
- Vol 38, Issue 4
- Volume 04
No Free Lunch
The more tools we have in our treatment toolbox, the greater the likelihood that we will ultimately find a treatment (or combination of treatments) to improve a given patient’s functioning and quality of life.
FROM THE EDITOR
The phrase “no free lunch” has its root in the mid-1800s United States. Beginning in that time period, bars and saloons offered free food at their establishments as long as you bought a drink. The merchants knew that their generous investment in free food for their customers would pay for itself many times over with the profits made from the beverages. Simply put, nothing is for nothing.
In the practice of medicine, we are all too familiar with this simple concept: No matter what benefit our treatment plan provides for our patients, there is always a cost. Our ethical responsibility is to provide
A Case Study of Depression
Let’s look at a common psychiatric disorder—a major depressive episode—and review the treatment complexities that are involved. Our first task is to complete a comprehensive psychiatric evaluation, collecting a treasure trove of information that often directs our recommended treatment options. We must consider the many possible
Once we have established that our patient indeed is having a primary major depressive episode, the next task is to differentiate if it is secondary to unipolar depression or bipolar depression, as the treatment recommendations will be very different for each.
Let us review a partial list of the possible treatment
So, what about no free lunch? Each of the listed treatment interventions, including the patient’s option of no treatment, is accompanied by a plethora of potential benefits
In this issue, we present 2 important series of articles related to psychiatry’s toolbox: a debate over the use and effectiveness of electroconvulsive therapy (ECT), and an exploration of psychiatric medications’ possible side effects. In the spirit of these articles, I would like to share a few of my memorable patient responses to treatment.
ECT for Psychotic Depression
I was in private practice 25 years ago when I was asked to evaluate a man, aged 72 years, who was brought to me by his family for an emergency evaluation. He had a history of recurrent severe major depressive episodes, often complicated by mood-congruent psychotic delusions. Because this man presented virtually mute to my office, his family provided his history and current symptoms.
According to the family, he had suffered 5 previous severe depressive episodes over the prior 20 years and had not responded to aggressive trials of pharmacotherapy. There were no identifiable psychosocial stressors; when he was not depressed, he lived independently and was high functioning. His
This was a
There was a dramatic change after the patient’s first ECT treatment: He wanted a meal, and his delusions virtually vanished. After 3 ECT treatments in the hospital, he significantly improved and continued his course of ECT as an outpatient.
I eventually learned that this was his usual presentation. He never responded to a litany of medications, but he did respond rapidly to ECT treatments. His long-term treatment consisted of 1
Dr Miller, You Are Fired
Several years after completing my residency training, I was working in a private group practice when I completed a seemingly straightforward psychiatric evaluation on a woman in her late 40s. She presented with a moderate episode of depression, with significant
Three days later she came in to see me for an emergency appointment. I quickly found myself being criticized and cursed by this woman. She reported that since starting the nefazodone, both her anxiety and insomnia had worsened. She fired me and transferred to another psychiatrist in our practice who put her on a different antidepressant. She responded nicely with full resolution of her depression and associated symptoms.
I was befuddled. At the time, my understanding and experience with nefazodone was that it was a reasonable antidepressant that
From a Lamb to a Lion
During my second year of residency in psychiatry at the University of Massachusetts Medical Center, I worked on the locked inpatient unit. I admitted a man in his early 60s who reported a lifelong history of recurrent unipolar major depressive episodes. When depressed, he could not function in his job, withdrew from his social relationships, became
On the morning of his third hospital day, as I walked onto the locked unit, this patient ran toward me with exuberance, praising me for turning him “from a lamb into a lion.” The staff told me he had been up all night calling old friends and business customers. Having never been hypomanic or manic in the past, he was excited and delighted over his perceived newfound exceptional functioning.
However, as is common in mildly manic patients, he remained fully competent to decide his fate. Despite a lengthy team meeting with him, in which we explained in great detail that the imipramine had flipped him into a manic state and shared the risks and unpredictability that accompanied mania, he insisted on discharge. We had to allow him to leave against medical advice.
I can still see him walking toward me that morning with such excitement and appreciation, all the while feeling dread about having prescribed the medication that transformed this man from having a major depressive episode with poor functioning into an individual with hypomania who had no insight into the
Conclusions
All experienced clinicians have had similar encounters to these. The blessing of the field of medicine is that we have numerous treatment options to draw upon, established by a solid evidence base and the accumulation of our aggregate clinical experience. The curse is that each patient is unique in ways that we cannot predict, and we have no control over how a particular patient will respond to treatments. Just as our patients have no free lunch when beginning our prescribed treatment, we have no free lunch when recommending what that treatment should be.
Dr Miller is medical director, Brain Health, Exeter, New Hampshire; Editor in Chief, Psychiatric TimesTM; staff psychiatrist, Seacoast Mental Health Center, Exeter; Consulting Psychiatrist, Exeter Hospital, Exeter; Consulting Psychiatrist, Insight Meditation Society, Barre, Massachusetts.
References
1. Miller JJ.
2. Davis R, Whittington R, Bryson HM.
Articles in this issue
over 4 years ago
Sedation: The Ups and Downs of a Side Effectover 4 years ago
Addressing Obesity in Patients Taking Antipsychoticsover 4 years ago
Finding Solutions While Managing Problemsover 4 years ago
Race, Ethnicity, and Chronic Painover 4 years ago
Phenomenology, Power, Polarization, and Psychosisover 4 years ago
In Memoriam: Eulogies for Beloved PsychiatristsNewsletter
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