Psychotherapist Asks for Prepared Info for Physicians and Patients re. Antidepressants
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Q:  Psychotherapist Asks for Prepared Info for Physicians and Patients re. Antidepressants

Dear Dr. Phelps,

I am a psychotherapist working in a medical practice in Arizona. Psychiatric appointments can be hard to come by in our community and it has been estimated that  family practice and ob/gyns are prescribing approximately 65% of all psychotropics. I am desperate for information I can share with physicians to prevent the sometimes indiscriminate prescribing of SSRI's. I see patients all the time with significant family histories and multiple soft bipolar signs who are not being referred for a comprehensive psychological evaluation prior to being prescribed meds.

My request is two-fold: Do you have any prepared information for physicians to alert  them to the dangers of potentially doing more harm than good by casually prescribing SSRI's? (I have a Bachelor's degree in nursing, a Master's in counseling, and I am a Licensed Professional Counselor. I have been a therapist for 13 years but without "MD" behind my name, the information I share with physicians seems sometimes undervalued.) Secondly, do you have any prepared information that encourages patients to consider having a comprehensive psych assessment before asking their prescriber for an antidepressant? In part because of the competitive nature of medical practice, physicians often feel compelled to give patients what they (reasonably) ask for when it comes to psychotropics. 

Thank you very much for your time and attention. I look forward to attending one of your conferences in California in November. 

Dear Paula --
As you are probably aware, your questions are music to my ears.  I've been working on trying to address this problem of too-easy-prescribing of antidepressant medications for years.  As you describe from experience, in most settings there is no screening for bipolarity before antidepressants are given.  None.  I can tell, even though in the last five years there has been a substantial consciousness-raising about bipolar disorder.  That's because  when I tell the primary care docs that a requirement for bipolar screening can be found in every antidepressant prescribing information (the rice paper tickertape that the pharmacist hands out with the pill bottle), I still see a look of surprise in their eyes.

Meanwhile, up here in Oregon -- just as you describe for Arizona -- and primary care prescribing of psychiatric medications is becoming more and more common.  The East Coast doctors don't seem to worry about this so much, but out here in the West, it is the norm, not the exception, to be unable to refer patients to a psychiatrist without a waiting time of many months.

So, this combination of inability to access psychiatric consultation, plus a lack of training for how to screen for bipolar disorder and the common conditions which accompany it (anxiety disorders, particularly PTSD; and substance use, especially), creates a situation of risk for patients.  What is to be done?

As you may have gathered, I am trying to teach psychotherapists about bipolar variations that are now well recognized by mood experts around the world, so that they might intercept patients before an antidepressant is given by an otherwise well-meaning a primary care physician who really does not have the time (even if they once learned about bipolar II) for a systematic evaluation of mood or anxiety symptoms.  Thus the workshop you are planning to attend in California (delighted to hear it; I will look forward to meeting you out there).

At the same time, I am trying to teach primary care doc’s that an untapped source of help for them is the group of therapists who have learned just what you have already learned (you will enjoy the workshop, but you’ve already integrated one of the main messages). Instead of trying to get the patient to a psychiatrist, which is difficult or impossible in many places in the West, send the patient to a therapist who has the skills to do that comprehensive diagnostic assessment; who will send the doc’ a typewritten assessment – not long, but thorough in differential diagnosis; and who is skilled in a variety of psychotherapies likely to cover the needs of a spectrum of patients, from unipolar depression to bipolar depression to bipolar episode-prevention to anxiety disorders of all kinds (what else are the primary care doc’s seeing? not much else, it appears; psychosis goes to county mental health programs, perhaps after hospitalization. What a system).  Such a report and ongoing management of all issues except medication trials will go a long way toward lowering that “no M.D. degree” barrier which is unfortunately common at present.

So, one attempt at the solution you are seeking is underway (and surely there are others), though slow in coming; together we can move it along.  I’ll look forward to meeting you in November. Please to introduce yourself there.

Oh, what about your specific questions, now that I’ve waxed grandiose for a while.  Well, you’ll find an attempt at the “prepared materials” on my website,  Take the Mood Swings but Not Manic link and you’ll find a version for primary care doc’s and a version for patients, respectively.  Not exactly on target for your requests; not effective all by themselves; but part of a partial solution, I hope.

Jim Phelps

Published November, 2008


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