Meds Compliance: The Problem Patient
This is the third on my series of posts on meds compliance. My first post set the scene while my second dealt with the topic of the problem psychiatrist. The two other parts to this equation are the problem patient and problem meds. Let's pick up with the problem patient:
Two and a half years ago, I delivered my first (and last) grand rounds to 50 or 60 clinicians at a psychiatric facility in Princeton, NJ. "Marilyn walks into your office," I began. "She reveals her moods have been all over the place. Everything points to bipolar."
The consensus in the room was that a mood stabilizer would be the way to go.
"But how does the most important person in the equation feel about this?" I countered. "Namely, your patient." After all, even the best med in the world is useless if patients won't take it.
Up on my PowerPoint went a slide from clinical guidelines issued in 2006 by the National Institute for Health and Clinical Excellence in the UK:
Treatment and care should take into account people’s individual needs and preferences. People with bipolar disorder should have the opportunity to make informed decisions about their care and management. … Good communication between healthcare professionals and patients is essential.
"Maybe we need to ask Marilyn a few more questions," I suggested. Here's the deal:
Marilyn is literally larger than life. Over the top is her baseline. It's a legitimate part of her personality. "How long do you think she is going to stay on her mood stabilizer if she thinks her personality is getting medicated out of her?" I asked.
Marilyn comes up quite a bit in my posts here in relation to hypomania, a condition much misunderstood by both psychiatrists and patients. According to the DSM, animated behavior qualifies as hypomania only if it amounts to a change in function that is "uncharacteristic" of the individual in question.
Thus, for someone else to act like Marilyn - that may be hypomanic. For Marilyn to act like Marilyn - that's normal. But even if the behavior is out of character, the mood state may not warrant clinical intervention. As the DSM notes:
The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization.
But, okay, we're in a gray area here. Maybe Marilyn does need to be reeled in a bit. And we definitely don't want her hypomania escalating to mania. So, what in the way of clinical guidelines do we have to go on?
Psychiatry is big on "evidence-based" medicine. Thus, we have an impressive number of clinical trials to support the notion that mood stabilizers and antipsychotics are effective in knocking out mania. Fine, but what about hypomania? Several years ago, I searched in vain for studies on treatments for hypomania and could not find any.
None! Zero. Zip-zilch-nada.
Maybe you can see where this is going. In treating patients with hypomania, psychiatrists are extrapolating from studies used to treat mania. It gets worse. The only reliable mania studies are acute (initial) phase studies, when patients are bouncing off walls. For long-term treatment, the astronomically high drop-out rates in the few studies to date renders these results useless.
"So," I asked. "Are you thinking of giving someone with hypomania an industrial strength dose?" That is, a mania-based dose, only tested on patients during a phase of their illness when getting them out of crisis almost any way possible (including major side effects) is the only objective. Keep in mind, even the low end of the recommended dosing are mania-based doses, based on treating patients in crisis.
Obviously, Marilyn is not going to stay compliant with any med that turns her into a fat stupid zombie eunuch. But there is a lot more going on with Marilyn than just hypomania. After all, this was an individual notoriously non-compliant in her duties as an actress, as well, not to mention as a wife many times over. If she didn't have an outright personality disorder (such as borderline), she certainly had personality issues in abundance. Just ask the directors and actors and husbands who had to put up with her.
So, between her mood disorder and her personality, we have an individual whose capacity to think rationally about her treatment is seriously compromised. Rationally, we know that noncompliance results in more relapses, recurrences, and hospitalizations. "But do you know where your patients are coming from?" I asked.
Up went a short list of irrational reasons a patient may fail to follow doctor's orders:
Issues accepting authority
Lack of insight
Lack of motivation
Failure to pick up social cues
And another slide:
Spectrum Axis II
Looking like a lot of your patients? I asked. Every head in the room nodded in knowing appreciation.
Here's the point I'm making, I told them. Not only are you treating the illness. You are treating any behaviors and attitudes that come in the way of treatment. And you're not going to find that out unless you talk to the patient - and listen.
I wasn't through: "Just sending a patient out the door with a prescription is not treatment."
So, here's Marilyn. We send her out the door with a prescription for a mood stabilizer that she almost certainly will not stay on. She's got three strikes against her, after all. For one, she's Marilyn. Plus, she has super-sized personality issues. Finally, her illness is affecting her judgment.
Of course, we have the advantage of knowing the tragic outcome. Knowing that, why would any psychiatrist be happy sending their patients out the door with just a prescription?