The last week hasn’t been a very uplifting one for psychiatrists who pay attention to the news. For as much as we complain about shrinking reimbursements, the undue influence of Big Pharma, and government meddling in our therapeutic work, we psychiatrists now have two new reasons to be concerned.
And, maybe, to lawyer up.
I. APA Threatens Blogger
Most readers who follow this blog will certainly have seen this story already, after first being reported in Allen Frances’ Psychology Today blog. So I know I’m just preaching to the choir here, but frankly, in my opinion, this story cannot receive too much attention.
As you probably know, American Psychiatric Publishing, a branch of the APA, threatened to sue a British blogger, Suzy Chapman, for her blog “dsm5watch.” They argued that the use of “dsm5″ in her blog title constituted trademark infringement. She has moved her content to “dxrevisionwatch” and describes her reasons for doing so here.
I had been following the “dsm5watch” blog since February 2011 via my RSS feed, and have linked to its content in some of my posts. It was first launched way back in December 2009. I thought it was a fair, balanced way for readers to keep abreast of the DSM-5 development process (for a while, I actually thought it was published by the APA!!). Granted, many of the posts were about CFS/ME (chronic fatigue syndrome/myalgic encephalomyelitis), and the blog often mentioned the DSM-5 controversy, but nothing that hadn’t been published anywhere else.
In my humble opinion, shutting it down was simply a misguided, heavy-handed move by the APA. Why “misguided”? As psychotherapist and author Gary Greenberg wrote in his blog Thursday, “the APA is a corporation that, like any other, will do anything to protect itself from harm…. And it spends a lot of time imagining dangers.”
Suzy Chapman, congratulations, you are the “bad object” of the APA’s paranoid projection.
This entire fiasco has the potential to become a huge embarrassment to the field of psychiatry. I guess I can understand why the APA might wish to protect its intellectual property, but the idea of “picking on the little guy”—especially when the “little guy” is simply keeping readers informed about developments in our field of (supposedly) intellectual, scientific endeavor—makes me ashamed to think that these men and women speak for me.
II. Patients Sue Doctors for Creating “Valium Addicts”
This article, too, has made the rounds on several blogs and news sites, and while it was published in a UK tabloid well-known for several anti-medication stories in the past, I think the message it sends is an important one.
Benzodiazepines, or “benzos” (which include Valium, Xanax, Klonopin, and Ativan), are some of the most widely prescribed drugs in the US and Great Britain, and among the most addictive. Tolerance to the anxiolytic effects of benzos develops very rapidly, so people often request higher doses; but overdose can be deadly due to respiratory depression, and the withdrawal syndrome—which can include seizures and delirium—can also be life-threatening.
Benzos have been popular since the 1960s. They replaced the barbiturates, made popular by the Rolling Stones as “Mother’s Little Helpers” back in 1966. Their rapid onset and calming effect—much like that of alcohol—and their ability to potentiate the effects of other drugs, like opiates, often leads to use, abuse, and addiction.
[Not to get too tangential here, but last week's episode of "Real Housewives of Beverly Hills" (hey, it's one of my wife's favorite shows, and we have only one TV) featured Brandi in a Xanax-and-alcohol-fueled daze, enjoying a mai tai with her girlfriends at a Lanai resort. Oh, and she had trouble keeping her right nipple in her cocktail dress. Is it any wonder why people request benzos by name???]
Anyway, to get back on track: Benzos are effective drugs. And their utility and versatility—not to mention their street value—gives them a cachet that’s hard to exaggerate. More importantly, the potential dangers, which are compounded in patients with a high tolerance, mean that they really should be prescribed for very short intervals, if at all.
But the responsible use of benzos requires effort on behalf of the prescriber. It takes time to explain to the patient the risks of tolerance and withdrawal. It also takes time to teach other methods of managing anxiety. Doctors (and, increasingly, patients) just don’t have that kind of time—or don’t want to find it. Moreover, they (we) find it difficult to say “no” to patients when they describe something working so well.
Hence, it’s not uncommon for doctors to see patients taking 4 mg of Xanax or 8 mg of Klonopin daily, and still complaining of anxiety or restlessness or “jitteriness” and asking for more. Patients on these regimens rarely want to stop them (even when told of the long-term dangers), and when they do, the withdrawal process is not one to be taken lightly. (The Ashton Manual—available online—is the authoritative resource for managing benzo withdrawal.)
Do I believe it’s fair to sue doctors who turn their patients into “benzo addicts”? That’s a difficult question, particularly because of the tricky nature of the word “addict.” If we instead talk about making patients physically dependent on benzos, then the question can be reframed as: Should we blame doctors for creating a physiological state in a patient which has the potential to be life-threatening if not managed properly?
Before answering “Hell yes!” it must be understood that just about everything we do in psychopharmacology (if not all of medicine) “has the potential to be life-threatening if not managed properly.” The real issue is, how likely is an adverse outcome, and how well does the doctor manage it? Of course, there’s also the question about whether the patient bears any responsibility in the overuse or abuse of the drug. But even if a patient knowingly takes more than what is recommended and the doctor knows this, it is the doctor’s responsibility to respond accordingly.
In my book, there’s no excuse for the indiscriminate prescribing of benzodiazepines. There’s also no excuse for abruptly discharging a heavy benzo user from one’s practice, or “dumping” him on a public clinic or detox facility. (Trust me, this happens A LOT.) Whether a doc should be sued for this is not my area of expertise. However, I think it is good that attention is being drawn to what is, in the end, just bad medicine. Hopefully the systems in place that foster this sort of care—inadequate medical education, poor reimbursement for therapy, emphasis on medication management, and arbitrary insurance-company regulations that limit access to more effective treatment—can be changed soon.
But I’m not holding my breath. I’m calling my attorney.