Those days.

The 26th Law of Psychiatry (The Law of Therapeutic Charity): Give yourself credit for being the one in the room.

I had one of those days.

I haven’t written about it much so far, but I spend a lot of my time helping people with a nasty genetic condition. It’s called sickle cell disease (SCD).

SCD is very high on the list of things you do not want to have. It’s caused by a defect in hemoglobin, but the main problem it causes is pain. Early on, it’s episodes of bonecrushing pain called crises. Later, for reasons nobody really gets, the pain tends to turn chronic. Chronic pain is not an easy thing to treat.

Most of my patients were told they wouldn’t live to adulthood, though now they have a 50/50 chance of making it past their mid-40s. With longer life comes more cumulative complications. Strokes, joint and bone damage, all sorts of organ injuries, blood clots, and on and on. Not everybody gets all that, of course. The disease is amazingly protean considering how uniform the cause is. That said, it’s a bad disease. Where there is brain injury and chronic pain, there is depression. Of course, it’s depression that’s harder to treat.

I have really, really good days. Walking three inches off the ground good days. Days when I see the first smile of the patient who’s been miserable for months. Days when, after uncountable complicated, ambiguous decisions; I push my head up over the waves and realize my patient has been out of the hospital for a solid year when he used to be in every month. Days when somebody who was utterly gorked on pain meds and in godawful pain finally comes out of the haze and gives me that stunned, “I think my pain’s actually better,” speech. Days when I’m pretty sure somebody’s way better off because of me.

Most days aren’t like that. Usually I don’t know if what I’m doing is working.

Part of that is just plain ol’ statistics. Clinical trials can tell you that if you do the thing for a large group of people, more of them will get better than if you don’t do the thing. They can’t tell you if the particular patient you’re doing the thing for will get better, or if he would have gotten better with time, with or without you. (If you just started singing a U2 song, shame on you. This is a serious post, you Philistine.)

Clinical trials also don’t enroll my patients. You can find a randomized trial with bajillions of people with major depressive disorder (north of 5% of the population). You aren’t going to find a single one with people with SCD (around 0.03% of the population), two strokes, bone infarction, bad kidneys, iron overload from multiple transfusions, chronic pain, and depression. There may be a dozen of those people in a given state, and they’re probably going to be in my waiting room.

I know that what I do works. I seldom know if what I’m doing is working. Such is doctoring.

With uncomfortable regularity, I find myself in a room with someone and we’re three tricks deep into my bag, digging around for numbers four and five. Thus it was on the day in question.

He’s been one of my flock for years now. Since then, he’s developed various painful complications, and his insurance is crap, so he can’t get some interventions that might help. He’s lived about three decades longer than he ever expected to live. He’s also got a grinding chronic depression, and partly due to all the dirt SCD does to your insides, our options for medications are limited and we’re already pretty deep into that bag of tricks. Some things are better – his mood has lifted some, he’s not holed up in his room all the time, he’s spending more time with his kids, and he’s more active than he used to be. Still, better ain’t great; and we both know it.

He and I share a certain sense of humor. We get on, he and I.

To wit:

“How’s it going?”

“Well, I haven’t thrown myself out a window yet.”

“That’s good. It would certainly reflect badly on me if you did.”

“I would hate to inconvenience you.”

Like I said, we get on. Aside from all the bad jokes, we’ve also had some serious conversations about suicide, and we’ll have another one at the end of this session. He’s been straight with me about what he’s thinking. He’s decided to stay alive, come what may. I’ve told him I’m never going to give up on him. That’s the understanding. He’s an honorable guy, with a lot of integrity under his rough edges. Or perhaps in his rough edges. I have decided to believe in him. He has decided to show up. So, on we go.

This particular day, he was dealing with an ongoing problem with his family. Underneath that problem is that he depends on them, and he’s not the sort who likes depending on anybody else. We talked it through, came up with some concrete things to try to improve his interactions. As he walked out, he said, “All right. I’ll give it a try.”

Then, “Thanks.”

There are times people thank you, and there are times people thank you. This was the latter. My chest ached. I watched him struggle out of the chair and limp out to make the next appointment. Everything I haven’t been able to do for him hit me, hard.

I had to give myself that talk. The one I give supervisees who are stuck between the simultaneous realities that you can always find another way to help, and that you never quite know if anything’s going to work until it does.

You are the one in the room with him. 

It might be that there are dozens of other docs out there who know stuff I don’t know, and who would have made a bigger difference. They’re not here. I still am, and I’m hoping if nothing else, that makes some difference all by itself.

So, on we go.


I am puzzled and bothered. I know why I’m puzzled, I’m not entirely sure why I’m bothered.

On the Book of Face a few days ago I saw a post from a mental health advocacy organization. To be perfectly honest, I don’t pay much attention to them, but they stroll through my feed regularly. Overall what I’ve seen from them is positive. No snake-oil remedies advocated, serious issues in the health care system pointed out.

Then comes this: A link to this site called The teaser pic is a clonazepam tablet, the headline is “Benzodiazepines,” and underneath is:

Discover why a class of drugs used to help curb insomnia and anxiety has become an important component of an effective bipolar treatment regimen.

“Important component?” says I. “…for bipolar disorder?” says I, somewhat redundantly.

I click through the looking glass, and at the top of that page I find this:

Content created by Healthline and sponsored by our partners. For more details click here.

“Sponsored?” says I. Dutifully, I click here.

This content is created by the Healthline editorial team and is funded by a third party sponsor. The content is objective, medically accurate, and adheres to Healthline’s editorial standards and policies. The content is not directed, edited, approved, or otherwise influenced by the advertisers represented on this page, with exception of the potential recommendation of the broad topic area.

Curiouser and curiouser. I didn’t say that out loud, since I realized I’m talking loudly to myself yet again, and it gets weird.

So the content is paid for by some unnamed third party sponsor. It is not influenced by the advertisers represented on this page. Now if you were a compulsive freak, a corrosive skeptic, and had a certain well-developed cynicism regarding the mixed motives of our colleagues in the pharmaceutical industry, you might start thinking in funny little Venn diagrams. Like, for example:

Venn Diagram

This might lead you to note that at no time was there a disclaimer that the third party sponsor was also an advertiser represented on the page who therefore not influenced the content.

Someone could, however, recommend a broad topic area. Such as, “reasons the sky is black. ” Pretty broad. No real advocacy for any one reason the sky is black.

At this point, I smell weasel.

A touch paranoid, you say? Well, I am talking to myself a lot, asking questions of inanimate computer screens, and having olfactory hallucinations involving small vicious mammals. So overall, we must acknowledge the signs aren’t good.

Benzodiazepines are an interesting class of drugs. They do work, in that they quickly relieve anxiety. They also do put you to sleep.

There are “buts.”

  1. Behavioral therapies for sleep work at least as well, and are no doubt safer.
  2. They are not first – line treatments for anxiety disorders.
  3. Recently evidence of all kinds of problems has been piling up. Most alarming are  increased risk of dementia and death with longer-term use.
  4. They are addictive, and bipolar disorder is a major-league risk factor for addiction.

So maybe in the short run, they have a role in some aspects of the condition. “Important component of an effective bipolar treatment regimen?” Harrumph.

The article itself says lots of things about how benzodiazepines have problems. It also does say that short term treatment is recommended.

It then goes on to list a whole lot of symptoms of manic depressive illness and say benzodiazepines are useful for them, without any particular evidence cited for those claims.

It is medically reviewed, we are reassured. The doc’s name is right there at the top.

When I took a moment to look into this worthy, I find he is a family practitioner. Also, he is an executive at Healthline. A couple more clicks, and I’m wondering if he’s practiced Medicine any time in the last decade, since he seems to be so busy being a tech executive.

Never mind. He’s wearing a white coat in his thumbnail. Must be legit.

I’ve seen this hustle before. Shill docs giving “educational talks” to other docs, with their meal and his salary paid by the company that makes the drug everybody is getting educated about. Commercials offering “health education materials” to patients, who then get a load of advertising for the newest, latest, and greatest (and most expensive) drug for that condition (not to mention now being on a junk mail direct marketing list patient registry).

So, this is nothing new.

Here’s where my puzzlement comes in.

Who is doing this?

If this were the newest, bestest, and most expensive drug, or one that’s on patent, that would make sense.  It would be the company behind the drug.

This is an entire class of drugs which, though widely prescribed (often inappropriately), are all generic. One would think that there’s not that much money left to be made, and the population prevalence of manic-depressive illness is probably less than the number of people on benzodiazepines. Off the top of my head, a few times more.

I don’t get this play.

Though in terms of marketing, it does make some sense. The advertisers get around all the regulations for direct-to-consumer advertising by putting three layers of “educational intent” between them and the actual content. Perhaps, generic though they be, the various sources of bad news about benzodiazepines have the manufacturers looking for some new, particularly loyal market?

There’s that smell again.

Maybe I need a doctor.

I hear there’s a family practice doc in the Bay Area who’s good with this kind of thing.