Category Archives: psychiatry

a clarification on my November post about knowing more than my doctor

I *loved* this comment from PreMedAA so much that I’m going to write a whole post in response to it. This comment followed my early-November post about my annoyance with my new psychiatrist.

The background for readers who don’t want to refer back to old posts (plus filling in some gaps I’ve previously omitted to help hide my real identity): I switched shrinks when I moved to a new state over the summer. Hubby and I knew that we wanted to start to try for a family sometime this autumn, which was my first in a faculty position after 3 years in a health sciences postdoc. Having discussed the issue of medication and pregnancy at length with my old shrink (a fellow in geriatric psychiatry at one of the best psychiatric hospitals in the nation who I very much  miss), I was keenly invested in seeking the best care possible in my new setting. My old shrink was supportive, and asked me to keep in touch with her about my treatment in this new setting. My old shrink appreciated that since Hubby and I have started talking seriously about kids, two limitations have been foremost on my mind: a) I’m able to work up to my full potential because of ritalin, and taking a 2-year break from it in order to conceive could potentially tank my chances for tenure, and b) having spent 9 years in pre- and postdoctoral training, I’m no longer a spring chicken. If we’re going to start a family, we need to start trying soon, or we risk running out of time.

S0, imagine my dismay when I called for an appointment at my new university’s med center specialty AD/HD clinic (in July) and found out I’d have to wait 2 months in order to get an appointment (September). My dismay was further magnified when I met my new doc and discovered how inexperienced she was. I brought up the pregnancy & meds issue at our first appointment in September. She promised to do research before our next appointment, and wrote me a prescription for the SSRI I take for PMDD (note: she wrote it for the bi-weekly dosing, which is quite standard for treating PMDD). When I came back in October, she hadn’t yet done any research on pregnancy & ritalin. I brought up the research I’d done on my own and with my old doc. She promised to look into it and get back to me. When I came back in November, she still hadn’t done any research and seemed to have forgotten about the bi-weekly dosing of SSRIs for PMDD (despite having written the prescription herself just weeks before). She promised to consult with her network of supervisors and colleagues, and assured me she would call me in a week. I had to call her a week later to remind her of our phone appointment. She was rather unprepared when she called me back, and asked me to come in before Thanksgiving for a short chat in person about the literature & promised to bring an important research publication. I made (& paid for) the extra appointment, for which she ran 30 minutes late. She forgot to bring the article (promised to fax it, but it still hasn’t happened & I’m not holding my breath), but still couldn’t say anything conclusive or provide me any strong evidence for any option during pregnancy. She pushed really, really  hard for my trying fish oil, which apparently shows decent efficacy with young children (alas, if I were only in the 2nd grade and just learning simple multiplication instead of spending my days doing matrix algebra…).  So I’m still on hold, and yet can’t get another appointment in the clinic until  early January.

So, my hubby and I have put off trying to conceive for an additional 6-7 months, and 4 months of that delay is due to my new shrink being inexperienced and inefficient. I’ve also wasted a total of 4 hours of my semester in the waiting room filled with people who function at a far, far lower level than I do… and to put this in practical terms, 4 hours = the preparation of 1 full lecture or 4 written pages of a research article.  The bottom line is that I sought a specialty clinic thinking it would save me time and effort, and I probably could have received better treatment from a GP.

(I suspect that quite a few ADDer readers have had similar treatment experiences. My situation is anything but unique.)

So, now I’ll deal with PreMedAA’s lovely comments…

Would you have preferred for the resident to attempt to cover her ignorance and simply take her ‘best educated guess’?

A physician at any level may not have confident answers on the tip of their tongue, especially if their patient has a keen grasp of pharmacology and medicine.

I agree with you; no, I wouldn’t want her to ‘cover’ by making a guess, but a competent medical professional in a specialty clinic shouldn’t need 3-4 months to come up with an answer to this sort of question, regardless of who the patient is, or how threatening the patient’s competence is to the physician’s ego. It’s not like ADD is a new condition, and I’m hardly the first woman who wants to get pregnant without tanking her career by going totally med-free.

Stating that you know more about something than a doctor may or may not be true. Your ‘knowledge’ may have been garnered from secondary sources or your educational background may be insufficient to properly digest the primary pharmacodynamics proposed by the manufacturing company. Your doctor is not a CPS or PDR, if they were, those compendiums wouldn’t exist.

Actually, I have a Ph.D. in the health sciences, and my research specialty is self-regulation, the set of skills directly impacted by the medical condition of AD/HD. It takes longer to get a Ph.D. in  my field than it does for a M.D. to complete medical school, and I have 3+ years of postdoctoral training on top of that. Furthermore, I’m 2+ years past diagnosis, and have been very actively involved in my treatment. This has included spending a great deal of my free time reading the literature on AD/HD and medication. Yes, I read the primary sources, and yes, I understand them, even the “yucky” stats part in the middle. In short, I have more years of research training in the field, and unless my doc has ADD herself, then most likely I also have more first-hand experience.

If you were particularly impatient, which you claim to be, then perhaps stating your acceptance of her consultation of her reference books in your presence would have saved you both time, as its likely that she didn’t feel dragging out the books in front of you would inspire much confidence, which you could have offered to alleviate.

For pete’s sake… the November post as just a blog entry, not a direct transcript of my conversation with my doctor. I actually would respect her more if she had dragged out her reference books. Of course I consented to allow her to consult with colleagues and do further independent research. I’ve repeatedly told her that I understand that residents are still training, and have also repeatedly expressed a desire to consult about primary references (i.e., current research). She’s the one who’s not been willing or able to meet me halfway on this. How much more open, supportive, and non ego-threatening can I really be? How long should someone be reasonably expected to wait?

You claim to know more about treating ADD/ADHD than your 1st year psychiatry resident-attending physician which is unlikely unless your a physician yourself and in the case of Adderall…at least a pharmacologist.

I’m not writing anything else about my specific academic credentials because I risk outing myself, and that’s  not a good thing pre-tenure.  Just a few points… a) she’s a 1st year resident, not an attending; b) it’s “you’re,” not “your,” and your sentence structure doesn’t make much sense; c) finally, if you’d bothered to read any of my other entries, you’d realize that I take ritalin, not adderall.

But since you don’t have time to permit your physician to ensure the validity of her counsel, then perhaps you ought to consult with a pharmacist about the possible effects of your drug regime on pregnancy…and perhaps they would be familiar with your atypical SSRI rotation.

The possibility that you havn’t done this already on your own suggests that such comments in regard to having a superior clinical knowledge of your diagnosis may not be advisable on your part, especially towards a medical professional.

Doctors are not gods, and the rest of us are not “lesser” beings.  Contrary to the belief of many MDs, they don’t know everything, they do make mistakes, their time is no more valuable than anybody else’s, and they don’t deserve to be treated any better or worse than anyone else.  I’ve given her plenty of time, and she’s wasted it. As a faculty member who is currently working 60+ hour weeks, I don’t have time or the patience to train somebody how to do their job OR remind them about how they’ve treated my condition at previous appointments. In these circumstances, I shouldn’t have to bend over backwards or jeopardize any aspect of my future in order to keep them from feeling badly about themselves or their abilities.

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I know more about ADD/ADHD than my psychiatrist

It’s annoyingly official… I know more about treating ADD/ADHD than my new psychiatrist (1st year psychiatry resident). I asked her today about medications & pregnancy and she said that she’d have to get back to me about it… and amazingly, this is a specialty ADD/ADHD clinic in my local university hospital.

In the same conversation, she also tried to order me to take my SSRI for PMDD continuously instead of in two week cycles. Actually, she’d never heard about people taking SSRIs in two-week cycles for the treatment of PMDD.

I’ll call her in a week to talk about ADD meds & pregnancy. I had to promise to not get pregnant in the  next week until she’s had a chance to do her research.

I respect that there’s a learning curve and that new doctors need to be given allowances to learn how to practice medicine… but I don’t have time for this, and think I need to find a new doctor.

pdoc troubles yet again

My Unkymood Punkymood (Unkymoods)

Sometimes I wonder if my pdoc needs her own ritalin prescription.

I had my regular appointment about two weeks ago. Med Shrink wrote my usual prescription for ritalin, and I barely looked at it before dashing back to the office. I wasn’t out and was pretty swamped with work, so I waited a few days to fill it.

I tried to fill it the following Tuesday, only to discover that a) she hadn’t written the actual dosage on the prescription (i.e., she’d written “15 mg 3x/daily” instead of “1.5 10-mg tablets 3x/daily”), and b) hadn’t signed the prescription itself. Naturally the pharmacy wouldn’t fill it, and the pharmacists probably now think I’ve swiped my doc’s prescription pad!

I called Med Shrink on Tuesday night. She called me back Wednesday afternoon, and said that she’d write a new prescription and leave it in “location a.” She called back a while later and said “I wanted to leave it in location b, but I couldn’t, so you can pick it up at location c sometime before 8 pm tonight.”

I went to location c at 4.45 p.m. on Thursday, and found that they’d closed at 4.30.

I went back to location c on Friday morning, and they said they didn’t have anything for me. I subsequently visited locations a and b in order to make sure I hadn’t misunderstood (keep in mind that I’m doing all this on foot, and it takes me 15-20 min to get from my office to location c). I hadn’t — they didn’t have anything for me, either.

I called Med Shrink on Friday afternoon to double-check the location. She didn’t call me back until Monday afternoon (Today), and was pretty testy with me about the whole ordeal. She called location c to verify that they had the prescription she’d written; it turns out that they did, and that the person I’d spoken to on Friday didn’t “know where to look.”

So, I stopped by location c on my way home this afternoon, and was finally able to pick up the envelope. I opened it on my way home and nearly had a heart attack.

It was written for 15mg 2x/day instead of 3x/day… and indicated that the pharmacy should dispense 45 10mg tablets.

Let’s do the math together: 15mg x 3 doses per day = 4.5 10mg tabs per day. 4.5 tabs x 30 days per month = 135 tablets. Not 45. The prescription I’ve now spent hours trying to pick up is enough for 10 productive work days, and my next appointment is 15 days away.

I’ve already called and left a message on Med Shrink’s voice mail. Given that it typically takes her 24+ hours to respond, it looks like I’ll run out of medication and waste several more hours of precious time before this mess is straightened out. At this moment, I have 4 tablets left, and I am hesitant to fill an incorrect prescription for ritalin.

But it does look like it’s time to find a new doctor, does it not?

medication, therapy, & web graphics (today’s miscellanous thoughts)

 

irst and foremost, let it be known that I have a new favorite graphics website. Clipart etc is a free site that includes a massive quantity of old-fashioned graphics, many taken from old books, etc. There are also sister-sites with powerpoint presentation & website backgrounds and maps. Very cool stuff, accompanied by a very friendly usage license for educators and students. I am suspicious that we will end up using this website for non-educational purposes. After all, who wouldn’t want to add a 16th century map of Scandinavia to their collection? (And yes, I am a big nerd, in case you didn’t know already). My blanket acknowledgement…. I will use their graphics as I can, I love having my blog look like a book from the middle ages. If there is no credit given to a particular old-looking black & white graphic on my blog, it’s from Clipart etc.

 

econd, I am pleased to announce that I tapered off of Lexapro over the past 2 weeks, and have not taken any in 48 hours. Unfortunately I am still experiencing SSRI discontinuation syndrome (AKA withdrawal), despite the fact that I took a tiny 10mg dose for a bare 3-4 months and reduced my dosage 2.5 milligrams every three days. If this is what it’s like to stop after such a short period of time, I hope that I never have to take it again. Today’s fun is dizziness and brain zaps. I don’t know when these symptoms will stop, but it’s still worth it to be rid of the side effects I experienced while taking Lexapro.

hird, I had my last appointment with Talky-Shrink last week. We didn’t quit therapy because I’m completely cured or no longer require additional support. It’s because she is a resident, and her year of training in Cognitive-Behavioral Therapy (CBT) ended at the end of the “school” year on June 30. It’s sometimes possible for residents to keep patients on their caseload after their training period ends, and Talky-Shrink tried to do that with me because we knew that I have recently been doing quite well and wouldn’t require too much more therapy. Unfortunately her supervisor disagreed, decreed that she needed practice with terminating the therapist-patient relationship, and issued the ultimatium that he wouldn’t continue to supervise her unless she terminated with me. Naturally I didn’t want her to have to find a new supervisor, so we terminated.

Just in case I do need help in the coming year (entirely possible, given the stress involved in the academic job search), my med-shrink has agreed to provide supportive therapy on an “as needed” basis. This sounds like a good plan to me, despite med-shrink’s overall weirdness. Med-shrink is also a resident, and is 1 year ahead of talky-shrink in their program. Med-shrink and talky-shrink share the same supervisor. Strangely, however, the supervisor allowed med-shrink to keep me on her caseload because med-shrink is “still learning from me.” I’m not quite sure what that means, other than med-shrink enjoys having me on her caseload. Apparently I’m a good patient because I come to appointments on time, am pleasant in interactions, take my medication as directed, and call her when I’m experiencing medication problems. This really makes me wonder what her other patients are like…

anticipate a change in medication dosage soon, incidentally. I’m having gaps in coverage during the day. I’m also spending a lot of time focusing on the wrong things, like blogging and decorating my blog with fancy capitol letters. Not a good use of time, even if it is stress-relieving!

“interim” medication for the holiday weekend & beyond

On Thursday, I left a voicemail for my meds-shrink that probably sounded pretty pathetic. I told her about my struggles to get the prescription filled, and that I was truly close to the end of my rope at work. I mentioned that she didn’t need to call me back, that I’d keep her in the loop about developments, and if it didn’t come in on Saturday, I’d let her know because we’d need to make alternate arrangements. I *need* to be able to work.

On Friday, I met with my talky-shrink for the first time in three weeks and told her all about the medication-related stress. While I was in the office, she emailed and directly paged my meds-shrink (they know each other from med school and are a year apart in their residency programs in Psychiatry at our local Big University-Affiliated Research Hospital). Two hours later, talky-shrink (heretoforth referred to as “TS”) called me on my cell and told me she’d found meds-shrink (“MS”) at a lecture and impressed the urgency of my situation upon her. TS said MS would be calling me soon.

MS called an hour later, said that she’d write me a script for short-acting generic ritalin, and would drop it off for me at my pharmacy. She told me that she was writing the prescription for 15mg twice a day, but that she trusted me to fiddle with it until I found the right dose that lets me get work done. She knows I’m not going to abuse it and just want to be able to think. She clearly felt terrible that I’d gone another week twiddling my thumbs at the office just because my insurance company is stupid.

A few minutes after that call, I decided I’d had it at work for the day. I got in my car and did the grocery shopping at Whole Foods and Trader Joes (silly me thought that there would be no crowds at either store between 1.30 and 3 on a Friday before a holiday weekend!) I picked up some corn, some shrimp, hummus and chips, salsa, and fixings for greek tomato-cucumber salad.

The decision to just “take off” was probably the best decision I’ve made in a while. It felt great, and I was pretty de-stressed by the time I picked up my chipper hubby at the airport, despite sitting in traffic for about an hour on the way. He’s always happy to be back at home after a long week of work, and I try to keep things like heat and humidity from bugging me when we reunite on Friday evenings.

We saw and I waved to MS in the parking lot of our grocery store on the way in to pick up my new ritalin script. She forgot herself for a moment and called across the lot, “I dropped off your prescription for ritalin hours ago, so it should be ready! Give me a call if you have any problems!” This was a little bit embarassing, but it could have been worse if it had happened elsewhere. At least nobody I knew was in the lot! We were pleasantly surprised to learn that the copay on generic methylphenidate was only $10, which is far less than I was spending on strattera!!!

We mostly enjoyed our dinner, and watched the season finale of “Lost” together. We also installed our window air conditioners, which made our kitties ecstatically happy. They’d been miserable in the humidity, and had been seeking my comfort constantly (They’d hop on me like they were thinking, “Mama, I feel bad! Snuggle me and make me feel better! Wait, it’s too hot to snuggle you… leave me alone!” Kitty dashes away. Repeat every 15 minutes). My hubby stayed up late playing on his PS2 with a friend in the Heartland, and I crashed quickly in the coolness of our bedroom.

I started generic IR ritalin on Saturday, and overall I’m pretty satisfied thus far. I noticed a slight feeling of shakiness on Saturday an hour after I took it. It went away after I had a little snack. My appetite was less than it usually is when I’m non-medicated. I had a little bit of dizziness, but nothing terrible. I also felt a little sick yesterday when I took it then tried to work out before eating breakfast. Bad idea — 13 minutes on the elliptical left me wanting to vomit. I stopped and ate and it went away. I’m happy that there’s no wonky exhaustion when it wore off, and no feeling of being sped up. No overall sensation of being drunk at a dance club, which is definitely how Adderall made me feel. With ritalin, thus it’s more like being at a quiet bookstore, which is definitely a better fit for me. Long-term, this seems like it might be a better option. Easier to find, packs a smaller punch to the wallet, and just feels better in my system than the other options.

This morning, I stopped by the pharmacy that ordered my long-acting generic ritalin (Metadate) last week. They were supposed to call on Saturday when my prescription was filled. They never called on Saturday because the metadate they ordered for me never arrived. Rahul the pharmacist told me that they’ve now been billed for it and expect it today. He also said that he’d start doing some research into what long-acting types my insurance will pay for, as they are as frustrated as I am that the wait has been so long (the other pharmacist behind the counter made a snarky comment like “this is why we don’t like to place special orders!” but I determinedly ignored her).

I have an appointment with MS tomorrow, and depending upon what Rahul tells me this afternoon, I may just ask to stick with IR ritalin for a while. Enough is enough.
<later> Rahul just called… they didn’t get it in, but he called the manufacturer, and they guarantee that he’ll get it tomorrow. He said this is common whenever they order narcotics, and that if it doesn’t come in by 10.30 tomorrow morning, he can talk with MS about what they do regularly stock during our appointment a little while later.

Overall, I am continually amazed what a difference a little pill can make. Writing is going better provided that I work to minimize distractions. I feel a little edgy today, however, which I don’t really like. Maybe that’s just because I forgot that we have a lab research meeting in 45 minutes, and I’m not prepared!

meds delayed again

I have now gone a total of 15 days without strattera. I thought I would have my new prescription today, but the pharmacy just called and said that it didn’t arrive with today’s order. They’ve reordered it and should have it on Saturday. The irony of the situation doesn’t escape me: I know I need to be patient, but it’s really hard to do with (unmedicated) ADD!

The last time I tried a stimulant I took “holidays” on weekends, ergo, I won’t really need it until I’m back at work on Tuesday. I just need to make it though 2 more days of work this week. I have a med management appointment with my medshrink on Wednesday, and that’s not nearly enough time for me to figure out whether the new med is working well enough or not.

In other less-interesting but related news, last night I put away last week’s clean laundry, did 6 more loads of laundry and swapped out my seasonal clothes, all before “Lost” began at 9. My increased energy from not taking strattera for these past two weeks is paying dividends! Now if I could just conquer the piles of junk on my dresser and cedar chest…

I will post some thoughts about the season finale of “Lost” later….

medication struggles, part ???

I found out late last week why the insurance company denied my claim for Concerta. It’s because I’m over the age of 18! They sent a fax about this to my medshrink, and I received a copy of the fax in the mail on Friday. They are only willing to pay for Adderall-XR (long-acting methamphetamine), Metadate ER, and Methylin ER (latter 2 are long-acting forms of ritalin), plus generic methylphenidate (generic short-acting ritalin). Great news: Everything but Adderall-XR will be $12/month, as they are generics! So, now it’s just a matter of getting my doc to call me back, me picking up the prescription, and then going through the whole verification rigamarole again. But, at least it looks like I’ll have meds tomorrow or Wednesday morning, which is a huge relief. I am tired of going off in a dozen different directions at once and not feeling like I can get anything done at work. I have a list of a jillion tasks, but anything involving more than a few steps and I feel like shutting down already.

When I was diagnosed about a year ago, I didn’t recall many symptoms of impulsivity or hyperactivity. Consequently, my formal diagnosis is “ADD — primarily inattentive.” I still don’t think I have enough impulsivity or hyperactivity to qualify as a “combined type,” but I’ve definitely noticed an increase in hyperactivity and impulsivity (or perhaps my forms of both) since going off strattera almost 2 weeks ago. I’m usually quite calm, but I found myself skipping around the apartment this past weekend. I also knitted virtually non-stop, and added about 3″ to the baby blanket I’m currently knitting. I’m really excited about having more energy, even if it is hyperactivity! I also just *feel* more impulsive and spontaneous, and am having to do a little bit of work to not act on these impulses. I’m also snackier. This makes me laugh, because the first thing I noticed when I initially started taking strattera last year was that I wasn’t snacky. Now I’m hungry all the time, and the timing couldn’t be worse! I never thought I had an impulsive/hyperactive vocabulary, but apparently I do, because it feels like my commend of the English language has returned.

I’ve read other ADDers’ writings about feeling more like themselves when they are off meds, and consequently some take drug holidays on the weekends. Perhaps I will do the same once I am back into a med routine, because I feel a lot better as my normal, silly, scattered self. To paraphrase Martha Stewart, “…this is a very good thing.”

<Later>

My medshrink called me shortly after I first posted this message. I picked up the script, and proceeded to visit 2 pharmacies in person to try to get it filled. No luck. I then called 12 of them, and nobody has Metadate-ER in 10mg. The pharmacist at Eckerd is going to order it for me, and it will be another 2-3 days before it comes in to the store.

It’s not necessarily a great thing to make somebody with limited frustration tolerance have to deal with so much frustration in order to get medication that will help them better handle it.

All the pharmacies have Metadate-CD, for which the copay is $48. One tried to tell me that ER and CD were the same thing, but my formulary says differently. Looks like no stores are willing to stock the cheaper generic…

Walking outside to try to get it ordered now…