Lockup Doc

Psychiatry needs a new marketing campaign to improve its credibility and appeal as an interesting and respectable career option for medical students. Also, exposing those who may be going into primary care to “bread and butter” psychiatry would enhance patient care since a large percentage of  psychotropic medications are actually prescribed by primary care doctors.

During the third year of medical school, students rotate through several required clinical clerkships, one of which is psychiatry. Since I started medical school 20 years ago, I have spoken with very few students and doctors who have had positive experiences with their psychiatry rotations. Read more…

The relationship between a psychiatrist and patient must be different from that between two friends. Friends share problems and concerns with each other because of the mutual give-and-take foundation on which friendships are based.

A psychiatrist-patient relationship is very different. A patient comes to and pays a psychiatrist for professional services. While a psychiatrist is probably going to be more effective by showing some human qualities and not being a completely blank slate, there is still a necessary professional veil that the psychiatrist must wear.

What I was always taught and still believe to be solid advice is that a psychiatrist should not disclose any significant personal information to a patient unless the intent is for that disclosure to help the patient. That’s been a great barometer that I’ve used with myself over the years. If I find myself beginning to talk about my own life, I stop myself and double-check my intentions. Read more…

I used to have a more “normal” job.

Early in my career I worked in a large medical center and hospital and rotated through a call schedule. I got called into the ER regularly. I covered the inpatient unit and performed consultations on the medical and surgical units. I did all of the typical work tasks associated with a traditional practice.

Then I left it all.

I started working half-time in correctional psychiatry. I have worked in various other less traditional settings to fill the other half of my schedule over the years, but most of it has been spent working with people with developmental disabilities.

My work life is Read more…

Bupropion (Wellbutrin, Zyban) is a unique but commonly prescribed antidepressant that inhibits the reuptake of dopamine and norepinephrine. It is FDA approved for the treatment of major depressive disorder, seasonal affective disorder, and smoking cessation. It is commonly used off-label for the treatment of attention deficit hyperactivity disorder (ADHD).

Anecdotally there have long been reports of abuse and diversion of bupropion in jails and prisons. In my own personal experience in these settings, I have not seen much evidence of such misuse. Inmates rarely present to me seeking this medication. By contrast, and about which I have previously written, quetiapine (Seroquel) is highly desired medication in corrections.

I conducted a literature search on this topic and Read more…

As a psychiatrist who has now been practicing for over a decade, I think back to the days of residency and fellowship and realize how much my approach to prescribing benzodiazepines has changed.

One of the key faculty members in my psychiatry residency program was considered an expert in treating anxiety disorders. He was very liberal with his prescription of benzodiazepines, the anti-anxiety class of medications including diazepam (Valium), clonazepam (Klonopin), lorazepam (Ativan), alprazolam (Xanax) and others.

Having no other frame of reference, I naively adopted his unsparing prescription-writing habit of these not-so-benign medications. I unquestioningly steered down this path for the first couple years of my post-training practice.

Then I had the good fortune of working with a very competent group of experienced psychiatrists who were in full-time clinical practice. Regularly collaborating on cases with them helped to initiate my transformation to more conservative, and in my opinion, more appropriate,  prescribing habits.

My prescription style inevitably evolved further when Read more…

The prescription of medications for diagnoses, to age groups, or in doses other than the FDA-approved ones, is a common, legal, and necessary practice in medicine today. This practice is known as off-label use or off-label prescribing. Those new to this issue may wonder why physicians and other prescribers would ever deviate from prescribing in territory where the FDA has not given their stamp of approval.

In the ideal world, clinical trials would be conducted for all patient populations and diagnoses for which various medications might be useful. In reality, though, this is neither practical nor possible. Consequently, many patient populations and many patients with particular diagnoses would have few treatment options available if the medical establishment avoided off-label prescribing.

For example, child psychiatry is a huge area where millions of mentally ill children and adolescents depend on off-label medications. The field of general pediatrics is no different. The fact is that most medications are not tested in children. But, does that mean that Read more…

Current Psychiatry (Vol. 8, No. 11/November 2009) recently published an editorial, “Health care debate: Do psychiatrists support the public option?“.

I thought the title was a little misleading, though, because the figures that ended up being presented were from a survey of 5000 readers asking, “If you could reform the nation’s health care system, you would favor a single government-run system to cover every American?”

The results: Read more…