Today one of my patients asked a question about her medication, an SSRI, and my answers might be useful to others taking similar medication.  She was taking fluoxetine, brand name Prozac, for a number of months.  Even at a relatively high dose of fluoxetine, she continued to experience significant anxiety.  Fluoxetine is ‘activating’ in some people, meaning that it sometimes increases the person’s sense of energy, which can, in turn, increase anxiety.  At some point we decided to change to escitalopram, brand name Lexapro, a newer SSRI that has a high potency and somewhat less activation.

After two months, the anxiety seemed to be a little worse if anything;  certainly not improved.  Moreover the person felt that her mood had dropped somewhat since making the change.  She called to ask if either fluoxetine or escitalopram are better for anxiety vs. depression, in consideration of changing back to fluoxetine, or to a different medication altogether.

My Response:

Hi XXXXXXX,

Lexapro and fluoxetine are both SSRIs, i.e. they both essentially do the same thing.  The same can be said for citalopram (which is virtually identical to Lexapro, generic name escitalopram), sertraline (Zoloft), and paroxetine (Paxil).  They ALL block the transfer of serotonin back into nerve terminals after it has been released at the synapse.  They ALL work in similar brain regions, on nerve terminals that release serotonin.

The individual differences between medications probably has more to do with misperception and placebo effects than true differences between the medications, with a few exceptions.  Besides their SSRI effects, each medication has minor actions at other receptors— paroxetine’s actionsat histamine receptors, for example, tends to increase appetite and cause drowsiness.  Some of these extra actions are useful some are not.  For example, fluoxetine tends to reduce appetite and  boost energy in MOST, but not all people— effects that some people find desirable.

I don’t think there is much evidence that one SSRI is better for anxiety vs. depression or vice versa.  In fact, I don’t think there is much evidence showing that one SSRI is better than another for any indication.  People who do pharmaceutical studies tend to avoid head to head comparisons of medications, for reasons that I’m not entirely aware of.  Maybe a company potentially funding a study would consider the stakes too high if the results favored the other medication.  There are, again, some minor exceptions.  Fluvoxamine is an older SSRI that has a reputation for treating OCD.  But even in that case I think the reputation is a byproduct of rumor and expectation, rather than the result of scientific study.

I think of SSRI’s primarily as ‘anti-obsessing’ medications.  They all have similar indications—for anxiety, OCD (which is a form of anxiety), panic attacks, and depression.  Fluoxetine is indicated for premenstrual dysphoric disorder or ‘PMDD’, but I think most psychiatrists would say that any SSRI would work in a similar fashion for that condition.

Why do SSRIs treat depression?  From what I can see, they reduce negative obsessing, negative rumination, obsessing over worry about perceptions by others… all ‘obsessive’ actions.  I do not generally see a ‘lift’ in mood, as much as a letting go of negative thoughts, negative self-reflection, and worry.

Lexapro is a very potent SSRI; the most potent of all of the SSRIs.  That doesn’t necessarily mean that it works better;  it means that a similar effect requires a lower dosage, which may mean getting the desired therapeutic effects with fewer side effects from actions at other receptor sites.

To boost mood, psychiatrists commonly ‘augment’ SSRIs with different typse of medication.  One common combination is an SSRI plus bupropion (Wellbutrin), the latter blocking reuptake of dopamine.  Other combinations have been heavily marketed in recent years, such as adding Abilify or Seroquel, but those medications have wide-ranging effects at multiple receptor systems, and are generally reserved for fairly serious depression.  They have significant risks and side effects compared to SSRIs and bupropion.

Let me know if I can answer any other questions for you.  I do not think you would do significantly differently on a different SSRI, but I would not rule it out completely.  One of the biggest mistakes that psychiatrists make is changing meds too frequently… but you have been on the Lexapro for some time, and a change back to fluoxetine would not be harmful.  The actions are similar and so it is considered a ‘lateral move’, i.e. one where you would not be starting over, but rather moving to a different side effect profile.

Take care,

J

Every now and then I post something just because it is an example of the beauty of our short human existance….

Like other docs, psychiatrists receive email surveys now and then asking about different aspects of life as a psychiatrist– about the medications favored for treating depression or anxiety, the fees charged for different types of patient visits, and the amount of time spent at work versus home.

I received such a survey last week, in multiple choice format.  Much of it was the same as usual, asking the things I described above and similar questions.  But one question made me pause for a moment, and to re-read the question and the choice of answers.

The question:  What is the average amount of time spent with each patient?

I looked for my answer among those listed:  a. 3 minutes; b. 6 minutes; c. 9 minutes; d. 13 minutes; or e.  20 minutes or longer.

That’s it?  No ’30 minute’ choice?  No 60 minutes?  I wondered if the survey was intended for a different specialty– perhaps for… for what, exactly?  I checked the survey email and sure enough, it was for psychiatrists.  And I wondered– how the heck can ANYONE take care of patients, based on appointments that last 9 minutes– let alone 3 minutes?!

I wondered if the answer template was chosen from a different survey; one that was used for a different medical specialty.  But when one thinks about it, is there ANY medical specialty, where the doctor can do a good job by seeing people for an average of 9 minutes?  I realize that the specialty of medicine has changed.  Doctors have ceased to be the friendly confidant, and are now ‘care gatekeepers.’  Somewhere, some doctor agreed to work for the insurer’s interest, accepting extra payment from the insurer in return for agreeing to keep the patient from seeing specialists– and now the role is taken for granted.  Isn’t that something?  Doctors being paid, by insurers, to prevent access to care.  The term for that, by the way, is ‘managed care.’  Funny how nice it sounds;  managed care. managed care.  Almost sounds like a good thing!

I’m getting off track… if you wanted to see a neurologist for your migraines, but your family practice doctor wants to get his low-utilization bonus and DOESN’T want you to go to a neurologist, how long would you like to talk about it?  Four minutes?  OK, but you just wasted half your appointment!

Psychiatry visits, I would think, run a bit longer than some other areas of medicine. Patients sometimes speak more slowly;  they are sometimes less organized;  they might be confused.  As I think about the visits in my own practice, I recognize that I would have quite a challenge if I took the generous ’9 minute’ option…  we walk from waiting area to office.  Stop on the way to offer a soda from the fridge, or a cup of coffee.  Walk the rest of the way, and choose a place to sit.  Gosh– that’s three minutes right there, only six left.  The person then takes a moment to tell me that she lost her job;  I encourage her to tell me the story quick– in two minutes or less.  That leaves four minutes.  She wants to tell me about her impending divorce, or about the trouble her son is having in school–but I tell her to stick to the facts.  But still, just saying that took up another minute! Three left….

I tell her that we could try an SSRI.  Darn– she doesn’t know what THAT means– that’s going to be two more minutes, even if she doesn’t ask any questions.  I speak faster and faster, but watch as the second hand makes those final three full circles…  and I haven’t said anything about the risks, the other options, and of course the many non-medication things that she can do, to improve her mood.

You get the idea.

This situation, the gatekeeper issue, and many other issues– such as requirements to follow their treatment plans to THEIR liking– are a few of the reasons for me to opt out of health care networks and insurance panels.  As a physician and as a psychiatrist, I want to have ONE boss–and that is you, the patient.

I have a hard time understanding how ANYONE would want it any other way.

As a solo-practice psychiatrist, I am more connected to the cost/value equation of my services than the typical system-employed physician.  I’ve also written in prior posts about my concerns with modern psychiatry.  I have worked in a variety of settings over the course of my career, and I realize that coming to an understanding of something as complicated as another person’s subjective life experience is a very difficult endeavor.  At the very least, such an understanding takes time.  It also takes a willingness to maintain the constant recognition that my perception may be wrong, and may be the result of my own bias.  Finally, it takes a certain amount of intelligence.  Over time, certain patterns of thought become apparent and easier to recognize– but these patterns are extremely complex, and trying to provide insight into such patterns, without causing a person to take offense, requires intelligence, patience, and tact.

I have come to the realization (a somewhat surprising realization, frankly) that psychiatry works, when practiced properly.  I’ve come to realize that the ten-minute med check is worse than worthless, as a ten-minute glimpse of a person’s day is more likely to lead to the prescribing of a harmful medication than a helpful one.

On the other hand, if one has the time to sit and share small talk, then review the important issues occuring in a person’s life, and then discuss the problematic symptoms that the patient is experiencing…. then ask questions that provide context for the symptoms, and perhaps make a small suggestion or two in order to provide outside insight into the cause of the symptoms…then present the different medications sometimes used for the person’s symptoms, after first discussing whether the person would prefer medication over working on the problem through more ‘mindful’ approaches… then discuss the different side effects possible with each medication, and the likelihood that the medication chosen would be helpful…

If one does all of these things, psychiatry can actualy lead to profound improvement in a person’s symptoms.

I thought about this situation recently, after paying over $500– my deductible– to repair my car, after hitting a deer.  The cost had to be paid, and I found the money and paid it.  I’m not a ‘rich doctor’ for reasons that I’ve discussed elsewhere, so the expense was significant– but I need a car, and it had to be paid.  Likewise, I had to come up with $3000 to repair my septic tank this spring, since the alternative– having disgusting liquid bubble out of my lawn– was not an option.  I had to pay my speeding ticket– I’m trying to slow down now, by the way– and I had to pay for my own health problems.

If I need surgery, the cost will likely run in the tens of thousands of dollars.  Heck, having a couple warts removed ten years ago cost $400, and the doc was in the room for about 5 minutes.  My auto repair bill, paid graciously by my insurer, amounted to $11,000.

Then there is the cost of psychiatric care.  For reasons I alluded to in the first paragraph, I have rejected the insurer’s model of psychiatric care– the 4-6 patient-per-hour, 10-minute med check.  I spend 90 minutes on the first appointment– often more.  And follow–up appointments last at minimum 30 minutes, and for more complicated cases, 60 minutes.  Because I see only a third as many patients, I do not accept the dramatic discounted fee offered by insurers, and patients are required to pay something.

For patients with a deductible, their cost is essentially the same as for an in-network doctor.  For others, insurers pay some portion of my fee, and for some, insurers pay nothing, leaving the burden of the full cost of an appointment– $199– on the patient.  For that $199, the patient receives 30 minutes of my attention, based on an education that cost me over $100,000 (not counting college), and 16 years of my life to complete– not counting grad school.

I see people who are truly suffering;  people with significant anxiety, depression, addictions, phobias– problems that cause much greater disability than would a torn ACL.  So here (finally) is my question.  Why is it that people will roll their eyes and pay their $2000 deductible for the torn ACL, as their insurer pays $20,000 more, yet refuse to spend anything to treat their depression?   Given the effect of social anxiety on a career, why will people pay $3000 for a septic tank, yet consider $400 unreasonable if spent to improve their ability to interact with others?

We all know the importance and value of a close relationship with a friend or spouse;  we all fear being alone at the end of our lives.  So why do we consider a $1000 plasma TV a ‘steal’, yet consider the same amount, if spent to solidify a marriage, a huge expense?

There is so much good that psychiatry can do.  But I am not impressed by the value of fast diagnoses, and rapid-fire medications.  On the other hand, a limited series of visits, to treat targeted symptoms, is one of the most cost-effective areas in medicine.  I often think to myself, ‘I can FIX this person’s problem– but not in 30 minutes!’  I’ll be frustrated that a person does not consider treating their psychiatric symptoms as valuable as purchasing a new car, or a larger house.  Gosh– my entire cost of treatment– enough for plenty of visits– can be covered by ONE monthly mortgage payment.  And while the mortgage bills keep coming, the benefits of treating one’s symptoms can become a gift that keeps giving, month after month and year after year.

Please help me out by answering the poll below– I’ll try to discuss the results on my radio show in a few weeks.  Thank you for helping me understand an issue that’s had me a bit frustrated!

Today on my radio show I mentioned my frustration with being ‘in my 50′s’, and the injury to my knee that happened while stowing stuff in the garage last night. She sent me the video below– and I got a kick out of it!

Universal healthcare sure sounds appealing. I resent the high price that my family pays for our health insurance, and my deductibles prevent the policy from paying anything toward the occasional minor surgery or consultation. But one thing is apparent for anyone who opens a newspaper this summer– the US is struggling to pay the bills. While we once gazed at Canada or the Brits with condescension, we now look with envy at the relative soundness of their economies. Canada balances their budgets in part by tapping their large oil reserves– while the US reserves at both coastlines are buried much deeper in regulations and prohibitions than in seawater. And Great Britain has found the courage to reduce government spending to a much greater extent than even the most ‘severe’ proposed reductions in the US.

Seniors Suffer in the UK

Even though Canada and Great Britain are on more sound financial footing than the US, both countries have struggled under the weight of their own healthcare programs. For many years both countries have rationed healthcare to an extent that would shock US health consumers. In Canada, the process is called ‘queuing’, which refers to long wait lines for procedures– sometimes longer than the life-span of the person in line. A patient recently complained that his MRI for his sore knee couldn’t be done for several weeks at his local US hospital; in Canada, the same test would be done after a period measured in years, and would include travel to a regional medical center– not the trip to the local hospital as in the US.

Limitations on care in both countries are minimized by the governments, although the press, save for the most liberal publications, frequently describe the dire circumstances for anyone unlucky enough to need surgery, a catheterization, or any other procedure. As the US chooses to step closer to the British model, we should take a look at the ‘future of US healthcare’ if that model is firmly adopted.

From the UK’s Independent:

Cataracts, hips, knees and tonsils: NHS begins rationing operations;   Almost two-thirds of trusts affected as cuts bite

Anne Ball, 71, a retired business consultant: ‘I have bilateral cataracts and under the original NHS criteria I was entitled to have at least one of mine treated – but then the West Sussex health authorities decided to change the threshold level to save money’

Hip replacements, cataract surgery and tonsil removal are among operations now being rationed in a bid to save the NHS money.

Two-thirds of health trusts in England are rationing treatments for “non-urgent” conditions as part of the drive to reduce costs in the NHS by £20bn over the next four years. One in three primary-care trusts (PCTs) has expanded the list of procedures it will restrict funding to in the past 12 months.

Examples of the rationing now being used include:

* Hip and knee replacements only being allowed where patients are in severe pain. Overweight patients will be made to lose weight before being considered for an operation.

* Cataract operations being withheld from patients until their sight problems “substantially” affect their ability to work.

* Patients with varicose veins only being operated on if they are suffering “chronic continuous pain”, ulceration or bleeding.

* Tonsillectomy (removing tonsils) only to be carried out in children if they have had seven bouts of tonsillitis in the previous year.

* Grommets to improve hearing in children only being inserted in “exceptional circumstances” and after monitoring for six months.

* Funding has also been cut in some areas for IVF treatment on the NHS.

The alarming figures emerged from a survey of 111 PCTs by the health-service magazine GP, using the Freedom of Information Act.

Doctors are known to be concerned about how the new rationing is working – and how it will affect their relationships with patients.

Birmingham is looking at reducing operations in gastroenterology, gynaecology, dermatology and orthopaedics. Parts of east London were among the first to introduce rationing, where some patients are being referred for homeopathic treatments instead of conventional treatment.

Medway had deferred treatment for non-urgent procedures this year while Dorset is “looking at reducing the levels of limited effectiveness procedures”.

Chris Naylor, a senior researcher at the health think tank the King’s Fund, said the rationing decisions being made by PCTs were a consequence of the savings the NHS was being asked to find.

“Blunt approaches like seeking an overall reduction in local referral rates may backfire, by reducing necessary referrals – which is not good for patients and may fail to save money in the long run,” he said. “There are always rationing decisions that have to go on in any health service. But at the moment healthcare organisations are under more pressure than they have been for a long time and this is a sign of what is happening across many areas of the NHS.”

According to responses from the 111 trusts to freedom-of-information requests, 64 per cent of them have now introduced rationing policies for non-urgent treatments and those of limited clinical value. Of those PCTs that have not introduced restrictions, a third are working with GPs to reduce referrals or have put in place peer-review systems to assess referrals.

In the last year, 35 per cent of PCTs have added procedures to lists of treatments they no longer fund because they deem them to be non-urgent or of limited clinical value.

Some trusts expect to save over £1m by restricting referrals from GPs.

Chaand Nagpaul, a member of the British Medical Association’s GPs committee, said he was concerned about PCTs applying different low-priority thresholds and rationing access to treatments on the basis of local policies.

He said the Government needed to decide on a consistent set of national standards of “low priority” treatments to help remove post-code lotteries in provision. “Patients and the public recognise that with limited resources we need to make the maximum health gains and so there needs to be prioritisation. What is inequitable is that different PCTs are applying different thresholds and criteria,” he said.

A Department of Health spokesman said: “Decisions on the appropriate treatments should be made by clinicians in the local NHS in line with the best available clinical evidence and Nice [National Institute for Health and Clinical Excellence] guidance. There should be no blanket bans because what is suitable for one patient may not be suitable for another.”

Bill Walters, 75, from Berkshire, recently had to wait 30 weeks for a hip operation instead of the standard 18. “I believe that the Government is doing this totally the wrong way,” he said.

Case study: ‘They changed the rules to save money’

Anne Ball, 71, is a retired business consultant who used to work in electronics

“I have bilateral cataracts and under the original NHS criteria I was entitled to have at least one of mine treated – but then the West Sussex health authorities decided to change the threshold level to save money.

“It’s like looking through gauze. Everything is foggy, and I’ve got quite a large ‘floater’ in my left eye. The consultant was as distressed as me, having to tell me, and he thought with my eyesight he wouldn’t be able to function.

“I’ve appealed because the cataracts are having a significant impact on my quality of life and it’s left me depressed and fearful about my low vision, which will continue to deteriorate. The new guidelines mean that people who fall below the standard set by the DVLA still do not qualify to have surgery. My vision is not good enough to drive at night.

“I’m not a cranky old lady. I’m the chair of a local village charity and I do a lot of computer work that is affected.

“It will just store up costs for future years, putting a strain on resources as more patients will end up in falls clinics. The longer you put it off the more complex the operation becomes and the riskier it is for the patient.”

I’ve described my approach to psychiatric care throughout my web pages. In case you’ve missed those comments, I’ll briefly summarize them below. I’m writing this post primarily so that I will have a web address to give people who ask about my practice.

Some background for the goals I’ve set for my practice:

- There are times when medication is a Godsend for psychiatric illness and symptoms, for example in treating moderate to severe depression, REAL bipolar disorder (i.e. not the bipolar label that is tossed on to every teen who is acting out), psychotic disorders, and moderate to severe anxiety disorders. Children and adults with significant ADD also do much better with medication than with treatments that do not include medication.

- On the other hand, there are many cases of over-reliance on medications. Studies have established that the best treatments are those that combine medication with attempts to improve insight into problem behaviors. Recent studies suggest that antidepressant medications do little for mild depression, and that at least some of the benefit comes from the patient feeling understood, cared for, and reassured that things will ultimately be OK.

- I find the practice employed in some psychiatric offices to be utterly deplorable, where people are seen for very limited periods of time, diagnoses are assigned, and potent medications are prescribed– without taking the time to understand ALL of the factors involved in the patient’s symptoms, and to explain all options for treatment– including the risks of each option.

- People do well when they are treated well. People want to be ‘understood’ by their psychiatrist, and that cannot happen if an appointment begins with a 30-minute wait! How, in such cases, can the psychiatrist claim empathy for the patient’s feelings– right after demonstrating the opposite? And how can someone accurately assess the personality traits of a person who has just been forced to go through a dismissive, frustrating experience?

- It takes time to understand a person– for many reasons. When I begin treatment of a person seeking help, I want to know that person’s strengths; not just the strengths that the patient knows about and describes, but the strengths that I witness and hear about as the patient settles into a long discussion. I also need to know the things that threaten the patient; those that the patient is aware of, but more importantly, the things that the patient does not yet recognize. And again, that takes time. People have a way of acting when meeting a person for only 15 minutes, that disguises how that person truly feels inside. It takes time for a person to let go of that presentation, and settle into being him/herself.

My practice

- With these principles as background, my practice is designed create an environment where people feel relaxed, respected, and understood. I set aside at least 30 minutes for every appointment, allowing time for us to truly understand each other. My appointments start on time. My patients wait a couple minutes for a 30-minute appointment– rather than waiting 30 minutes for a 5-minute appointment!

- I provide formal psychotherapy, usually with hour-long appointments that are scheduled for a predefined period of time, in order to tackle a predefined problem. My approach is ‘psychodynamic,’ meaning that I assume that we all have an unconscious part of our minds, where we repress painful and frightening feelings.  I sometimes use tools from cognitive behavioral therapy as well, depending on the particular symptoms and on the patient’s style of interaction and comfort level.  Beyond formal psychotherapy, I use every visit as a chance to understand the person seeking help, and to help that person understand their symptoms and options. Having a full 30 minutes for a ‘medication visit’ allows us to get things right the first time, instead of random trials of medication after medication.

- I do not belong to insurance panels. I realize that by not contracting with insurers, some patients may pay more for care than they would from a participating doctor. Unfortunately, insurance is set up to pay for ten-minute med checks– a form of psychiatry that I find to be worthless, in cases where it is not actually harmful.  I wish that I could be flexible, and accept insurance in some cases, but the insurance industry does not allow that situation.   I encourage people to consider the ‘big picture.’  Recent articles in the Wall Street Journal and the New York Times have decried the loss of traditional psychiatry as a result of the pressure by insurance companies.  The articles describe the problems with the ’15 minute med check’ in a field as complex as psychiatry.

- I do submit to all insurers, and many do cover non-participating doctors, at least in part.  If you have a high deductible, my relationship with panels may have no relevance to your costs.  I do accept charge cards for payment.

- I ask that people consider a couple of factors when choosing a psychiatrist.  You will not wait more than a few minutes in the office when see me, meaning that your time away from work or from home is more predictable.  I answer e-mails, so that I can answer the short questions that invariably come up when starting any new treatment. But most of all, I believe that my approach is more likely to reduce your symptoms, and more likely to prevent recurrence of your symptoms.  Working together we will improve your insight into the causes of your symptoms, helping you become more proactive in maintaining good health.

- The kind comments that I hear most often from my patients is that they feel that they can ‘be themselves’ with me; that I do not judge them, and that I act as if I have been where they are.  Those comments are accurate;  I have been there.  Life is sometimes very difficult, and I have had times of great struggles, as well as times of success.  I make no secret of my own experiences, hoping that my own openness will help to reduce the stigma that people continue to feel and experience when dealing with psychiatric symptoms.

That is my practice, in a large nutshell!  If you have any questions about my practice, feel free to write to me drj@fdlpsych.com .

JJ