Sunday, December 12, 2004

When doctors take antidepressants

Yet more e-mail from the blogging world, about a post on antidepressants.
Mr. Schuler writes,

If, as you've reported, 10% of American women are taking anti-depressants, it's a reasonable inference that the use of anti-depressants by female American physicians is substantially higher. What proportion are actually disclosing their use? My guess is very, very few. Self-policing of such things is a paradox. If one's judgment is impaired by medication doesn't this impairment apply to the decision to comply with laws requiring disclosure as well? And asking someone to put their own livelihood at risk is putting possibly unreasonable demands on people.

Self-prescription (or any of the several easy dodges around such things) compounds the problem.

I think the real need is a general cultural shift in the society at large and
physicians in particular against routine prescription of drugs for mood-
aleration in the absence of real clinical depression. The likelihoood of this right now isn't very high for reasons you've outlined.

Dave Schuler
The Glittering Eye

I think the boards have weighed the risk of supporting sick doctors in getting treatment and possibly having problems with the treatment, vs. creating a situation in which sick doctors won't even consider treatment because of risks to their licensure. If you're a doctor in treatment, there is another doctor looking after you, and (one expects) watching you like a hawk for side effects (including behavioral side effects). The illness is more likely to impair judgment than the treatment.

I wish that one of Mr. Schuler's points could be shouted from the rooftops: these meds should never, ever be given casually or "routinely." Their ease of dosing has perhaps lulled doctors into a sense that they are easy to prescribe and monitor. And direct-to-consumer marketing may spread the idea among patients that these are not serious meds with serious side effects. Neither is the case.

And here's Dr. Maurice Bernstein, of the excellent Bioethics Discussion Blog:

Responding to your paging me.. "The focus is on competence, whether you're medicated or not. I'm interested in what others think about this. (Paging Dr. Maurice...) Of course, you are correct. What also troubles me is based on what you wrote.. "If a patient has stopped functioning, is unsafe, or is deteriorating because lack of appetite is causing malnutrition, we reach for these meds readily. Often it's not so clear-cut." OK..what if the treating physician is on mood altering drugs him/herself, might that not affect the therapeutic decision of that doctor with regard to the patient by explaining "if that drug is working great for me, maybe it will be helpful for my patient." A not so clear-cut patient illness is thus put on drugs. It is a given that all physicians should be aware that their own personal problems of any sort can affect judgment regarding patient care. ...Maurice. (You may publish this if you desire)
I agree. There can be subtle (or not-so-subtle) bias toward the use of these meds. This applies to doctors of all specialties (most antidepressants are prescribed by non-psychiatrists). And this also applies to other categories of meds, including tranquilizers, stimulants, and mood stabilizers. The difficulty in identifying this sort of problem with the meds is obvious.

Now seems like a good time to link to my post about resources for impaired physicians:
"Doctor, we have a problem..."

addendum - I didn't go far enough in my comments above. I don't know about Mr. Schuler's inference about the number of physicians taking mood-altering meds, and why it should be substantially higher, and that it's going unreported. I'm certainly not aware of any data about this. Antidepressants can affect mood, behavior, and judgment, but that does not mean they are necessarily placing patients at risk. I've watched the efforts of medical directors dealing with physicians who have perplexing behavior changes. There are many potential causes for such changes. These changes won't only be apparent at work. They affect multiple areas of a person's life, i.e. self-care, family relationships, driving, and so on. Are there enough safeguards? Mr. Schuler clearly doesn't think so. This issue extends far beyond complications of the use of antidepressants by physicians.

another update: The Rebel Doctor weighs in:
Being treated for mental illness or taking psyciatric medications is no longer career ending, but it will haunt a physician for the rest of his career. He will be asked about any history of psychiatric treatment on every residency/fellowship application, application for hospital staff privileges, and application for medical licensure. He will also be asked about it when applying for malpractice insurance. A doctor with a history of mental illness will have to disclose it for the rest of his career.

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