Tuesday, January 6, 2009

Noncompliance - Time for Psychiatrists to Practice Real Medicine

In my most recent blog, I mentioned a grand rounds lecture I delivered last year to a psychiatric facility on meds compliance. In the talk, I made two comparisons: 1) A psychiatric drug trial to a cancer drug trial, and 2) A hypothetical oncologist appointment to a psychiatric appointment.

The first clinical trial was an Eli Lilly trial of bipolar patients on the antipsychotic Zyprexa. These were patients who responded well to the med in the initial going. Despite that, 79 percent dropped out of the study after 48 weeks. Believe it or not, Eli Lilly actually found a way to put a positive spin on the findings.

This study is all too typical of long term studies on virtually all classes of psychiatric meds, with drop-out/noncompliance rates averaging about 70-80 percent. In one trial, 100 percent of the patients dropped out. In other words, no one finished the study.

The second trial I referred to was an AstraZeneca study of breast cancer patients on tamoxifen. In that study, 26 percent dropped out after one year, almost the exact inverse of the Zyprexa study. But rather than put a positive spin on the finding, AstraZeneca was so alarmed by the high drop-out rate that they stopped the study.

What is going on? Both drugs have horrible side effects, but one group of patients is obviously buying into long term treatment and the other isn't. Could the difference lie in what doctors are telling their patients?

Consider the gist of the message the oncologist gives to a patient:

"It's going to be hell, but there's an excellent chance your cancer will go away."

I made sure all the heads in the room were nodding on that point before proceeding to my next PowerPoint. Now here's what I know too many psychiatrists are telling their patients, I said:

"What are you complaining about? These meds work. Something must be wrong with you. You're much better off than you were before. You need to stay on these drugs for the rest of your life."

I sensed the hackles in the room rising, but plowed straight into my next PowerPoint:

"What the cancer patient may be thinking: One year of hell - if that's what it takes to get my old life back, I'm willing to put up with that.

"What I know the psychiatric patient is thinking: This is the best you can do? You mean I am going to have to spend the rest of my life - like this?"

By now, my audience of clinicians was turning into a lynch mob. But it was only going to get worse. Up until now, I had only been presenting the facts. Now I was about to tell this group of highly-educated and highly-experienced clinicians how to do their jobs:

There is the crucial "window of opportunity" phase in the doctor-patient relationship, I said. The patient has been brought out of crisis and has been reasonably stabilized, but is clearly not well. For many patients, a long hard road lies ahead. You have one chance to get your patient to buy into long-term treatment, and you need to be brutally frank about presenting the bad news along with the good.

First the bad news: These meds are not magic bullets. You may have to put up with significant side effects in the short term. It may take time to dial in your meds just right. You may not feel like yourself. You may want to quit altogether.

Now the good news: I am going to work with you on your recovery. As your knowledge and skills improve, I will be in a better position to help you. You will also be in a better position to help yourself. Trust me, there is light at the end of this tunnel.

So how did this go over? No sooner did I wrap up my talk than I was looking at empty chairs. Literally, it was as if the fire alarm had gone off.

I rest my case ...


Anonymous said...

I agree with most of what you have said. However, as a former RN, (I had to stop working when the Depression got so bad I was scared I would make a mistake and kill someone) I think you have forgotten the role the Insurance Companies play in this. In some states they still get away with not covering Mental Health. Even when it is covered, like here in Minnesota, it goes something like this; one hour initial consultation with psychiatrist is covered, meds started. A certain number of visits with a talk therapist (usually not able to prescribe meds) are covered---between 12-20 per year depending on diagnosis and your state. Follow up medications assessment with psychiatrist of l5-20 minutes is covered every 3-6 months depending on diagnosis and which medications are involved. The organization the psychiatrist works for usually manadates that a certain number of patients per day be seen--as dictated by the insurance companies and their own accountants.This is in addition to making rounds on any inpatients and conducting groups and staff education. In short, as in every branch of medicine, level of care is not usually decided by the professionals providing the care but by accountants, lawyers and other bean counters. On top of that, insurance companies get away with messing even more in the case of Mental Health, because too many lawmakers and memebers of the general public don't believe Mental Health issues really exist.

Even in the Medical Field, when I was still practicing nursing, I had a work restriction ordered by my psychiatrist--I was not supposed to work more than my scheduled hours. Somehow, this fact was never passed on to supervisors and I was constantly being told, "Well, surely you could do one extra shift,or stay over, or 'you just need to think more positively about yourself'"

John McManamy said...

Hi, Anonymous. I absolutely agree. In my talk, I did sympathize with the bind clinicians found themselves in due to insurance companies. Definitely, due to all kind of constraints, they cannot practice medicine and therapy the way they want to. I made it very clear that they weren't at fault on this point and other points. But still, they cleared that room so fast it made my head spin.

Anyway, I very much appreciate you posting and hearing your story. I very much value what you have to say. Welcome to "Knowledge is Necessity" and please let's keep the conversation going.