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A Lot of Prescriptions (I).

While driving to the clinic, Ms. Blue thought about what she would tell her doctor. She didn’t want to come across as needlessly anxious, but she wanted him to understand how unwell she felt. Was there something wrong with her?

Fifteen minutes passed before Dr. Rules joined her in the sterile office.

“Hello, Ms. Blue,” he said while glancing at the chart. He dropped himself onto the rolling stool. “What’s going on?”

“Well, I think I might—well, you see, I’ve been really tired lately. There’s been a lot of stress in my life and I haven’t been able to sleep—”

“I’m sorry to hear that,” Dr. Rules said, glancing up from his notes. “How much sleep have you been getting?”

“Oh, I don’t know, maybe four or five hours. I think this is because—”

“How much sleep were you getting before?”

Ms. Blue paused to think. “Maybe seven hours? I’m usually in bed by eleven, eleven-thirty, and up—”

“So that is a change,” Dr. Rules continued. “Have you noticed any change in your appetite?”

“Um, I don’t think so,” she said. “But I—”

“How about your energy? You said you feel more tired now?”

And so it went. When she tried to tell him that her father recently passed away, Dr. Rules interrupted and asked if she had feelings of guilt. Because he then asked about her ability to concentrate, she wasn’t able to tell him that her mother, who had dementia, would likely move in with her family.

“Have you thought about suicide?” Dr. Rules asked.

Ms. Blue looked at him blankly. “No, no. Things aren’t that bad, but I don’t feel—”

“It sounds like you’re depressed,” Dr. Rules said, “but let me listen to your heart and lungs, just to make sure they sound okay.” His gaze settled into the middle distance as he moved his stethoscope first across her back, then over her chest. After quickly pushing on her belly and murmuring, “Everything’s fine,” he dropped back onto the rolling stool and rotated towards the desk. He hastily scribbled something onto his prescription pad, tore the top sheet off, and handed it to her.

“Take this,” he said. “It’s an antidepressant. It might have some side effects, like dry mouth, sleepiness (but you could use that, right?), and problems with sexual climax, but you should start feeling better in a few weeks. I’ll see you in about a month, okay?”

He was already walking away, though he suddenly paused and returned to where she was sitting. Putting a hand on her shoulder, he said, “It’ll get better.”

She walked out of the office, feeling both relief and dismay. On the one hand, Dr. Rules apparently didn’t think that she had a major medical condition. On the other hand, she wondered if he at all understood her current situation and how terrible she felt.


Later on in the day, Dr. Rules pulled Ms. Blue’s chart from the file and reviewed his notes. He looked at the checklist of symptoms for depression and saw that he had checked five boxes.

“Five out of nine means major depression,” he murmured. He continued to mumble to himself as he completed the note.

“Assessment… major depression, mild, single episode. Plan… prescribed an antidepressant for thirty days with one refill. Follow up in one month… repeat checklist at that time…”

He resolutely closed the chart. Diagnosis guides treatment. He had succeeded in both.


This is part of a series about why some physicians write many prescriptions for psychiatric medications. You can read more stories here.

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A Lot of Prescriptions: Introduction.

Doctors write a lot of prescriptions for psychiatric medications.

According to this paper, pharmacies filled 472 million prescriptions for psychiatric medications between August 2006 and July 2007. There weren’t even 472 million people in the United States in that year. (In 2009, there were 307 million people in the country.)

Furthermore, the National Institute of Mental Health has reported that many people have psychiatric conditions. It said that in 2004, 57.7 million people suffered from a diagnosable mental disorder.

Were those 472 million prescriptions written for the 57 million-ish people with diagnosable mental disorders?

What about those prescriptions that were written, but not filled? Were those for individuals with psychiatric diagnoses?

Or what about the prescriptions for people who don’t have psychiatric conditions? Were those prescriptions even necessary?

And, of course, what about the people who have psychiatric conditions, but never receive prescriptions?

People understandably express concern about the widespread use of these medications. Do all those people actually need those pills? Just what conditions or symptoms are being treated? Do people ask for these medications, or do doctors reflexively write prescriptions?

Following are some short stories that may help explain why many physicians–for better or worse–write a lot of prescriptions for psychiatric medications for their patients.

  1. Dr. Rules
  2. Dr. Rush
  3. Dr. Distress
  4. Dr. Fixit
  5. Dr. Refer
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Privacy?

His wife just called. The ambulance took him to Big Block Hospital. He’s probably been admitted by now.”

“Thanks for letting me know. I’ll call Big Block later and talk to the docs,” she said.

After she snarfed down her lunch, she dialed the phone number for Big Block. Her patient had a complicated medical history. The inpatient service would appreciate background information, she thought. Plus, she could then learn what had happened that led to this hospitalization.

Unsure where in the hospital the patient was, she selected the automated option to speak to Patient Admitting.

“Big Block Hospital, Admitting,” a female voice said. In the background were sounds of papers rustling and people who were talking loudly at each other.

“Hi. My name is Dr. Betty Crocker and I’m the outpatient doctor for Mr. Paul Stuart. Can you tell me what unit he’s in?”

Computer keys tapped faintly in the background.

“Paul Stuart, born 1970. He’s on 6 South. Would you like me to connect you?”

“Yes, please,” Dr. Crocker said, surprised.

After the phone rang twice, a tired voice answered, “Six south.”

“Hi. My name is Dr. Crocker and I’m the outpatient doc for Mr. Paul Stuart. May I speak to the physician who is taking care of him so I can pass along some medical information?”

“I’m sorry,” the voice answered. “I can’t tell you if he is here.”

“I’m sorry?” Dr. Crocker said, again surprised.

“I can’t tell you if Paul Stuart is in the hospital.”

“But I know he’s there.”

“For patient privacy reasons, I can’t tell you if he is here.”

“But I know he’s there,” Dr. Crocker said again. “I’d just like to give some information to help the treating team. Can I please speak to the someone there? Anyone?”

“I can’t tell you if he is here.”

“Okay. No one needs to tell me anything right now—I just want to pass along some information that might be helpful for the team.”

“You know about HIPAA? For patient privacy reasons, I can’t say if he is here.”

“Fine. Can I speak with your supervisor?”

“Yes.”

Before Dr. Crocker could say anything, there was a soft click.

The phone rang five times before an automated message began to play: “Hello. You have reached the department of Decedent Affairs at Big Block Hospital. We are unable to take your call right now…”

Dr. Crocker muttered something profane as she forcefully returned the phone to its cradle.

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Power.

Everyone liked him. Though he had the shoulders of a baseball player and the complexion of a surfer, Paul was a post-graduate student in music and the conductor of the symphonic band.

After tapping the baton against the metal music stand several times, he called, “Okay, settle down, everyone. Let’s start from the top.”

The murmurs of the group faded away. Instruments were poised at lips in preparation for the first note.

To cue the band, Paul quickly extended his arms out overhead. He left them raised, elbows slightly bent, fingers loosely holding the baton. Though his eyes were open, Paul did not see what was before him. He was looking inside, watching and listening to the metronome within. Both baton and band waited.

Paul swiftly brought his arms up. The baton carved a large arc in the air. Everyone breathed in, ready to exhale into their instruments so the song could be released.

Except Paul didn’t bring his arms down to mark the first beat.

The baton remained in the air, restrained from freeing the music. Like the baton, Paul’s body was rigid and still.

Everyone’s diaphragms stretched in anticipation. Lungs were full, uncomfortably pushing ribs out. People could feel the pressure in their abdomens travelling to their throats.

Everyone waited, their unblinking eyes fixed on Paul.

The air did not move.

Suddenly, Paul’s body relaxed, the baton tumbling down with his limp arm. An embarrassed smile crossed his face.

“Sorry about that—”

—and everyone laughed, finally exhaling.

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Fence.

This is what a teacher once said to me:

You’ve seen farms with wooden fences around them, right? They have posts every few feet. Logs link the posts together. Farmers or ranchers rest their feet on the lower beams and lean on the upper beams. They look out over these fences at their crops, their livestock. You see that?

Imagine you’re out there and you see your patient leaning against the fence. If you’re respectful, he’ll invite you to stand next to him. Now you can both lean against that fence and share the view, see what’s on the other side. Farm land, mountains, valleys, whatever.

That’s exactly where you want to be. You want to stand next to your patient and listen to what he’s telling you. He’ll tell you what he sees and what he thinks about all of it. You’ll have the same perspective. You can talk about that thing out there and you’ll both be on the same side of the fence.

That’s how you can start understanding who he is and where he’s coming from.