Maria Yang, MD

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?

Shortly after she was escorted into the examination room, Dr. Distress entered the room.

“Hi, Ms. Blue,” he said. “What’s wrong?”

“Well, I think I might—well, you see, I’ve been really tired lately.” Ms. Blue paused. “My dad died about a month ago. I haven’t been able to sleep.”

“That’s terrible. I’m so sorry to hear that,” Dr. Distress said.

“Yeah, it was unexpected. I guess no one ever expects someone to die, but he was actually training for his first half-marathon. He was running regularly! Eating healthy! The stress of caring for Mom was high, of course, but he was taking care of himself.”

“Uh huh, uh huh.”

Ms. Blue’s face began to distort. Her voice sounded tremulous. “It was so sad to see Mom look at him and have no idea who he was. She’d get up in the middle of the night, insisting that she had to go to work. She hadn’t worked in almost ten years! She’d get so upset when he tried to get her back in bed. ‘It’s okay,’ he’d say, ‘the work will be there for you in the morning.’ He was so gentle with her and she would scream at him, calling him all sorts of names for getting in her way. He spent the last four years of his life devoted to this woman and she had no memory of his efforts!”

The tears collected in the corners of her eyes before spilling onto her cheeks. She tried unsuccessfully to stifle her sobs.

“Oh, it’s okay, it’s okay,” Dr. Distress blurted, his eyes frantically darting around the room for a tissue box. Unable to find one, he abruptly got up and pulled several paper towels from the dispenser.

“Here, take these,” Dr. Distress said, trying to put them into Ms. Blue’s hands. Using the back of her hand to wipe her face, she looked up, wincing.

“I’m sorry,” Ms. Blue said. Another wave of tears came bursting forth.

Dr. Distress began to tap his foot quietly on the tiles. His fingers rotated the earbuds on his stethoscope. He looked at her, looked away, looked at her again, opened his mouth, then said nothing.

“I miss him a lot. And now Mom lives with me and… it’s hard,” Ms. Blue said.

“Yeah, yeah. Yeah, I can see that.” Dr. Distress suddenly stood up and said, “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 pushing on her belly, he declared, “Everything’s fine.”

“I feel terrible, Doctor. I just don’t know what to do. I can’t sleep, I don’t want to eat—I mean, I am eating and I eventually fall asleep, but I’m tired all the time and I just miss him so much and I want to take good care of her and keep her out of a nursing home but I’ve got to work and—”

“Here, here,” Dr. Distress blurted. He had scribbled something onto his prescription pad, tore the top sheet off, and was flapping it at her, insisting that she take it. “This will help you feel better. You might have some side effects—headache, dry mouth, things like that—but it’ll help you feel better. You’ll feel better.”

Ms. Blue wiped her eyes and looked at the prescription. “What is it?” she asked.

“It’s an antidepressant. It’ll help you feel better. Just try it. Come back in a month and we’ll see how you’re doing.”

“Um, okay,” Ms. Blue said. “I’m sorry that I cried. I’m just—”

“It’s okay, it’s okay, you’ll feel better, it’ll get better. I’ll see you soon, okay?” He walked to the door and began to open it. She quickly wiped her face again and took a deep breath.

“Okay, good-bye,” Dr. Distress said, walking out. In the hallway, he heaved a huge sigh of relief.

She walked out of the office, feeling tired and embarrassed. What did he give her again? Oh, she could look at it later. She just wanted some time alone.

---

“Recurrence of leukemia… new diagnosis of HIV… hospitalized for complications related to diabetes… father passed away….”

Dr. Distress was going through his charts at the end of the day. He sighed again. Ms. Blue looked so sad. What could he possibly do to help her? It was so hard to see her cry like that. He was relieved that she left when she did.

---

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

When the psychiatrist told her, “I’ll try to keep you out of the hospital for as long as possible,” she cringed. The psychiatrist presumably meant well, but she caught the meaning in his absentminded comment.

“What did he mean, ‘for as long as possible’? Doesn’t that mean he thinks I will end up in the hospital again? Doesn’t that mean he thinks I will only get worse… and not better?”

She frowned.

“I don’t want to work with him anymore,” she said. “I don’t think he’s a good doctor.”

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?

Upon entering the office, she was promptly shown into an examination room. Only three minutes behind the scheduled appointment time, Dr. Rush entered the room.

“Ms. Blue,” he greeted, extending his arm. They shook hands and he sat down on the rolling stool. “I understand you’re not feeling well?”

“Well, I think I might—well, you see, I’ve been really tired lately.” Ms. Blue paused. “My dad died about a month ago. I haven’t been able to sleep.”

Ms. Blue and her father had always been close, though they increasingly relied upon each other for support in the past five years. Her mother’s memory was steadily worsening over time. Prior to his death, her mother periodically woke up in the middle of the night and tried to leave the house, believing that she had to go to work. She remembered less and less of her history with her husband with each passing day. He never cried when he talked with Ms. Blue, though his weariness and sadness were obvious. Since his passing, her mother had moved in with Ms. Blue and her family. Neither Ms. Blue nor her mother were adjusting well to the change. Any energy she had was now gone and—

“I’m sorry to interrupt, but we’re running out of time,” Dr. Rush said. “So you’re not sleeping well, you’ve been feeling depressed, you’re tired—all understandable. I’m sorry for your loss.”

“Thank you,” Ms. Blue said, wiping her eyes.

“With all that has happened, have you had any thoughts about wanting to be dead?”

“Oh, no, no. Nothing like that. I just wish I didn’t feel this way.”

Dr. Rush nodded, putting the earbuds of his stethoscope into his ears as he said, “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 pushing on her belly and murmuring, “Everything’s fine,” he sat back onto the rolling stool.

“Maybe we can talk more about this next time, in about a month? And, in the meantime, you can try an antidepressant. You might start feeling better and have more energy,” Dr. Rush said, checking his watch before taking the prescription pad out of his pocket.

“You think I need an antidepressant?” Ms. Blue quietly asked.

“It probably won’t hurt,” Dr. Rush said. He scribbled something onto his prescription pad, tore the top sheet off, and handed it to her. “Some people experience side effects—sleepiness, dry mouth, stomach discomfort—but those usually go away in a few days. It might help.”

“Thank you,” she said, tucking the script into her purse.

“You’re welcome. I’m sorry that our time was cut short, but they have me on a tight schedule,” Dr. Rush murmured. They said good-bye.

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 she really needed an antidepressant. Was her condition that bad?

---

While going through his charts later that evening, Dr. Rush spread his arms out to loosen his shoulders. He sighed.

“If only I didn’t have to see so many people in a day,” he mumbled. “I might actually be able to help people more. I can’t possibly do a thorough job in fifteen minutes.”

He heard a knock on his door. The clinic manager stuck her head into his office. “Only one no-show today. Your productivity numbers have been great. Our reimbursement will be high this month. Good work!”

A weak smile crossed his lips and she ducked out of the office again. When he looked down, he saw Ms. Blue’s chart in front of him. He wondered what she didn’t tell him today.

---

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

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.

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