View Full Version : NYTimes: Mind Over Meds


Sit-n-Spin
04-28-10, 07:06 PM
Here's an article from the New York Times today titled Mind Over Meds (http://www.nytimes.com/2010/04/25/magazine/25Memoir-t.html?pagewanted=3). This article is not primarily about AD/HD, but does mention it as an example of the dilemma of providing just medication, just therapy or both. An excerpt: When I started to probe my patients, I realized I barely knew most of them. I had exuberantly documented their moods, sleep habits, energy levels and whether they had suicidal thoughts, but I didnít know what made them tick as people. For example, I had treated Jane (her middle name), a health care administrator in her 40s, for depression and bulimia (http://health.nytimes.com/health/guides/disease/bulimia/overview.html?inline=nyt-classifier) for many years, focusing on a complicated combination of medications like Effexor, Provigil and Xanax. Then she had a depressive relapse. This time, rather than simply adjusting her medication, I asked her what was going on in her life. I found out that her boss had recently given her an impossible assignment to complete and had berated her when the results were not to his liking. It seemed clear to me that her depression was partly triggered by the fact that she blamed herself for her bossís poor communication skills and managerial lapses. I encouraged her to question that assumption each time it popped into her mind. Over the next few visits, she improved ó relating better to her boss, able to take his criticism with a grain of salt and feeling more confident.

But while my simple therapeutic suggestions were helpful, as Jane and I continued to explore her work issues in detail, she said that she often lacked focus on the job. Knowing that poor concentration can be a symptom of depression, I asked if she associated her distractibility with periods of sadness. But she said there was no such correlation with her moods.

I wondered if she might have an adult version of attention deficit disorder (http://health.nytimes.com/health/guides/disease/attention-deficit-hyperactivity-disorder-adhd/overview.html?inline=nyt-classifier). Indeed, carefully reviewing her years in school, I saw she was always easily distracted but overcame this problem by working extra hard, and managed to achieve good grades. Even now, her job performance was consistently rated as excellent, but the extra work this entailed sapped her energy.

I decided to prescribe her a version of Ritalin (http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/ritalin_drug/index.html?inline=nyt-classifier), the standard treatment for A.D.D. (http://health.nytimes.com/health/guides/disease/attention-deficit-hyperactivity-disorder-adhd/overview.html?inline=nyt-classifier) The next month, she said she felt that this medication had turned her life around. Not only did she feel more focused and productive at work, but she was more apt to get things done at home, which in turn enhanced her mood, indirectly improving her depression.

Is Janeís story an argument for psychiatrists providing both medication and some sort of psychotherapy? I think it is. This does not mean that dedicated psychotherapists are not crucial ó they are, because they can provide the in-depth therapy that psychopharmacologists will never have time to deliver. When our patients need more from us than just medication, however, we should be prepared to provide it. Oddly, managed-care companies discourage us from doing psychotherapy, arguing that it is cheaper to have psychiatrists do 20-minute medication visits every three months and to hire a lower paid non-M.D. for more frequent therapy visits. But the few studies that have analyzed the economics of these arrangements have found that integrated treatment actually saves money. Mantosh Dewan, the chairman of psychiatry at SUNY Upstate Medical University in Syracuse, found that when psychiatrists do both medication and psychotherapy, the overall amount of money paid out by insurance companies is actually less than when the treatment is split between psychiatrists and psychotherapists. When patients see only one provider, they require fewer visits overall.

I recommend the entire article.