The .Plan

Irritable Bowel Syndrome.
Migraine headache.
Bipolar Affective Disorder Type II.
Gastro-esophageal Reflux Disease.
Depression.
Adult Attention Deficit-Hyperactivity Syndrome.
Fibromyalgia.
Chronic Low Back Pain.
Anxiety.

As the pharmaceutical industry fuels the colonization of ever more aspects of human life, I realize that I hate prescribing under duress. Back in the day, when the only medication in the psychiatrist’s pharmacological armamentarium was the tricyclic antidepressant (a medication that had many unpleasant side effects and could be easily toxic with a minor overdose), primary care physicians’ reluctance to prescribe such medications must have been a psychiatrist’s dream. But these days, because medications like serotonin specific reuptake inhibitors are comparatively safe even when taken in overdose, outside physicians dispense these medications like cotton candy. Prodded into action by their patients who are in turn prodded into action by drug advertisements, these uncritical physicians hand out diagnoses like “bipolar depression type II” when it is quite clear that these fully functional individuals have never had a true destructive hypomanic episode in their lives.

Then the patients come to us expecting the same.

This week I was strongly persuaded by an attending to prescribe antidepressants for several patients whose problems were likely interpersonal and characterological in nature, and I was gently chided for being a pharmacological Calvinist. Today, when it came to another patient who came in with primary complaints of “anxiety” and “depression” despite having no objective signs of being in a vegetative affective state, I held the line. No Valium for you. Boy did that make him angry. And hostile. And verbally abusive. And threatening. I was surreptitiously reaching for the panic button (which doesn’t really help me much, it just means that a patient can only beat on me for about 5 minutes before the security guards finally show up) when he just picked up his 240 pound body and left abruptly.

Don’t go away mad. Just go away.

This is going to be a long three years.

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[*] All names, dates, and other HIPAA non-compliant details have been confabulated.