I have a confession to make. I don’t think what I do each day makes any sense.
Perhaps I should explain myself. Six months ago, I started my own private psychiatry practice (one of the reasons why I haven’t posted much to this blog, but I hope to pick up the pace again!). I made this decision after working for several years in various community clinics, county mental health systems, and three academic institutions. I figured that an independent practice would permit me to be a more effective psychiatrist, as I wouldn’t be encumbered by the restrictions and regulations of most of today’s practice settings.
My experience has strengthened my long-held belief that people are far more complicated than diagnoses or “chemical imbalances”—something I’ve written about on this blog and with which most psychiatrists would agree. But I’ve also made an observation that seems incompatible with one of the central dogmas of psychiatry. To put it bluntly, I’m not sure that psychiatric medications work.
Before you jump to the conclusion that I’m just another disgruntled, anti-medication psychiatrist who thinks we’ve all been bought and misled by the pharmaceutical industry, please wait. The issue here is, to me, a deeper one than saying that we drug people who request a pill for every ill. In fact, it might even be a stretch to say that medications never work. I’ve seen antidepressants, antipsychotics, mood stabilizers, and even interventions like ECT give results that are actually quite miraculous.
But here’s my concern: For the vast majority of my patients, when a medication “works,” there are numerous other potential explanations, and a simple discussion may reveal multiple other hypotheses for the clinical response. And when you consider the fact that no two people “benefit” in quite the same way from the same drug, it becomes even harder to say what’s really going on. There’s nothing scientific about this process whatsoever.
And then, of course, there are the patients who just don’t respond at all. This happens so frequently I sometimes wonder whether I’m practicing psychiatry wrong, or whether my patients are playing a joke on me. But no, as far as I can tell, I’m doing things right: I prescribe appropriately, I use proper doses, and I wait long enough to see a response. My training is up-to-date; I’ve even been invited to lecture at national conferences about psychiatric meds. I can’t be that bad at psychiatry, can I?
Probably not. So if I assume that I’m not a complete nitwit, and that I’m using my tools correctly, I’m left to ask a question I never thought I’d ask: is psychopharmacology just one big charade? **
Maybe I feel this way because I’m not necessarily looking for medications to have an effect in the first place. I want my patients to get better, no matter what that entails. I believe that treatment is a process, one in which the patient (not just his or her chemistry) is central. When drugs “work,” several factors might explain why, and by the same token, when drugs don’t work, it might mean that something else needs to be treated instead—rather than simply switching to a different drug or changing the dose. Indeed, over the course of several sessions with a patient, many details inevitably emerge: persistent anxiety, secretive substance abuse, a history of trauma, an ongoing conflict with a spouse, or a medical illness. These often deserve just as much attention as the initial concern, if not more.
Although our understanding of the pathophysiology of mental illness is pure conjecture, prescribing a medication (at least at present) is an acceptable intervention. What happens next is much more important. I believe that prescribers should continue to collect evidence and adjust their hypotheses accordingly. Unfortunately, most psychopharmacologists rarely take the time to discuss issues that can’t be explained by neurochemistry (even worse, they often try to explain all issues in terms of unproven neurochemistry), and dwindling appointment times mean that those who actually want to explore other causes don’t have the chance to do so.
So what’s a solution? This may sound extreme, but maybe psychiatry should reject the “biochemical model” until it’s truly “biochemical”—i.e., until we have ways of diagnosing, treating, and following illnesses as we do in most of the rest of medicine. In psychiatry, the use of medications and other “somatic” treatments is based on interview, gut feeling, and guesswork—not biology. That doesn’t mean we can’t treat people, but we shouldn’t profess to offer a biological solution when we don’t know the nature of the problem. We should admit our ignorance.
It would also help to allow (if not require) more time with psychiatric patients. This is important. If I only have 15-20 minutes with a patient, I don’t have time to ask about her persistent back pain, her intrusive brother-in-law, or her cocaine habit. Instead, I must restrict my questions to those that pertain to the drug(s) I prescribed at the last visit. This, of course, creates the perfect opportunity for confirmation bias—where I see what I expect to see.
We should also make an effort to educate doctors and patients alike about how little we actually know. The subjects in trials to obtain FDA approval do NOT resemble real-world patients and are not evaluated or treated like real-world patients (and this is unlikely to change anytime soon because it works so well for the drug companies). Patients should know this. They should also know that the reliability of psychiatric diagnosis is poor in the first place, and that psychiatric illnesses have no established biochemical basis with which to guide treatment.
Finally, I should say that even though I call myself a psychiatrist and I prescribe drugs, I do not believe I’m taking advantage of my patients by doing so. All of my patients are suffering, and they deserve treatment. For some, drugs may play a key role in their care. But when I see my entire profession move towards a biochemical approach—without any good evidence for such a strategy, and without a fair assessment of alternative explanations for behavior—and see, in my own practice, how medications provide no real benefit (or, frequently, harm) compared with other treatments, I have to wonder whether we’ve gone WAY beyond what psychopharmacology can truly offer, and whether there’s any way to put some logic back into what we call psychiatric treatment.
** There are areas in which psychopharmacology is most definitely not a “charade.” These would include the uses of benzodiazepines, psychostimulants, and opioids like methadone and Suboxone. With each of these agents, the expected effect is quite predictable, and they can be very effective drugs for many people. Unfortunately, each of these can have an effect even in the absence of a diagnosis, and—probably not coincidentally—each has a potential for abuse.
“To put it bluntly, I’m not sure that psychiatric medications work.”
This really is different from the takeaway from many of your pasts blogs, the ones that are like, “blah blah blah despite the lack of evidence, psychiatric medications work. People get better.”
While many people do experience relief from medications, as people have been saying for a long time here, there ins’t evidence to show that it is actually the chemical effects of the medication that actually is helpful (while much of the chemical effects are demonstrably harmful). Did it really take a switch to private practice to see this? Did you really think your regulatory limitations were the problem with psychiatric practice?
“Did it really take a switch to private practice to see this? Did you really think your regulatory limitations were the problem with psychiatric practice?”
To be honest, I think the answer is “yes.” In my private practice I have the opportunity to listen to the patient’s story; follow the significant events in the patient’s life; and examine the thoughts, attitudes, and beliefs that evolve as the patient proceeds through treatment. If the patient improves (i.e., he or she begins to meet the goals that we set at the outset of their course of treatment), that’s great, but I’m frequently unable to say whether such improvement is due to pharmacological intervention, psychotherapy (or, more accurately, whatever I ask the patient to talk about, whether it’s a form of structured psychotherapy or not), or something else entirely.
On the other hand, if financial pressures or administrative rules require me to see 3 or 4 patients per hour, I only have enough time to ask about “target symptoms.” Most of these fluctuate naturally– and may even resolve on their own– but once we see them as drug targets, our interpretations become tainted by our expectations regarding what we’ve prescribed. In other words: improvement = drug effect; no improvement = drug failure.
Private practice, by its atheoretical foundation, allows for the consideration of multiple hypotheses for behavior and behavior change; while insurance-based, Medicaid, and Medicare settings require an emphasis on DSM criteria, proper diagnosis and coding (and documentation thereof), and evidence-based treatment, when the “evidence” is a clinical trial literature that resembles nothing in the world of “real” patients. To put it bluntly, private practice deals with people, while third-party payment systems require us to fit square pegs into pharmaceutical holes.
Then I guess it’s back to square one. If the evidence base you have to work with is not based on helping real people, regardless of whether or not people “deserve treatment,” I think you then have to make a case why you and your credentials are beneficial for helping someone or even more helpful than much cheaper, less stigmatizing alternatives. If you don’t have a case to make, than treatment lacks an ethical grounding.
“I think you then have to make a case why you and your credentials are beneficial for helping someone or even more helpful than much cheaper, less stigmatizing alternatives”
I’ll let you in on a little secret, Nathan. My “credentials” have nothing to do with how helpful I can be to patients. My “credentials” demonstrate that I’ve mastered knowledge of psychopharmacology and DSM-IV criteria. But most of my patients don’t care about those things. They just want practical tips, support, and skills to help solve problems in their lives, offered by someone who will listen to them and not pathologize (or stigmatize) them.
There is an enormous chasm between our current understanding of neurochemistry and actual human thoughts, emotions, and behaviors. While that gap may be narrowed someday, it’s shocking (to me) how many mental health professionals in 2013 consider the two to be one and the same.
Dr. Balt, it’s not much of a secret, but it is also kind of my exact point. What makes it ethical for you to have a practice when someone without such credentialing who can provide help-seekers “practical tips, support, and skills to help solve problems in their lives, offered by someone who will listen to them and not pathologize (or stigmatize) them” can’t.
I truly don’t doubt your intentions to be helpful and don’t don’t that you are, But if you say, ” even though I call myself a psychiatrist and I prescribe drugs, I do not believe I’m taking advantage of my patients by doing so” and do a lot of things in practice that “don’t make sense” and ask if pharmacotherapy is a facade, it seems that what you do that is different than a friend is call yourself a psychiatrist and still prescribe medications. So I am trying to get at, why shouldn’t/can’t someone who is good doing the things you describe your patients want, set up a practice and do the same thing (and charge psychiatrist prices)?
I will take a little gander in answering my question. It is a big part of the benefit some people get from seeing professionals is the belief that they are helpful because of their credentials (they are smarter, know more, trusted to help, respected, have authority, etc.) Even though what makes someone a professional, as you say, is not helpful for people, I think that as someone who embraces professional titles, it is cultural expectation in the helpfulness of professionals that helps people get better. I think this is a big ethical dilemma: maintain a false belief in the helpfulness of doctors/professionals as such because of our beliefs in their specialized knowledge and helpfulness and trustworthiness creates expectancy effects (even their expensive prices add to that), or recognize that, you and others may be “taking advantage” of patients by perpetuating this falsehood, as I disagree with your explanation of of what patients care about. If it was, your “secret” wouldn’t have to be such a secret.
Just revisiting after a while here. Perhaps I am biased by my own experience of being stigmatized and pathologized by my experience with Psychiatry, but looking back, why should anyone not expect to be pathologized when seeing a psychiatrist. It is their job to pathologize (differential diagnosis) and then hopefully treat well. Unfortunately, treatments are lacking in predictable effectiveness so what a lot of folks are left with are just the experience of pathologization.
That’s nice that you asked your patients about drug reactions.
My shrink used our 10 minute med checks to talk about himself, his upcoming vacations, his dog, and politics. I finally walked away from him and his pills after years of doing so-so or worse. He made thousands of dollars off of me and the meds actually caused harm. I had terrible insomnia and restlessness from the cocktail he had me on and eventually went manic.
I discontinued all drugs over the course of several weeks using a pill cutter. That was no fun.
I am drug free and fine these days.
You might find of interest this fascinating documentary about the science and psychology of placebos, centered on a gathering of the Harvard Placebo Study Group
I wonder to what extent psychiatry benefits from placebo effects without really giving proper credit…
Good to see you back and congratulations on opening your practice.
I thought I might be reading a writing of Duane’s ((*_*)).
I am not a medical person and have to wonder if there could ever be a biological model. So many people who come for help have life issues, as opposed to, say, endogenous depression or schizophrenia. “problems in living” cannot be addressed, I would not think, biologically or prescriptively.
leejcaroll,
not to worry
i’m back
see comment below (scroll down)
duane
[...] if-medications-don’t-often-work [...]
[...] [...]
This is exactly what you would expect if, after all the infomercials published as “scientific studies,” the true results are no better than placebo: About a third of subject get effects they interpret as beneficial, a third get adverse effects and quit, and a third feel no effects.
You might have pills, but you don’t have medicine, which requires at least a degree of predictability of benefit beyond placebo.
You might have a lot more fun with your patients if you took MDMA with them, with about the same results.
Problem is if the studies hold talk therapy and antidepressanst are no better then placebo. A lot of ‘getting better’ is the old tincture of time. It does give pause to the idea that many of the problems people see a psychiatrist for are not worth the time and expense of an MD. One wonders if insurance companies will stop paying for anyone who does not have a full blown psychosis.
http://www.reuters.com/article/2011/12/21/us-antidepressant-idUSTRE7BK1ZU20111221
leejcaroll – To say that something is no better than placebo is NOT to say that it doesn’t work. Read Irving Kirsch or Daniel Moerman – Kirsch’s conclusion is that antidepressants work no better than placebo precisely because antidepressants themselves cause a placebo effect. Kirsch and Moerman define placebo not as “no treatment,” but as “the meaning response” – patients’ expectation and hope of improvement actually produce improvement.
They cite Jerome Frank’s belief that psychotherapy’s function is to change negative “meanings” into positive meanings in clients’ lives. This is more than just the passage of time – it involves engaging in positive relationships that support clients’ constructing new, positive meanings in their lives. You are right that the passage of time can be a huge benefit, but “placebo” – meaning, hope – is one of the most powerful influences in our lives, and only reductionist medical science obscures this.
Congratulations on a new chapter in your professional life! And thank you for your delightfully candid comments about the pitfalls of reductionistic models to explain the complexities of human struggles. If we psychiatrists are to be useful in helping to relieve suffering, then our clinical models need to be relevant to our patients’ biopsychosocial experience.
this is so refreshing
I have been a peer advocate for 30 years in the public mental illness system. I have been watching my peers suffer and die from the effects of prescribed neurotoxic behavior-control chemicals. Are you distributing this blog post to your customers so that they have the information that you are experimenting on them? I like what Alto says, if you want to be a healer, take the medicine WITH your customers and heal together.
THANK YOU!!!!! Excellent post!!!
Dyane Leshin-Harwood, B.A., C.P.T., Freelance Writer
Founder, Depression and Bipolar Support Alliance (DBSA)
Santa Cruz County Chapter, CA
Author of the upcoming book:
“Birth of A New Brain: My Ultimately Medication-Free Recovery From Postpartum Bipolar Disorder”
Creator, Natural Healing for Mothers with Bipolar Facebook Community
Blogger, http://proudlybipolar.wordpress.com/
From my own experience after a short time on the neuroleptic haldol, I have come to the conclusion that the only way the drugs can be said to work is in providing an extra hurdle to have to overcome in the process of recovery. i.e. what doesn’t kill you makes you stronger. Cognitive dissonance allows us to see simultaneously that “nothing works” and “anything works”. It’s basically down to convincing yourself of the potential efficacy of whatever your preferred poison may be (e.g. medication, psychotherapy, faith, creativity, etc).
Congrats on getting to this point of understanding Dr. Balt. There is still much good that can do. Start by undiagnosing people and learning how to withdraw them safely from the harmful medications. This kind of support would be invalueable to those of us previously condemned to a “mentally ill” diagnosis and a life of psychotropic drugging.
I just hope everyone on this thread reads Robert Whitaker’s incredible book “Anatomy of An Epidemic” – by my reading that book, I (who SWORE I would be on my drug for life) decided to go off lithium slowly, under supervision of my shrink with a support team and contingency plan firmly in place, and that has been the best decision of my life!
This psychiatrist’s post validated things that I already know in my heart, and it was great to read it today and then share it with my new “Mothers with Bipolar Disorder” network – 77 members and growing every day!
Dr Balt – thank you for advancing this complicated and important topic. I’m also a psychopharmacologist and struggle with these same issues each day.
I was struck by your footnote: “** There are areas in which psychopharmacology is most definitely not a “charade.” These would include the uses of benzodiazepines, psychostimulants, and opioids like methadone and Suboxone. With each of these agents, the expected effect is quite predictable, and they can be very effective drugs for many people.”
Isn’t it interesting that arguably, these meds, which the benefit is clear and unmistakeable are also the exact meds that many a psychiatrist is wary to prescribe? We’ll hand out atypicals for every condition under the sun, exposing patients to risks of metabolic syndrome and movement disorders, but label a patient a “drug seeker” the minute they ask for some lorazepam?
Andrew, my ex-psychiatrist readily prescribed Xanax and actually told me that my brain didn’t make enough of its own benzodiazepine, hence the panic attacks. He told me that I needed Xanax for the rest of my life. He would not refer me to talk therapy and I asked. This in spite of all the warnings about long term benzo use. My side effects were all dismissed as part of the disease. I got angry enough to take action. I finally got off of Xanax and the SSRIs that he also insisted I needed for life. I was on Xanax daily for over a decade. A year on, and I am just now beginning to enjoy good sleep and improved concentration. Psychiatry needs to take a step back and reexamine its motives. Patient care or easy profit?
Dr. Balt–I’m glad to see that this blog site is re-activating. I had feared it was going cold. You host one of the most thought-provoking mental health sites currently in existence.
Thanks for your courage to confront the toughest questions in this realm, especially “what went right/wrong?” Psychiatry is far from alone in the uncertainty of outcomes. I expect that only Pathology is the only area of medical specialty exempted from this. Surgeries go well every day, only to result in death or worsening of the original condition. Similar examples abound from all areas of practice. Thank you for thinking out loud!
Steve, Don;t remember which post related to your being given a sandwich and called out for it but thought you would find this interesting:
Why Didn’t Your Doctor Prescribe A Generic? Look In The Mirror
….
The researchers found that doctors’ willingness to prescribe a brand was associated with their acceptance of free food from drugmakers. …
http://www.npr.org/blogs/health/2013/01/07/168810473/why-didnt-your-doctor-prescribe-a-generic-look-in-the-mirror?guid=1357602616959#commentBlock
[...] Click Here to Read: If Medications Don’t Work, Why Do I Prescribe Them Anyway? by Steve Balt, MD on the Carlat Psychiatry blog. [...]
If I had to do what I do the way you are required to do public psychiatry I wouldn’t do much “healing.” High school teachers are in a position similar to yours; theoreticians have made a hash of common sense.
However:—a little moderation please?
1. “I don’t think what I do each day makes any sense.”—This is a self-indulgent exaggeration.
2. “I’m not sure that psychiatric medications work.”—Welcome to medicine. They do work, at least sometimes.
3. “There’s nothing scientific about this process whatsoever.”—Almost all science, clinical science especially, is ambiguous. 4. “The patient, not just his or her chemistry is central.”—We are animals; our chemistry is what we are.
5. “We shouldn’t profess to offer a biological solution when we don’t’ know the nature of the problem.”—Why not? You aren’t saying the solution will work, or if it seems to, why it does. 6. “When I see my entire profession move towards a biological approach….”—The very best people in your profession are doing their best and are modest about their limitations. There aren’t a lot of them, but the good ones are really good. Likely, that includes you.
Professionalism in many endeavors is often little more than fraud, and always has been. So what? Don’t define yourself by your credentials. Do what you can; you will live an honorable life disturbed by frustration and anger. I am not a believer, but I am reading the Synoptic Gospels now… talk about anger…
“Professionalism in many endeavors is often little more than fraud, and always has been. So what?:
The fraud allows systemic damage to be done to countless people, perpetrated by folks who willingly make a great living at it. Perhaps professionalism has always been just a step beyond fraud, but that doesn’t make it ok.
I’ll admit I took some “artistic license” with this post and some statements may be hyperbole. But then again, I’m not so sure:
1. “I don’t think what I do each day makes any sense.” – Actually, I try to feel confident in everything I say or do. When I pull out the prescription pad, that’s when I really have to wonder.
2. “I’m not sure that psychiatric medications work.” – This is correct. I’m not sure. I never will be. No person is a system in which all variables can be controlled. If someone says a drug “works,” I believe them, but I’ll never know if it’s because of the TV ads, the fact that Aunt Louise did so well with it, or because it actually modulated their neurochemistry in a positive way.
3. “There’s nothing scientific about this process whatsoever.” – There isn’t.
4. “The patient, not just his or her chemistry, is central.” – I agree our chemistry is what we are. Show me the chemistry responsible for moods, delusions, psychosis, impulsivity, irritability, etc., and I’ll agree with you.
5. “We shouldn’t profess to offer a biological solution when we don’t know the nature of the problem.” See #1.
“When I pull out the prescription pad, that’s when I really have to wonder.” If you talk to your patients with that attitude you are a good doctor. Why should you talk to a patient confidently? I think Jim Phelps has been writing a lot of interesting things about patient empowerment.
“There isn’t.”—Gravity works, but nobody knows its mechanism. Quantum Mechanics is pure probability, it works and there are no ‘hidden variables. Mathematics may be a useful fiction. Again, see Phelps on the Quantum Mechanics/Bipolar metaphor.
This is written about learning, “which is more important, nature or nurture, genetics or environment, should be answered with the question, which leg is more important for walking, the left or the right?”
Cooper, Bloom and Roth
No, I haven’t studied the book, it’s on my bucket list. And no, I don’t know a lot about psychiatry, just enough to be prudent with drugs.
Hmmm….I was thinking that this may be a good opportunity for Steve to do some of his own research by using his private practice setting. He does get to follow his patients a lot better because he is not restricted by the rules of a free clinic, etc. Maybe he can document which kinds of patients tend to respond to meds, which ones don’t respond at all, which have only little response. He can see if there is any kind of correlation.
i missed your voice
I have just stumbled onto this blog, and will certainly be here again.
I am a child psychiatrist and simply want to say that I agree with Steve Balt that I have enormous concerns about using psychotropic medications, in part because I am not at all convinced that they “work,” and in particular because there is no evidence that they are safe for children and adolescents whose brains are developing. I have serious worries, and do not understand why my colleagues do not, that there may be long-term changes in brain function/chemistry whatever with early use of some/all of these medicines. It seems clearly an unacceptable risk to take. If we remotely see ourselves as “scientists,” how do we ignore the possible dangers our use of medicines pose.
In part, it is certainly a risk/benefit equation, when there are serious symptoms, but if one considers the risk of medicines, then one has to consider other types of treatments. Certainly for young people, family therapy and supportive psychotherapy, group modalities, DBT, help.
What I do see is that medications likely have an effect, but do not necessarily treat the “disorders” we have constructed. What I have observed is that the numbing effects of both antidepressants and antipsychotics (especially the latter) is sometimes helpful; when there is simply so much emotion and impulsivity that there is danger, I do justify using these medications but in as low a dose as possible and for as short a time as possible. Certainly, in the absence of functional psychiatric hospitals, one has to deal with the realities of real-life psychiatric emergencies in an out-patient setting. But that does not mean these medications treat “depression,” or “bipolar disorder”; it means we are tranquilizing out of control behaviors until ways can be found in the family system, and sometimes the social system, more slowly in the individual, to lessen the need for chemical “restraints.’
I also agree that stimulants and benzos seem, for various reasons, to have discernible and often positive actions of a specific nature, and I use them with less worry.
Thank you for an opportunity to discuss these issues with colleagues.
HarrietMD, You have no idea how heartening it is to read your post. For 9 years I directed a treatment foster care program and was constantly fighting against the drugging of kids; I almost always lost. Dr. Julie Zito of the Univ. of Md. School of Pharmacy published a national study (maybe 6 years ago) that found kids in foster care were 17 times more likely to be on psych. drugs than other kids on MA.
My social workers regularly encountered psychiatrists whose gaze never left their lap top screen in their once-a-month, 10 minute med checks with foster children. Informed consent was a virtually extinct animal in these encounters.
Thank you for thinking outside of psychiatry’s extremely narrow box. This is a great site for those who think carefully about the “mental health” system. Try also the Mad In America, and the ISEPP site.
HarrietMD, I concur that your perspective is heartening. My son was on numerous medications for a psychiatric condition as a child. I had concerns about how it might affect his neurological development but reasoned the risk was necessary as we had acute safety issues. He was in so much turmoil that nothing was developing except chaos and shame. I am now near completion of a masters degree in clinical counseling and serving my clinical hours at a state psychiatric hospital which uses team treatment. The psychiatrists, social workers, counselors, psychologists, and nursing staff all work in close proximity which results in treating the patient holistically. It is a much better model than piecing patients out with multiple appointments in differing locations. I firmly believe we need to employ this model for outpatient community clinics as well.
I will note, however, that psychiatrists record in the patient charts that patients receive adjunct psychotherapy. I would argue that psychopharmacology is the adjunct therapy. As you stated, drugs stabilize the mind to then receive the psychotherapy and support that brings change to thinking and behavior.
[...] http://thoughtbroadcast.com/2013/01/04/if-medications-dont-work-why-do-i-prescribe-them-anyway/ [...]
you are the greatest. This article is absolutely right, and deep down we all know it. Absolutely correct. Tremendous damage can be done to people with some of these drugs. Most things can be cured or fixed with counseling and lifestyle changes and supportive people that believe in the patient and reinforce strong positovy for success and life achievement.
I commend you for your truthfullness,. and , this shows to me that you really DO CARE about people. that is what matters. you really do want to HELP not hurt them. you are not a pawn to the big pharma industry that make profits from medication sales. You really are the greatest and we need more people like you that stand up for the right thing. and recognize reality when you see it. Keep up the good work, it is working, people are waking up. GREAT ARTICLE. NICELY DONE.
you are not bad at it, you are simply too good at it, you actually see what is happening. the results don’t add up and you state it. that is the scientific method. so many have fogotten this in this day and age , which is so full of technology, but lacking scientific principles of thought and reason.
you are THE GREATEST. absolutely well done and correct. Most doctors do not want to admit they are not completely sure about something because it makes them look incompetent. Instead they say things are directly the way they are , for sure, and they makes them directly wrong. they can not admiot that we dont know this, we dont know, and Maybe it is this, it could verl well be that, etc. Most patients are too stupid to understand these things and will think the doc is incompetent, and does not know FOR SURE ANYTHING. they wil not reccommend the doctor, and then the doc’s career will suffer. they have all realized this and realized that they are in the position of power, and so they state what they believe is probably what is happening AS A DEFINITE FACT, and they are done. thats it, they have said what they have said and who dares to question their word. This whole system is based on ignorance and not taking into account the myriad of factors involved , of which many may be underestimated as to the critcal nature of their relavance.
home life, the people they are exposed to , stress, economic condition /situation all play Critical roles. to think that a drug will override all this and magically transport them into another home with different people. in another part of town ( upper class area) with better intelligence , is wrong, that will not happen. lol
the real problem is ignorance.
Mike says about honest doctors”,
“they wil not reccommend the doctor, and then the doc’s career will suffer.”
Now I get it, patients want a cure, no ambiguity. I have an acquaintance. This person said to me, “I take an antidepressant. This works for me but it makes some people crazy.”
So if a doctor says the above and follows up “if you get worse we can try a mood stabilizer. Maybe an atypical for awhile, but, long term these can have subtle, bad side effects…”
This person is not going to make money practicing medicine? I want to hear things like the above. It gives me confidence that I am dealing with someone who is grounded.
I wasn’t going to write more here, but now I wonder if Steve Balt isn’t being made crazy, in the colloquial sense, by untenable patient expectations.
This has been said over and over, but: Do you want to be ‘normal.’ Most ‘normal’ people on the basis of no evidence at all believe that they have a soul that will survive their deaths. Isn’t that psychotic?
Dear Dr. Steve,
“and see, in my own practice, how medications provide no real benefit (or, frequently, harm) compared with other treatments”
I am honestly curious, what do you tell patients who claim to have developed ‘drug dependence’ from long term use?
I developed drug dependence on xanex after 3 months. i suffered from it for 6 years and wound up disabled for years. The withdrawal was torture, it took me 7 years and many, many attempts, to finally get off it. The withdrawal symptoms unfortunately, continue to persist almost a year after discontinuation. The medication was prescribed to treat acute SRI withdrawal – or “Panic Disorder” (this was just before “SRI discontinuation syndrome” was officially recognized).
In my personal experience with 4 psychiatrists, all have tried to lie away the possibility (claiming the black box warning wasn’t accurate, or that they participated in the study that created it), or tried to argue it was my ‘illness’ getting worse and not benzodiazepine dependence, or otherwise dismiss me and the claim. My last psychiatrist actually said something he didn’t seem to understand was really offensive, “My other patient on 8mgs of xanex is fine”.
If a patient reads the Drug Labeling Information and sees benzos, stimulants, opiates, and/or other drugs have warnings not to prescribe them longer then a short number of weeks ‘due to the risk of dependence’, then there doesn’t seem to be any way to address a patients complaint about their decline in mental and/or physical health without lying, misleading, or deflecting (possibly for legal reasons). Diagnoses is unfortunately subjective, so simply not believing the patient is also a possibility.
This situation seems impossible to address without taking advantage of the patients ignorance. How do you handle it?
Interesting points, Jeff. I run a Web site for tapering off psychiatric drugs at http://SurvivingAntidepressants.org
You are far from the only patient who’s been injured in exactly the same situation. Physicians know next to nothing about physical dependency incurred by psychiatric drugs and methods of tapering.
I have no doubt that there are millions of people injured in this way, but medicine is so far into denial — misdiagnosis of withdrawal syndromes is endemic — they are all but invisible except for their postings all over the Web.
I’m aware. Upon researching the definition of drug dependence I found there was more then one definition.
How neurons perform “Information Processing” is basically the same principle by which all systems that perform information processing do it. As a bonus, Transistor logic is very similar and both neurons and transistors use electricity to change their state – meaning we can actually design circuits to connect them together.
That’s why the field of Cybernetics exits, and why we have products on the market that perform an objective function – pacemakers, Cochlear Implants, and newer retinal implants (this year clinical trials are undergoing for device that gives a 72×72 resolution).
Truth is, there are only (was it 17 or 19?) 19 neurotransmitters. There are hundreds of receptors, but they basically perform the same function. A neurotransmitter is either inhibitory or excitatory. All neurons in the nervous system use all 19 neurotransmitters, there is no variation. Depending on what function a particular structure of neurons has (what it’s processing) – the desired effect will be subjectively different with the same drug.
Problem is, the chemical synapses have feedback mechanisms that allow them to perform their task properly, these are absolutely required for information processing to occur properly. There 5 primary feedback mechanisms, these control Release, Reuptake, Metabolism (breaking down what’s not taken back up), Receptor Density, and Production of neurotransmitters. Chemical synapses are closed systems with feedback, which are externally disrupted by the action of a drug.
Receptor density, as well as other feedback depending on the specific action of the drug, will change in the synaptic cleft in response to a drug. The purpose of neurotransmitters is to control the frequency of neuronal firing.
There are no mechanisms to keep feedback uniform from neuron to neuron – synapse to synapse. Feedback becomes non-uniform thought the brain and drug dependence and withdrawal syndromes.
This is the specific reason there is no longer funding of psychopharmacology, it’s understood objectively it doesn’t work, and could never be made to work.
Truth is, the drugs are only being used to get a subjective effect. I’m sure some of this shows up on PET scans and QEEGs, but psychiatrists don’t use them because their profession does not treat the nervous system. They treat the ‘Mind’. The brain produces the ‘Mind’, through performing ‘information processing’. Any disruption or damage to the brain will disrupt or damage the ‘Mind’. Schizophrenia is obviously a disturbance in information processing, meaning that until the brain is addressed there will never be an adequate treatment or system. In short, the truly sick people will never have a working alternative until psychiatry and it’s DSM and ICD are gone.
“Physicians know next to nothing about physical dependency incurred by psychiatric drugs and methods of tapering.”
I fully agree. Subjective observations make it physically impossible to identify object causes.
Er, there’s a few typos in my reply there. I didn’t mean to imply the full ICD is bad, I just meant the psychiatric symptoms section of the ICD (the ICD covers just about all illness in general).
Outside of medicine psychiatry can play a role in helping people, but it inside of medicine.. it’s sort of damaging the ability to investigate and research the cause of ‘psychiatric symptoms’.
Congratulations on getting off of Xanax- I was on it for 10 years and was told I needed it for life, yes there are psychiatrist and psychopharmacologists who peddle this lie to patients and then dismiss their concerns as part of the so called disease. Patients must read the product literature and be their own advocate. I was even called a “scientologist” for voicing concerns about the long term use of the drugs I was on. What nonsense!
Reading the Drug Labeling information was probably the best thing I ever did for myself.
It certainly did not agree with the words coming out of my psychiatrists mouth.
I’m astonished by your ordeal. Wow. It makes me happy to see other people have gotten off these things too, after my own ordeal I didn’t think most people could do it. It was nightmarishly unpleasant and resulted in complete disability for 2 years.
Quite frankly, when I read in the new york times that psychiatrists and psychologists were participating in developing methods to torture prisoners in guantanamo bay, I just assumed they were using the acute withdrawal symptoms of psychotropic drugs to torture them. It’s nice to know in modern times political abuse of psychiatry is still a terrible problem. Next time a psychiatrist calls you a “scientologist’ maybe you can point that out, along with informing them the drug labeling information (written by the manufacturer as instructed by the federal regulatory agency) will hold up in court while their ignorance will not :3
(References)
http://www.nytimes.com/2005/12/16/opinion/16iht-edstone.html
(APA released a response discouraging participation in torture)
http://www.nytimes.com/2006/06/07/washington/07detain.html
Do you still suffer withdrawal symptoms? Out of all published literature I could find on Medline, no study exceeds 6 months. Many of which end with the statement “It is not known if withdrawal symptoms ever end, or simply need more then 6 months to resolve – more research is urgently needed”.
I guess it’s been about 11 months, It’s definitely improved at least slightly. Still see Flashes of light and all that fun stuff.
This article is tremendous! I applaud your honesty. I hate to say it is rare from an M.D. but ok I just said it! lol. I am in recovery and once was on about 7 or eight meds that lead me to be hospitalized, etc. I hope you or someone out there checks out RTP – I wrote on there as did many others about what works.
http://thoughtbroadcast.com/2013/01/04/if-medications-dont-work-why-do-i-prescribe-them-anyway/
Steve,
It seems as though you are making all of this much more complex than it needs to be.
This is *not* rocket science.
In fact, it’s not any kind of *science* (other than perhaps, pseudoscience).
Keep it simple.
If the drugs cause more harm than good (and they do!) then try some other tools.
Duane Sherry
discoverandrecover.wordpress.com
And if you and your colleagues lack those tools, then step out of the way and let others take a shot – including integrative, non-drug practitioners, peer and survivor groups.
Duane
Conventional psycho-pharmacological psychiatry is dead.
Duane
Well, that’s technically the problem.
I agree psychiatry has nowhere to go, forward or back (given that funding to psychopharmacology is almost completely gone and there will never be new classes of psychotropic drugs).
The problem is psychiatry actually can’t reject the drugs. The Pharmaceutical industry has made sure of that, using the DSM as justification (which they pretty much write directly due to stock ownership by the DSM board staff) these companies were free to create subjective medicine and illegally market it to every field of medicine for on or off label uses.
The survivor groups unfortunately don’t offer a working alternative, neither does anyone else.
Human greed is perhaps the most powerful force on earth, and it runs everything. I’m sure in the long run things will work themselves out, but in the mean time bad people will get away with terrible things, like marketing antipsychotics to orphans to make a buck.
One solution would be to petition and put political pressure on the FDA to no longer accept Subjective Endpoints in clinical trials. This single thing is the sole reason these drugs exist.
Actually, Jeff, survivor groups do offer alternatives. Robert Whitaker has provided a gathering spot for them on MadinAmerica.com. You may wish to browse it.
Yes, good to “see” you back too ((*_*))
As always you and I disagree.
You want to throw the baby out with the bathwater, as it were.
There are psychiatric illnesses, disorders, and periods of time in some people’s lives where medications are helpful and necessary. (An acquaintance’s son with schizophrenia comes to mind as does my mother who suffered with severe clinical depression for most of her life, as 2 anecdotes, both of whom required medication to get through their daily lives and activities. ) Some people are benefitted by a short period of medications to get through very difficult times.
For Steve to acknowledge that maybe psychiatry has moved too far to a pharmaceutical reliant model is important. He has not agreed with your stated belief that meds are always more harmful then good.
I am writing from outer space I think.
It is hard to say this to victims, but the problem is not the clinical science of psychiatry, but the people who practice it. Years long successful outcomes, can be achieved with very small doses of very few drugs? Suggestively there is interesting evidence that places with high lithium levels in their soil experience less than expected amounts of violence. I think the administered does of lithium is order of magnitude 2mg per day. Emily Deans suggests that human life evolved in places where people drank highly mineralized water.
Is it possible that far lower doses of meds. than are administered in practice might be effective and do less damage? Are there studies in which 1/10 of the typical dose of an atypical is administered for a month?
As for new drugs, find a benign glutamate antagonist and half of psychiatry will disappear? Well, that’s a thought.
The solution is simple, you and the internet are smarter than your doctor.
I agree the physicians are a major part of the problem, but there is no doubt the clinical guidance has been muddied by commercial and political interests. If there is valid clinical science in the literature, the world needs a hero who will identify the treasure in the trash.
Hello Alto,
I like the approach that Jim Phelps and his web page take.
Validity in psychiatry is difficult to come by, but even in other medical fields, cardiology for example, doctrine is suspect.
The problem is that doctors are not afraid of their drugs and their protocols.
Example—It is interesting to watch Nancy Andreessen be a nice guy and admit that neuroleptics are a factor in the brain damage observed in schizophrenics—after animal experiments make this impossible to deny. On the other hand for a million dollars one can surely find a couple of dozen entirely drug naive thirty-five year old schizophrenics and verify that they have some observable brain damage?? Maybe this has been done?? I don’t follow Whitaker. He probably knows.
I
Jim Phelps is an open-minded, creative clinician who listens to his patients. Also see http://www.medical-hypotheses.com/article/S0306-9877%2812%2900252-6/abstract and http://www.ncbi.nlm.nih.gov/pubmed/21920673
However, he sees bipolar disorder much too often for my taste, including in withdrawal symptoms; he and I have corresponded about that.
Other studies have looked at antipsychotics and brain volume http://www.sciencedirect.com/science/article/pii/S014976341200125X
Alto:
Very cool and many thanks. Now I want to learn some neuroanatomy as I have been promising myself. Briefly scanning, the role of stress in neural alteration cannot be ruled out. It does seem likely that schizophrenia is associated with brain alteration, and not to use a bad word, bipolar too.
As for Jim Phelps—exactly what we need in psychiatry. Agree or disagree, you know the issues when dealing with a person like him.
I am a “bipolar imperialist,” a name I picked up somewhere and like to use for fun. It’s a strange disease, may I propose, under diagnosed and over-treated.
Your kid has bipolar—we are going to give him/her 300mg. of seroquel and trade bipolar for diabetes, and you can have the bipolar back later.
Calling everything bipolar disorder makes a diagnosis of bipolar disorder meaningless. Depression? Unipolar bipolar disorder. Withdrawal syndrome? Bipolar disorder NOS. A volatile personality? Must be bipolar disorder.
Whatever true bipolar disorder is, it must certainly be under-diagnosed, since no one seems to know what it is, but the label is applied promiscuously as a catch-all when the clinician is too dumb or lazy to investigate the source of the symptoms. Bipolar miscellaneous.
For personal reasons I can’t do details. I am trying to write something but I can’t. I will only say that the current evil of bipolar diagnosis is treatment. No one is going go crazy experimenting with 900 mg of lithium for a month or two. You can go crazy experimenting with antidepressants especially if, in your phrase, “the clinician is too dumb or lazy to investigate the source of the symptoms” as the patient worsens on anti depressants.
Yeah, maybe you will fix the patient, three years after career, marriage, future and whatever else has been lost.
True, antidepressants sometimes do ruin lives.
I don’t mean to beat up on you, Richard Parker. But why start with throwing lithium, with its drawbacks, at someone?
About 20% of the population has low vitamin B12, 30% low folate, 50% low B6, 60% low magnesium, 75% low iodine, and 80% low omega-3 fatty acids (Cordain, 2005) — any of which may have psychiatric symptoms.
BTW, if you’re looking to temper glutamatergic transmission, there’s lamotrigine, which has considerably fewer dangers than lithium. Unfortunately, it’s usually dosed too high, causing paradoxical reactions, which has diminished its reputation for effectiveness.
I’m always looking for clinicians knowledgeable about tapering people off psychiatric drugs, for local referrals. If you are such, please send me note at survivingads at comcast * net.
Alto,
So, you admit that many folks have nutritional deficiencies that mask as “mental illness”, but you’re against “alternative” (your phrase, not mine) medicine?
Orthomolecular Medicine *is* nutritional medicine…
Heaven-forbid (according to your views) someone should see a licensed MD who specializes in nutrition… and address the *root cause(s)* of their symptoms.
“Alternative” medicine is not good, according to your countless comments….
I’m not a genius, but this seems quite illogical, Alto.
Duane
Alto,
You cannot beat up on me. I respect you and nothing you say will ever hurt me.
So, wonderful!!!! I have changed my name but I am not a doctor. I agree with you more than you can imagine. Magnesium is in my meds. box. I spent a couple of years on Lamictal doing sort of ok considering what I was dealing with, and you remind me that maybe that should be tried again. Will goggle.
We agree completely. Every patient should be evaluated maybe, approximately, in the following way:
1. What stressors are you under including those generated by this damned society in which people are commodities?
2. Take your vitamins and eat right. I am doing better on a low glycemic diet and some exercise.
3. Now try psychotropic drugs, carefully.
The problem is that the alternative meds folks think they can save you as do the big pharma whores. Meanwhile you send us the most interesting psych/neuroscience paper that no psychiatrist will ever read.
Very true about the alternative med folks.
Thank you for the kind remarks.
Allow me to be absolutely clear about my opinion of alternative medicine: There are at least as many quacks in the field as there are in conventional medicine.
From my own research and experience, the “alternative” programs that claim they can get people off psychiatric medications or cure withdrawal syndrome by utilizing supplements are invalid, without exception.
Especially suspicious are alternative practitioners who espouse their own version of the brain “chemical imbalance” theory, as many so-called orthomolecular psychiatrists do. The “chemical imbalance” theory is not any more valid in alternative than it is in conventional medicine.
The positive aspects of alternative or integrative medicine are 1) they tend to be nicer than conventional doctors and 2) they tend to be concerned with basic nutrition and healthy lifestyle. Because of our bad eating habits and factory farming, good nutrition is a growing problem in rich as well as poor populations.
Addressing possible nutrient deficiencies is an important part of any medicine, alternative or otherwise. Sometimes those deficiencies cannot be corrected by anything other than supplements as certain nutrients are scarce in our mass-produced food.
Allow me to clarify…
You know some things about drug withdrawal, Alto.
And, what else?
Duane
Before you paint all forms of integrative medicine with a broad brush, and throw its practitioners under the bus, read this. -
http://psychoticdisorders.wordpress.com/bmj-best-practice-assessment-of-psychosis/
Duane
I can’t find specific post to which I wanted to reply but thought I would give an anecdote:
My mother was psychiatrically ill although also had a lot of inappropriate social behaviors, talking over people, not listening, etc that were not psych related – lived alone and got used to behaving in public as though she was still alone in the house.
Her psychiatrist put her on antidepressants and tranquilizers.
Everytine my mother would call her, usually paniced about being alone, the doctor would tell her to take more of her meds.
The doctor also called her to ask for dog training information (my mother had dogs and long experience with them).
I wrote to the state psych. association and they told me I should be grateful someone was willing to help my mother.
Her experience is anecdotal. The woman should have been yanked from the profession or at least reprimanded but the medical community thin blue linerotects the bad guys. My mother was made much worse by this woman.
That does not mean that all psychiatrists, or all psych medications, are bad.
I think from what I read here this is most definitely a case to be made against many of the psych meds and primarily for their overuse/inefficacy (or worse).
It is docs like Steve who are willing to ask put forth the questions that will ultimately (hopefully) make the changes necessary.
Jeff and anyone else interested … Matt Samet’s book called Death Grip was just released. It spells out his harrowing ordeal of coming off benzo’s. He’s a terrific writer and tells it how it is in all it’s graphic detail. I’ve gone thru the withdrawal too and there is no torture on earth I’m sure that can compare. To that doctor on here that said he’s alright with RXing benzo’s, man, you really need to get educated in reality.
I hope Matt Samet’s book gets a LOT of attention, and he hits all the talk shows.
From Wiki, “Reckless endangerment: A person commits the crime of reckless endangerment if the person recklessly engages in conduct which creates a substantial risk of serious physical injury to another person. “Reckless” conduct is conduct that exhibits a culpable disregard of foreseeable consequences to others from the act or omission involved. The accused need not intentionally cause a resulting harm. The ultimate question is whether, under all the circumstances, the accused’s conduct was of that heedless nature that made it actually or imminently dangerous to the rights or safety of others.”
Richard, what is that supposed to mean?
Richard unless you are talking about someone who prescribes because they are getting a kickback it would be very hard I would think to prove any doctor heedlessly prescribed.
The post was impulsive and I apologize. I am talking metaphorically.
Let’s try this: Henry Nasrallah(sp?) recently wrote an article pointing out that a large number of psychiatrists do not discuss the metabolic side effects of atypicals when they are prescribed. These drugs can and often do cause serious weight gain and diabetes.
Further, as above, many may not point out that benzos are addictive, or that anti depressants can be dangerous to patients with undiagnosed bipolar disorder.
Reckless endangerment is too strong a phase for the serious failure of informed consent.
So if a physician prescribes a dangerous drug and fails to inform the patient about its dangers—???? What if the patient would have refused to take the drug given full information???
What is the word of phrase??? I apologize again, I have the wrong phase. What is the word or phrase that describes the behavior of a physician who prescribes a drug without fully discussing its known dangers?
Errrr….about antidepressants and undiagnosed bipolar disorder:
There’s some question as to whether antidepressants trigger bipolar disorder. What happens is that the patient might have an adverse effect from an antidepressant — sleeplessness, restlessness, agitation, akathisia — that is misdiagnosed as bipolar disorder.
Then, instead of taking the patient off the antidepressant, the doctor loads on benzos, antipsychotics, sleeping medications, etc. to quell the adverse reaction.
Years pass, and you have a person who’s suffered adverse effects from an excessive, unnecessary drug load. She can’t go off any of the drugs because withdrawal symptoms are interpreted as emergence of yet more psychiatric disorder, causing addition of yet more drugs, in a never-ending loop of psychiatric mistreatment.
Alto,
We have to stop meeting like this. I have much overstayed my welcome anyway.
You are right. It is insulting to you to suggest that because anti depressants made you worse you have bipolar disorder. My issue is that psychiatric treatment is just god damned flat out dangerous.
I don’t want to discuss my personal history too much but, after I gave up on being “saved” and decided I would have to suffer for the rest of my life, I stopped anti depressants and it was like spring came in the middle of winter.
I so wish I could say more, but like you, I suspect, I am still paying .
My deepest sympathies to you, all these drugs cause, or can cause terrible withdrawal symptoms. Ask any alcoholic.
Richard Parker, fortunately I was never diagnosed with bipolar disorder. When it was suggested to me, I laughed heartily at the absurdity. My patient was hypothetical, but I see her (and his) story all the time at http://tinyurl.com/3o4k3j5
I agree, leejcarroll, doctors can’t read the package insert to their patients, it would take up too much time. However, they could be aware of all the side effects, even the rare ones. Even if the incidence of a side effect is 1%, it could be affecting your patient. Too often, doctors dismiss a patient’s report of a side effect merely because they believe the chances are against the patient having it.
Now we have the InterWeb, so we can Google our own symptoms and find out we do, indeed, have those “rare” side effects, probably at a much higher incidence than reported to the FDA or other agencies.
I am not a doctor nor a psych patient but have been a chronic pain patient for many, many years. A doctor cannot go through all the potential risks because pharma is required to list even the most oblique of potential risks. I was on a drug many, many years ago and noticed I had a sore throat. Doctor never said that could be an indication of an adverse event from the medication. I found out because I had been reading the PDR (I was an ER ward clerk at the time so had nothing else to read during a lull). A cardiologist came into my office and told me “Don;t read that. It will scare the heck out of you because it has to list every possible potential problem.” I ignored him and attended to the list including the sore throat. In fact it was from the drug which I was told to stop immediately and never take again.
I could not blame the doc for not telling me about a sore throat as a sign or problem.
When as Altostrata notes there is a question whether one thing causes another you cannot then say that this must be disclosed when the information is not known, or agreed upon. (or is an esoteric symptom of drug reaction.)
I disagree.
I think that any time a psychoactive drug is used, *each* of the possible “side effects” (they are actually *effects*) needs to be addressed *before* the drug is prescribed.
Also, the doctor needs to explain that the effects are *much higher* than indicated in the package insert, because the “side effects” listed are only what was found during the short-run (often only a few weeks) clinical trial.
For instance, tardive dyskensia is listed as “rare”, when in fact, it is quite *common* when the drug is used for years (rather than weeks).
‘First, do no harm” needs to be taken much more seriously by doctors, especially psychiatrists who use mind-altering drugs – all of which (each class) have the potential to do enormous harm to the body and mind.
Duane Sherry, M.S.
discoverandrecover.wordpress.com
And the following need to be address *before* a drug is prescribed:
1) Information on non-drug options (there are many).
2) Information and referral (including support groups) to help somone get *off* the drug – so a person has the knowledge on how to *stop* taking the drug before they ever *start* taking it.
Psychoactive drugs should not be prescribed to children.
And only for adults with fully-informed consent, for the short-term, and as an abolute *last* resort.
Duane
Dear SteveMD,
Sometimes whistle blowers are blamed by both sides, if not often.
It’s problem with society.
There’s often no way to say there’s a problem without upsetting people. There’s a lot of emotion, a lot of patients already knew these things and some react badly when they here a physician finally come around.
Bad people get away with bad things, but in the end things will work themselves out – thanks to people like you. Eventually even the people who left those nasty comments will respect you for the good you done by raising a public voice. That’s the most respectful thing a human being can do.
Keep blogging, keep writing. Keep it going.
Just found this blog from PsyCritic’s last post, so will link and hope the writer will be posting with some regularity, perhaps at least biweekly. Docs like me are interested in other colleagues’ opinions, if not at least some other perspective.
Thanks for the opportunity to comment, never take that for granted.
Joel Hassman, MD
cantmedicatelife.com