Thursday, April 15, 2010

Rerun: Treating Marilyn

My most recent blog piece touched on a section of a grand rounds I delivered on meds compliance two years ago at a psychiatric facility in Princeton. That section, "The Problem Clinician," received a decidedly frosty reception from my audience of clinicians. This section, from "The Problem Patient," went over a lot better.

This piece first appeared on my blog in Feb, 2009.

The following is based on the first part of a talk I gave to clinicians on meds compliance as part of a grand rounds at a psychiatric facility in Princeton:

'Marilyn walks into your office," I began. "She reveals her moods have been all over the place. Everything points to bipolar. Okay. How do you treat her?"

Believe it or not, no one raised their hands. I was the one who had to suggest that a mood stabilizer might be a good idea, then I had to make sure we had a consensus. Then I went to the catch, namely how does the most important person in the equation - the patient - feel? After all, even the best med in the world is useless if patients won't take it.

Maybe we need to ask Marilyn a few more questions, I suggested. Consider:

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?

Hypomania is the first thing to come to mind when thinking of Marilyn, but the operative word from the DSM regarding this type of behavior is "uncharacteristic."

"For someone else to act like Marilyn," I said, "that may be hypomanic. For Marilyn to act like Marilyn - that's normal."

In support, I cited Ronald Fieve MD of Columbia University, who coined the term, "the hypomanic advantage."

"Keep in mind," I said, "a lot of us view the world through the eyes of artists and poets and visionaries and mystics. Not to mention through the eyes of highly successful professionals and entrepreneurs. We don't want to be like you."

How can I describe the look of surprise from my audience? Like I had let rip a roof-rattler and they were too polite to laugh - I think that best sums it up. I should have thrown away my prepared talk at that stage. Seriously, I should have said. We don't want to be like you. Why should that surprise you?

Instead I plowed ahead:

"We don't want to fly too close to the sun," I continued. "But don't clip our wings. Obviously Marilyn needs to be reeled in a bit. But how do we proceed? What do we have to go on?"

Believe it or not, there are zero published studies for treating hypomania. Zip, zilch, nada. The only solid evidence base involves the acute phase of full-blown mania, when we're bouncing off walls, 911 cases.

"So," I asked, "are you thinking of giving someone with hypomania an industrial strength dose?"

What else is going on with Marilyn? Personality issues? Quirky behavior? Does the bipolar itself affect her capacity to think rationally?

"You're the rational ones," I said. "We know where you are coming from. But do you know where your patients are coming from?"

I clicked to two slides: Fear/feeling threatened, problems accepting authority, cognitive distortions ...

The list went on and on. "Looking like a lot of your patients?" I asked.

"Here's the point I'm making," I continued. "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 - in my opinion - is not treatment."

Back to Marilyn. She's Marilyn. She has enormous gifts and doesn't want her wings clipped. She has various personality issues. And her illness is affecting her judgment.

"We have the advantage of knowing the tragic outcome," I concluded. "Knowing what you know, are you happy just writing her a prescription and sending her out the door?"

Postscript: This first part of my talk - "The Problem Patient" - went fairly well, perhaps because the audience could spin my message in a way that assigned all blame to the patient. There was no way they could do that with the next two sections, "Problem Meds" and "The Problem Clinician," and I got a very different reaction.

More later ...

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