care docs about psychopharmacology. This seems obvious, yet it is not usually done. One reason is the lack of respect for psychiatry as a field. Those doctors trained before 1988, trained before Prozac came out, and as such, their view of psychiatry is that it is a field which does not have a lot to contribute to the walking wounded. That is, to them psychiatry is a field which is only useful for chronic mental illness. My hope is that as more doctors are trained ‘post-Prozac’, then more physicians will have respect for psychiatrists who can help them improve the quality of their patients’ lives. I hope and I rant. That is not a contradiction.

4 Responses to “Psychopharmacology Ranting”

  1. Shelly said

    You are correct in your writings about physicians not respecting psychiatrists but one things you are forgetting is that if PCPs write down the indications for SSRIs, insurance companies and then employers will find out about the diagnoses and stigmas will be attached. Instead of working to change the atmosphere surrounding respect or disrespect for psychiatrists, perhaps work on lessening the stigma surrounding mental illness? Once a physician dispenses antidepressants to a patient (and it is written in an electronic file), everyone in the entire medical system knows that the patient is “depressed” and they take the patient’s physical complaints less seriously, attributing all somatic symptoms to his emotional or psychological problems. No wonder nobody wants to be diagnosed with a psychiatric condition!

    • I understand what you are saying but ethically if a physician writes a prescription, he/she must write what the indication is. I agree that this can create an unfair bias about the patient, but that is another problem that needs to be addressed.

  2. AA said

    Dr. Vollmer,

    I am not following your reasoning.

    Too many people are placed on psych meds for life issues when they should have been offered counseling. For example, many years ago, I worked with someone who was the victim of domestic abuse and somehow, the doctor interpreted her symptoms as being bipolar. She was about as bipolar as I was the President of the United States.

    You might want read various blog entries by Dr. Mark Foster, http://www.madinamerica.com/madinamerica.com/Foster.html, who realized that he was one of those physicians who previously thought that SSRIs were the answer to everything and realized how mistaken he was.

    Anyway, these folks are wrongly placed on meds and the PC physician stops monitoring them. When the person realizes they know longer need the drug, they can’t get off because so many of your colleagues are clueless about tapering. People in these situations end up on boards like this for help,
    http://survivingantidepressants.org/index.php?/index.

    And of course, now they are dealing with stigma that Shelly talks about.

    • Hi AA,
      Thanks for your comments and thanks for subscribing to my blog. As you can tell, I am a big proponent of psychotherapy. I am also very concerned about the over-diagnosis of bipolar disorder. Thank you for referring me to Dr. Foster’s blogs. SSRIs are not the answer to “everything” but they can be helpful. The biggest problem, as you said, is that most primary care doctor does a poor job in monitoring these medications. The stigma will go away when more people are open about their experience with these medication. As with all of pharmacology, the drug has to be a good fit with the person taking it. This is a trial and error process, so generalizations are hard to make. The point about this blog is that the DSM has not kept up with the indications for our medications. In other words, many people benefit from an SSRI even though they do not meet criteria for a mental disorder. For example, many people who suffer from terrible irritability feel better on SSRIs even though irritability is a symptom and not a diagnosis. Thank you again for your comments. Let me know if you have any more questions.

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