Why Aren’t Doctors More Honest With Patients in the Hospital?

Inpatient Prescriptions of Antipsychotics

Yesterday I received this comment from Leah,

. . . At the mental health clinic [where] I stayed, they were really into prescribing low doses of Seroquel [quetiapine] for unipolar depression . . . after reading up on this stuff I became somewhat angry for the widely prescribed off-label use of these antipsychotics since side effects can be strong. Especially since I was not told. Do you maybe have any thoughts on this practice?

Thoughts? Yes. Far too many. Ask anyone.

I have, over and over, lamented about the lack of honesty and transparency in the doctor-patient relationship. Specifically, why is it doctors prescribe antipsychotics, often off label, without disclosing their risks? It’s happened to me many times. In the hospital may be a special case, however.

Prescribing Antipsychotics

Antipsychotics (by which I mean atypical antipsychotics) are being prescribed for all sorts of things these days. Traditionally schizophrenia, but now frequently bipolar disorder and major depressive disorder (MDD) too. There is considerable evidence for atypical antipsychotic treatment in all three disorders.

Antipsychotics and Risk

Antipsychotics are not pleasant medications. Antipsychotics turn down the dopamine and serotonin in your brain, those neurotransmitters typically considered to be “happy chemicals.” Why does that help depression? That is extraordinarily fuzzy, but we know they work for some people.*

Trouble is antipsychotics carry very serious risks. Risks like permanent movement disorders, weight gain and diabetes. I have had fits about such things.

Antipsychotics FDA-Approved for Treatment of Depression (Unipolar)

  • Aripiprazole (Abilify) is an antipsychotic “indicated for use as an adjunctive therapy to antidepressants for the treatment of major depressive disorder (MDD).”
  • Olanzapine (Zyprexa, antipsychotic) and fluoxetine (Prozac, antidepressant) come combined in one medication called Symbax. Olanzapine and fluoxetine, when used in combination is “indicated for the treatment of treatment resistant depression.” **
  • Quetiapine Fumarate Extended-Release (Seroquel XR) is an antipsychotic “indicated for use as adjunctive therapy to antidepressants for the treatment of MDD.” *** (Study of quetiapine monotherapy for MDD)

Prescribing of Antipsychotics

[push]Antipsychotics do work quite well for many.[/push]

Often when multiple antidepressants fail for depression, antipsychotics are up next, typically as an adjunct (like aripiprazole, above). And in all honesty, in a case of severe or treatment-resistant depression, in my opinion this practice is quite reasonable.

Antipsychotics in the Hospital

One of the places people are often introduced to antipsychotics is in the hospital. There are generally three reasons for this:

  1. Patients in the hospital are there because treatment has failed thus far
  2. Patients are in the hospital because they are in crisis
  3. Patients need something that will stabilize them so they can leave the hospital

Those are the realities of being in the hospital. Under these circumstances it’s quite reasonable to prescribe powerful, more risky medication as the person is in more danger. This doesn’t mean it’s pleasant. As I remarked after having been given quetiapine in the hospital:

Seroquel [quetiapine] is the new med . . . 50 fucking milligrams a day. That’s ridiculous. He had to know that would kill me. And yet, somehow he doesn’t care.

I will say though, he looked like I had punched him in the stomach when I saw him today. I don’t know what he was expecting but I did look pretty bad. His medication made me that way for fuck’s sake, where’s the surprise there?

Doctors and Honesty in a CrisisHospital Prescribing

Here’s the thing about hospital prescribing – doctors really, really want you to take the medication. No, they can’t make you (bearing legal exceptions) but they do want you to. And this is not for some dark, sinister reason, it’s because they want you to get better.

You’re sick. You don’t have the mental capacity to be considering antipsychotic study data comparisons. You don’t have cognitive ability to make good choices and assess risk. You’re already overwhelmed. You’re in a psych ward. It’s not the place to be discussing the nuances of treatment.

Skip the Messy Medication Details

So doctors often overlook things like telling patients a drug is being prescribed off label (if it is) and there may be serious side effects. They choose the treatment they feel gives you the best chance at recovery. (By the way, doctors do this all the time, not just in psychiatric cases.)

Because if you don’t accept treatment, how will you get better? And if you don’t get better how will you leave the hospital? And if you don’t leave the hospital, how will you get back to your life?

Doctors Have a Tough Call When Prescribing in a Hospital

That’s the choice. Do you tell the patient more information and run the risk of them refusing treatment and not getting better? Or do you tell the patient less information to increase the chance they will accept treatment?

Antipsychotic Prescription in the HospitalI feel for doctors in this scenario. From personal experience I can tell you, being in a psych ward is seriously unfun. And when I was there I was incapable of making good decisions. He could have given me heroin and I probably would have taken it. But that’s the game folks. Your brain isn’t working. Your brain is in crisis. That’s why you’re in the hospital. You can’t expect your brain to make good choices at that moment.

I understand the conundrum. I understand why doctors do it and I understand why patients get made about it. But what the heck else is the doctor supposed to do? ****

Antipsychotic Prescriptions after the Hospital

But, of course, then there’s the problem of what happens once you leave the hospital. You should be more stable and more able to make good decisions. So it’s time for the doctor to cough up whatever it is they skipped over while you were busy being crazy.

I find doctors tend not to do this. I can’t really say why. They don’t want to rock the boat if you’re doing well? They’re lazy? Who knows? I’m not a doctor and really couldn’t say. I consider it to be unprofessional, unethical and bad practice, but that’s me.

Honesty and Doctors

I’m sorry to say doctors are often only as honest as we make them. We have to question them. We have to get the information even if they don’t offer it. It’s our responsibility. Not because it should be but simply because we’re the ones with the most invested. Like I said, the time to do this isn’t likely going to be in a hospital ward, but at some point, the unpleasant information has to be dealt with. And it may only happen if you force the issue.

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Notes of the Foot

* I actually have a pet theory on this regarding depression and mild psychosis, but that’ll have to be another day.

** Treatment resistant depression is defined as “major depressive disorder in patients who do not respond to 2 separate trials of different antidepressants of adequate dose and duration in the current episode.”

*** Quetiapine fumarate (the non-extended-release form) is not FDA-approved for unipolar depression (making that information extremely hard to find).

**** An answer, by the way, might be to have a patient’s proxy or advocate make the decision, as they are not ill at the time. However, as time is an issue, and decisions have to be made extremely quickly, it’s unlikely a proxy could get up to speed on the treatment fast enough. Not to mention, many of us don’t have such people.

 

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