A thinking doctor

bifrost99 · � #1 � 12-26-2006, 04:16 AM

Doctors should do more of this type of thinking, though it would be better if they just prioritize the non-drug approaches. 8) The article is a bit encouraging, though, showing that there are doctors who don't just take the word of big Pharma.

From the online issue of the Los Angeles Times:

Quote:

Pressured to prescribe

The drug rep was only too happy to fill his sample closet with an antipsychotic. But as an internist, he felt it was outside his domain.

December 25, 2006

LOOKING at my supply closet, I was suddenly struck by the boxes of Zyprexa samples piled high inside. I'm an internist, a doctor who treats sore throats and high blood pressure. This medication was an antipsychotic drug designed to treat the severe delusions and agitation of bipolar disorder and schizophrenia.

What are these doing here? I asked my office nurse. The drug rep brought them, she said. She wants to speak to you.

I had long ago developed the time-saving habit of ignoring the drug reps who appeared in the hallways of my office offering unsolicited advice on what I should prescribe. I accepted their free samples to give to my poorer patients and their free lunches to feed my staff — but I ignored their advice. I, not they, had studied drug pharmacology.

But on this particular afternoon several years ago I had an opening in my schedule, so I invited the rep into my consultation room. I wanted to know why she was suddenly bringing me Zyprexa.

Like all the drug salespeople who came to visit me, she was better dressed and younger than I was — and eager to recommend treatments.

Sitting across from my desk on the small blue couch, the Eli Lilly rep tried to convince me that there was a good reason those boxes should be piled next to my coveted cholesterol drugs. She said that I was likely seeing bipolar patients, as well as demented patients who were agitated.

I acknowledged that one 85-year-old patient, Anne, who had been coming to see me for 20 years, had been placed on Zyprexa when she became demented and paranoid that ruffians who had harassed her as a child had somehow re-entered her life (they hadn't). A small dose of Zyprexa had helped Anne enormously, and she was now much calmer and no longer paranoid.

But I told the rep that I hadn't prescribed the drug, that I had sent Anne to a psychiatrist who had prescribed it. Bipolar disorder and agitated dementia (for which Zyprexa is sometimes used off-label) are in a psychiatrist or a neurologist's domain.

I mentioned that most of the psychiatrists I knew used milder and better-tolerated mood-stabilizing drugs such as Depakote for bipolar disorder, that they didn't rely on the more powerful and side-effect-plagued Zyprexa as a mainstay of treatment. And neurologists had told me that antipsychotics such as Zyprexa are often over-prescribed for dementia and are not indicated if the patient is relatively calm.

When the drug rep persisted in trying to persuade me to prescribe the drug, I grew angry. Raising my voice, I accused her of trying to jeopardize patient care.

At that point, she said the company had given her a directive to reach out to as many internists as possible. The company felt that we internists as a group were underutilizing the drug, she said.

That's dangerous thinking, I replied. I told her that such persistence would no doubt lead to the drug being wrongly prescribed — that it would hurt patients. She seemed insulted by my charge, and left, and I gave all her sample boxes to Anne, the one patient I had who was clearly benefiting from the drug.

I was reminded of the incident last week when news reports emerged that Eli Lilly had reportedly urged primary care doctors to use the drug for elderly patients with symptoms of dementia. The company has denied promoting the drug for off-label uses.

The reports highlighted for me the crucial role that internists and other primary care doctors play in screening for psychiatric illnesses but also in knowing when to refer these patients for proper treatment. Although psychiatrists are not always available and not all patients are willing to see them, doctors must carve out our areas of expertise in keeping with our training and experience, and depression and psychosis are simply not my areas as an internist.

Not everyone agrees. Several years ago at a dinner, I was introduced to William Styron, the author who penned, along with his novels, the groundbreaking memoir on depression, "Darkness Visible." When Styron heard that I was an internist, he remarked that it was an internist who had diagnosed his depression, and that it was the internists and primary care doctors on the front lines of medicine who he felt are best equipped to treat depression.

I don't deny I can play a role in the treatment of mental illness, but this is best accomplished in conjunction with a true expert. For instance, when I learned that Zyprexa can cause weight gain, I called Anne's psychiatrist and together we made the decision not to stop Anne's prescription because she had not gained weight on it. She already had diabetes, which has recently been associated with Zyprexa, but the pill had not worsened her condition.

Prescribing medicines requires a cost-benefit analysis, and patients like Anne clearly benefit from Zyprexa. With others the decision is not so clear, and I have received several calls recently from relatives of Zyprexa patients who fear these patients will gain more weight, develop diabetes or even die prematurely.

I tell them that this cost-benefit decision should be made in conjunction with the patient's psychiatrist, not solely by an internist placed under pressure by a salesperson.
--------------------------------------------
Dr. Marc Siegel is an internist and an associate professor of medicine at New York University's School of Medicine. He can be reached at marc@ doctorsiegel.com.

https://www.latimes.com/features/heal...adlines-health

Gerry

Marcus · � #2 � 12-26-2006, 08:58 AM

Good article Gerry.

On the front lines primary care docs are confronted more and more with psychosis and problems associated with dementia.

Look at the stats. By 2030 about 30 percent of elderly, (thats you and me) will have alzheimers or some other significant dementia requiring an antispychotic due to the combative and delusional states associated with the diseases.

Where are we going to get all those psychiatrists from to see all these patients?

bifrost99 · � #3 � 12-26-2006, 01:25 PM

Quote:

Originally Posted by Arrowwind

On the front lines primary care docs are confronted more and more with psychosis and problems associated with dementia.

Look at the stats. By 2030 about 30 percent of elderly, (thats you and me) will have alzheimers or some other significant dementia requiring an antispychotic due to the combative and delusional states associated with the diseases.

I still tend to think that all these mental "problems" are just convenient inventions to sell drugs. (In fact, a lot of physical "problems" are also now being invented to sell drugs. "Gastric reflux" comes to mind.) Nutrition may be a simple solution to some of them. Others might just be plain discipline (ADD/ADHD, depression, anxiety) -- we control our minds, not the other way around, and definitely not by drugs. Still others might just be from simple disuse atrophy -- use it or lose it. Then there's excitotoxins like aspartame. Or blood glucose level spikes. Etc., etc.

The more I learn, the more I see that health -- physical and mental -- does not need ANY drug to prop it up. But big Pharma would not want that. We are made to believe through numerous ads that the only way to be healthy is to be taking some drug daily. Big Pharma would happily welcome conditions, invented or otherwise, that would call for the taking of a drug for the rest of one's (drug-shortened) life. The problem is that many would prefer a magic pill instead of going through the discipline needed for health.

One rule of thumb I have: With very few and rare exceptions, if a drug has to be taken for more than a week, it's not a cure. It's a sales pitch.

Just my thinking at the moment. Still learning... :wink:

Gerry

Mad Scientest · � #4 � 12-26-2006, 06:35 PM

Gerry:
Don�t know if you have seen this? But Joyce posted this site a while back on in the humor thread.
I think it fits in quite well with what you are saying.

https://www.cafeoflifepikespeak.com/V...0To%20Pill.swf

Marcus · � #5 � 12-27-2006, 04:19 AM

That video is a riot! I've sent it to everyone I know!

Meanwhile......I agree basically with what you are saying Gerry and MadScientis. but the reality is .... is that dementia is significantly on the rise and if it continues as it is statistically, it will cause economic devastation for the US as the boomer move up in years.

Regardless of causes of the conditon it is a coming down the pike.
There are too few people interested in mainstaining brain health and the knowledge to correct problems that are already in the make is severely limited.

Now I can't get my 18 and 21 year old sons to detox and eat right. How you gonna get an old fart at 65 to do it who may already be exhibiting early signs of dementia? How you gonna educate that family? Who is going to prepare the healthy diet. Where is all the money going to come from for the supplements? Many people can not afford perscription medicne never mind vitamins, etc.

Alzheimers is a significant disease that is expoentially increasing. that combined with all the other kinds of dementia....well its a real problem.
When the mind deteriorates to such a level psychosis sets in. It can be extremely hard to manage such a person. to keep them safe, to feed and dress them and all the other cares necessary for some level of dignity.

Many nursing homes and assisted lliving places invite such persons to leave when their condition really starts to show and become a management problem. They are being cast into expensive facilities with limited healthcare professionals to take care of basic needs in a proper way.

It is predictied by some of the leading doctors, even those strongly into alternative treatment, that we will be seeing warehouses across the nation springing up to deal with the massive numbers of alzheimers predictyed to appear in the next 15 to 20 years. One doctor, Dr Dharma Singh Khalsa says that the goal must be to divert alzheimers progression with natural supplements long enough so that the person dies of something else before the alzheimers gets really bad. He beleives this can be done with brain nutrients. But who is listening? Who is doing it now? Certainly not the hundreds of thousands required to forstalll the coming alzheimers plague.

As a hospice nurse I see more and more of this condition and when I talk to nurses who have been doing geriactrics longer than me they report very significant change in alzheimers as the cause of death. When these situations arise I thank god for Zyprexia, and I have recommended it to doctors and patient's families many times, along with seroquel and haldol, ativan etc etc.

Really, it is for unretractible disease. Once things are at this level it is way too late. There of course is help for early dementia and alzheimers but you won't find much help in a drug bottle. Aricept is reported by patient families to be of some assistence but of course it only delays the process, not a cure by any means.

To maintain health you are best off taking on the probems before serious disease come around. For the vast majority all is too little too late.

(sorry for typos, can't find my glasses)

Mad Scientest · � #6 � 12-27-2006, 07:15 AM

Nutrition is important but like a muscle the brain also needs exercise. If you stop doing creative thinking it just withers a way.

Had a neighbor who had a small photo business it was his whole life, when he retired he had no hobbies or other interests so he pretty much just sat around and did nothing. He died about a year later!

Mari · � #7 � 12-28-2006, 05:24 AM

But is this a "the chicken or the egg" type of situation. Does the lack of stimulation cause mental decline or does the mental decline cause the lack of interest in activities?

We have been told to stay mentally active in order to maintain brain function, but I wonder if this is really the way it works.

Mari

Marcus · � #8 � 12-28-2006, 10:48 AM

Mental decline from depression and lack of interaction with life is not the same as Alzheimers and vascular dementia. These are true physiological disease states that I do not associate with negative thinking or depression although those may or may not be present.

bifrost99 · � #9 � 12-29-2006, 02:48 AM

Quote:

Originally Posted by Mari

But is this a "the chicken or the egg" type of situation. Does the lack of stimulation cause mental decline or does the mental decline cause the lack of interest in activities?

We have been told to stay mentally active in order to maintain brain function, but I wonder if this is really the way it works.

I think lots of aspects of our health involve the principle, "Use it or lose it." So I would think that this would also apply to our brain and minds.

Nutrition can only supply raw materials. But for the body to use such materials, there must be stimuli.

The "chicken or egg" question can be similarly applied to muscles: does lack of activity cause muscle weakness, or does muscle weakness cause lack of activity? The answer should be obvious. Besides, if it's a "circular" situation, then one can break or enter it at any point, and in health issues, the convenient point would be to provide the stimulus for the wanted reaction.

Oh, and in case you don't know, the chicken came first. The egg could not hatch by itself.

:wink:

Gerry

Belle · � #10 � 01-15-2007, 03:42 PM

Gerry, I think you are right on.

On this issue I can speak with the voice of experience. I had a serious fall 18 years ago that caused a number of structural problems and also head trauma.

Even though I was often not lucid, I continued trying to read as much as I could. Yes, I'd have to go back chapters to remember who was who etc. but I persevered. I couldn't read my technical stuff most of the time but when I knew I was lucid I did what I could. I wouldn't allow myself to get depressed. I got involved in volunteer work I could do via phone etc.

As the head and neck got better, so did my ability to concentrate and my short term memory improved. I still have times where memory or concentration is a problem, but not often anymore.

I feel very strongly that if I'd sat around watching TV like many disabled folks my mind would never have recovered. I still don't watch TV.

Marcus · � #11 � 01-15-2007, 05:04 PM

Yes, using your mind will promote better mental health but I don't think it really has anything to do with Alzheimers and vascular dementia. These are severe physiological problems and you can't think your way out of them no more than you can think your way out of arthritis or cardiac disease. Vascular dementia is from a lifetime of poor diet and inflammatory processes and with alzheimers the verdict is still out. But even those who are brilliant and think a lot get alzheimers. Believe me I know. I've taken care of some very brilliant people in an alzheimers psyche unit. Engineers, golf pros, clothing designers, struch down at the height of their careers or at points where they should be in professorship.

I would not want people to think that keeping mentally active will protect them from these diseases. We must keep up the endeavor to get to the bottom of alzheimers. Vascular dementia we probably have figured out. If the potential for the disease, early diagnosis and corrective measures are not taken you will not think your way out of it. You will be to demented to find your way.

Did Ronald Reagan lack mental stimulation? Those close to him have said that they thought they saw the earliest signs just after his presidency.

Mari · � #12 � 01-15-2007, 07:35 PM

Quote:

Originally Posted by Arrowwind

Vascular dementia we probably have figured out. If the potential for the disease, early diagnosis and corrective measures are not taken you will not think your way out of it. You will be to demented to find your way.

Arrowwind, can you explain what you would do for vascular dementia.

Mari

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