[Magdalen] Drug research.

[James Oppenheimer-Crawford]

It's a dicey business.  On the one hand, you're absolutely right: only
board certified psychiatrists ought to be able to prescribe.  On the other
hand I can think of two serious considerations here:
First of all, many psychiatric facilities run by the states have a history
of employing MDs who are not board certified. It's not too extreme to say
that if only board certified MDs could prescribe, we would not be able to
hire the people at the price they are willing to pay. They simply wouldn't
be able to get the personnel.
And the other matter is the rapidly changing pharmacological picture.  I
recall when I first began to work back in 1975, there were not a lot of
meds available. But that quickly changed.  I had kept current on
medications' main purposes, side effects, general dose range, etc., but in
just a few years it became a hopeless case.  Every year brought some new
validated medication and new protocols. And also, the sudden terror of
retinitis pigmentosa from Mellaril and the general concern about tardive
dyskinesia suddenly changed utterly the way medication was prescribed.
Also, we would welcome a new antipsychotic with the hope that this one
might be that magic bullet. And it almost never happened that way.  I say
this to illustrate how a physician completely up to date and certified in,
say 1990, might quite easily be completely out of touch in just a few years
unless she or he conscientiously takes refresher courses.

Rehabilitation was a known factor from years back (I still remember an old
film we watched, made in England in the 1950s, which introduced the basics
of what we ended up doing for years), and it gradually gained traction over
time in my facilities. By the time I retired about ten years ago, the
strategy had become medication to stabilize and then a lot of day programs
of various types, designed to build on each consumer's strengths.  We
talked about the illness, how the consumer had to understand the nature of
their illness and learn to avoid trigger situations, and move toward things
that helped. Meds were merely a very beginning step.
Early on, I was taught that we expect the psychiatric patient to require
constant medication to compensate for their chemical imbalance for the rest
of their lives.  As time went by, we found that was simply not true.  A
person can be acutely psychotic and then, after a robust rehabilitation
intervention, can learn to live a fairly normal life with reduced
medication. I had the pleasure of meeting and talking to some of these at a
psychiatric rehabilitation convention. I wanted to get these folks into my
facility; there's nothing so powerful as someone standing there talking to
a very ill consumer, saying, "I used to be right where you are now, and I
took my meds, talked with my doctor, and went to programs, and today I'm
working a fulltime job.  You can too."
I've seen some amazing accomplishments too -- folks I really never expected
to leave the facility did in fact get it together with the help of titrated
meds and the right programming.  We sometimes were able to do some very
good work.
By the time I retired, most physicians had bought pretty solidly into the
rehab model, although the drug companies kept up their promotions, claiming
that certain difficult psychiatric patients could be cured with the
particular pill they were selling that month.
I was hired into a hospital whose Director was a psychiatrist (one who was
deeply committed to psych rehab, but still a psychiatrist). After that, the
head was an administrator who had come up through some other career ladder.
We have all those pictures of those psychiatrists (male, of course) who
used to be the director. Now, the pictures are just as often female as
male, and we have not had a physician director after the one previously
mentioned.
When I was hired in one facility, the sister facility across the county was
still directed by the old style director, and nurses generally wore their
whites. I only saw a nurse in whites in the medical clinic. I can imagine
that if I were to go to another state, things may well be very different.
Sometimes, folks would say that New York State was the best of the best.  I
had to wonder, if we were "the best," then how was the rest of the world
doing? We certainly had our share of dropped balls...

So meds still plays an important part, and always will, but it's also only
a piece of the puzzle. Each consumer is a separate puzzle, requiring her or
his own special interventions.

James W. Oppenheimer-Crawford
*“A life is like a garden. Perfect moments can be had, but not preserved,
except in memory. LLAP**”  -- *Leonard Nimoy

On Sun, Aug 28, 2016 at 11:01 AM, Jay Weigel <jay.weigel at gmail.com> wrote:

> Here in the U.S., only M.D.s may prescribe psychoactive drugs.
> Unfortunately, Drug companies have put big bucks into advertising ("Ask
> your doctor if this medication is right for YOU!" blares the TV) and this,
> plus loose regulations on which doctors may prescribe such, can lead to
> some awful messes. IMNSHO, no doctor should be allowed to prescribe such
> medications who has not taken an intensive course in psychopharmacology,
> passed an exam with a sufficiently high score and been certified.
> Furthermore, also IMNSHO, prescription drug advertising should be outlawed.
> It is coercive and leads to patients who are poorly informed pestering
> their doctors for medications which may not be in their best interests and
> are generally very high-priced.
>
> Stepping off my soapbox,
> Jay
>
> On Sun, Aug 28, 2016 at 12:54 AM, Sally Davies <sally.davies at gmail.com>
> wrote:
>
> > For me this is an interesting and helpful thread, aside from the personal
> > rebukes.
> >
> > As a psychologist who does not prescibe but has to work with medicated
> > patients, I feel confused at the moment regarding best practice in mental
> > health. There has been so much manipulation and outright corruption in
> > mental health, and the (thinking, reading) public is also confused
> > especially regarding children. Meanwhile MH problems in the elderly often
> > go undiagnosed or treate.
> >
> > I seldom advise anyone to consult a psychiatrist any more but these days
> > most of my patients are hospitalised in a general hospital, and the
> > physicians - you would call them internists - often prescribe calming,
> > sleeping and antidepressant medication.
>