My Recent Promotion


Sometimes when you complain for long enough about the disastrous nature of something, you end up being nominated to fix it.

“Sometimes when you complain for long enough about the disastrous nature of something, you end up being nominated to fix it,” laughed Dr S. “Look at me,” he continued, “I thought that the psychopharmacology teaching you were getting was terrible and now I’m stuck as your professor, whether I like it or not.”

“But Dr S,” I began, “You love teaching because it gives you a chance to brainwash us.”

Dr S grinned and raised his bushy eyebrows, “I do love brainwashing you, but not as much as you’re going to love being the new Chief Medical Officer at the local Department of Mental Health.”

“Someone’s gotta fix it, I guess,” I responded.

“You certainly qualify as a ‘someone,’” Dr S said as his grin widened, “Plus you’ve got 2 full years of training under your belt, which makes you grossly overqualified.”

“Where do I start?” I asked. . . .

“Well, let’s say for the sake of simplicity that your budget of $600 million just got cut in half and now you’re left with 6000 folks to feed, clothe, house, medicate, hospitalize, and provide psychiatrists, therapists, and case managers for. That leaves you with approximately $50,000 per person per year and then subtract your hefty salary and pension.”

“As long as I take in more than the 12 bucks an hour I’m making as a resident, I’ll be happy.”

“Let’s further assume that you can’t build any more houses or group homes because 50% of your budget is getting eaten up by psychopharmacology prescriptions. Frankly, this is one of our main problems: nearly half of our guys are on the streets and sleeping on park benches, if they’re lucky. To make this even easier, let’s just say you’re only in charge of chronic psychotic patients and don’t have the complicating variables of substance abuse, personality disorders, and malingering to deal with.”

“Thanks for making it simple, Dr S.”

“So what do you want to do to maximize services and minimize costs? Starting today and starting right now because we don’t have any time to waste, Dr Freedman.”

 “Well, let’s start by outlawing prescriptions for any of the brand-new super-expensive drugs until we find out whether they work any better than the other ones we’ve come to know and love.  They’re costing us a fortune.”

“But what about one of these new drugs that might modulate BDNF? It might be the most pro-cognitive antipsychotic medication we’ve ever had! Do you really want to be personally responsible for preventing your chronically psychotic patients from having their BDNF tweaked? That could make all the difference and finally cure our most refractory patients!”

“I love it when you play ‘the excitable sales rep,’ Dr S. And you’re right, I guess I can’t rule out putting something that exciting into our local water supply, but I need more research saying it actually works differently from anything else we’ve already got before switching over all of our folks to it because it’s gonna bankrupt my whole department.”

“OK, fine, but what about atypical antipsychotics in general? Walmart only charges us 10 bucks a month for the first-generation meds, and we’re hemorrhaging nearly $1000 a month for each new atypical antipsychotic script. Not to mention the cost of metabolic adverse effects on our patients in terms of decreased functionality and increased mortality/morbidity as a natural result of obesity.”

“I can see that you want me to grossly oversimplify the academic literature in a Reader’s Digest kind of fashion, but I still don’t find it particularly ridiculous to suggest that any single drug is better than its peers, with the exception of clozapine1 for our most chronically psychotic patients. But am I really ready to treat these folks with only typical antipsychotics and clozapine at this point?”

“You tell me, you’re the boss.”

“I guess I can’t say I’m prepared to be so black-and-white. But it makes sense to have a darn good reason not to treat our guys with clozapine and I’m not sure we have one in a lot of our cases.”

“Frankly this makes me pretty livid at times; I need to forget about it now or I’m going to need a PRN. Next subject: any thoughts on treating with long-acting injectables? Those cost us a fortune, too, when we use them.”

“True they’re expensive, but not as costly as hospitalizing someone when he misses a few oral doses accidentally or starts refusing his PO meds because he’s ‘doing better’ and ‘doesn’t need’ his antipsychotics anymore.”

“Good point, I like the idea of increasing the use of shots as long as our patients go along with it. Did you know that in Great Britain more than 30% of their psychotic patients are treated with long-acting injectable formulations?”

“I actually take the time to read the articles you recommend to us, so yeah, I’m familiar with that figure and with the fact that many of our patients would clearly benefit from the stability and guaranteed treatment adherence of long-acting injectable antipsychotics. In short, I’m definitely willing to increase the use of long-acting injectables in our population in order to minimize hospitalizations that could have otherwise been avoided with better treatment adherence.”

“OK Dr Freedman. You’ve done a good job so far as the Chief Medical Officer of DMH. Unfortunately you’re fired because we need to get you back to the inpatient unit to finish rounding.”

“That’s it? No severance pay, no state pension?”

“Maybe I’ll rehire you again next week during psychopharm seminar, OK?  Now go save the world.”

Acknowledgment-The author would like to thank Dr S-as well as Drs A, Z, P, C, and F-for the superb psychopharmacology teaching he’s received over the past few years.The author reports no conflicts of interest concerning the subject matter of this article.



1. McEvoy JP, Lieberman JA, Stroup TS, et al; CATIE Investigators. Effectiveness of clozapine versus olanzapine, quetiapine, and risperidone in patients with chronic schizophrenia who did not respond to prior atypical antipsychotic treatment. Am J Psychiatry. 2006;163(4):600-610.

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