What is there to Treat?

I enjoy having friends, like just about everyone does. But that’s not why I’m in this business. When a patient needs help, I will do my best for them every single time.  And if a few colleagues get bruised egos along the way, so be it.

She was a 53-year-old woman, but I don’t think she even would have liked to hear me to refer to her as a woman.  We’re talking about someone who was short and stout and wore the kind of cap one would expect to see on a newsboy during World War I.  She wore a very male looking zipper jacket, and told me she had the name of the other woman to whom she had dedicated her life tattooed on the back of her neck.

Regardless of all this, her face was red and she was crying. She told me she was chronically suicidal and never thought about anything else.  Despite being medicated, her depression seemed to have gotten worse.

I reviewed the chart and saw that she had been on Zoloft in steadily increasing doses.  She insisted the increasing doses had only made her feel worse.  I tracked down more about her history, including a list of all medications.   I found out that while her Zoloft had been increasing at the mental health clinic, she had continued to take medication prescribed by her primary care physician at another clinic.

When I tried to speak to her physician, I discovered that he was a decent man.  He had put her on Amitriptyline, a tricyclic anti-depressant.  He told her that she could get her medications “adjusted” at the mental health clinic.

Well, the mental health clinic did not realize she was already on Amitriptyline.  So, she was still taking the Amitriptyline prescribed by her physician of origin while she was taking the Zoloft.  There is an interaction between these two medications that is well documented.  As her Zoloft increased, so did her Amitriptyline level.

People can get into trouble with this class of drugs.  In this class of anti-depressants — known as tricyclics — one of the first signs of toxicity is an increase in the intensity of the depression.  I told her immediately I thought this was most likely her problem and sent her to the local laboratory for a STAT.  That meant immediately, on emergency basis, to find her tricyclic level.

Somehow, this got everybody at the lab laughing.  They had never ordered tricyclic blood tests before and they said that they couldn’t do it.  I told them to do it anyway.  They did, but it seemed unlikely we would get anything back the rest of the week.

In the meantime, I needed to help her feel better.  She would have to get off one of the two drugs. It seemed to make more sense to continue Zoloft, which was safer to continue than the Amitriptyline.  I knew that any toxic effects she had would not be from Zoloft, which has a therapeutic index that doesn’t really require blood levels. With Amitriptyline — which is a tricyclic – blood levels are required.

It was back in my residency that I learned something from Dr. Sheldon  Preskorn at the University of Kansas, Wichita.  He said that tricyclics simply cannot be prescribed safely without knowing blood levels. He also suggested there was no need for a physician to learn about the pharmacokinetic and pharmacodynamic effects of tricyclics.  The effects of the toxicity were already well known.

Increased depression and increased sedation are some of the less dangerous clinical side effects of toxicity.  People also try to kill themselves using tricyclics, and this chronically suicidal woman told me she’d had that thought.  And if a person takes a week’s worth of a tricyclic prescription at once, what doesn’t kill them could cause considerable cardiac conduction difficulties, possible heart attack, and more.

Since no one on the staff had ever drawn a tricyclic level before, I talked until I was blue in the face.  They had to send the tricyclic level out of state and told me I’d get results in about a week.

I talked to this patient and told her that in the meantime, I would deal with her clinically.  The health center I was working in made it so that I could not see her in less than one week, so we took some telephone appointments.  Clinically, she had the signs of toxicity –she was a little dizzy and a little woozy. The tricyclic medications can lead to diminution and alter static blood pressure, so all of her symptoms were consistent.

I suggested she go home and try skipping that evening’s dose of tricyclic.  By doing this, there were two things that could happen.  She could start feeling better, and this would be the fastest way to diminish her toxicity.  Or she could start feeling quite ill.  The sudden severance from tricyclics at a therapeutic level will often cause an intractable headache which is resistant to all basic antalgics — like aspirin or Tylenol — given for headache. Depending on how she felt, we could consider restarting her on a lower dose the next day.

In any event, she called me or I called her every day.  I just couldn’t figure out a more efficient way of doing this — although I did offer her hospitalization which she declined.

She’d recently had an electrocardiogram as part of a general annual physical and lucky for us, there were no signs of conduction reflex.  This did not necessarily mean there was no toxicity at all.  This meant that the toxicity had not been powerful enough to affect her cardiac function.

The next day, she had no symptoms whatsoever and she was starting to feel better.  She said she wasn’t thinking about suicide, which was very good news.  So I put her on a program of daily calls and monitored her dose.

In about a week, the tricyclic levels came back.  They showed that her combined total of metabolites was about 50 percent more than we would have expected.  This is nowhere near the worst case of tricyclic toxicity I’ve seen, but as in so many things, there is absolutely no correlation between the biochemical severity of the symptom and how the patient presents clinically.

So we brought her through and we brought her out of it — but there is one curious side effect here.  This woman had been a weekly psychotherapeutic patient for at least two, maybe three different interims.  She had been marked as someone whose problems were psychodynamic since anti-depressant drugs had failed her. Psychotherapeutic interns had been sent to the books to read up on and discuss with her the psychodynamics of lesbianism.

Since we had a clear biochemical basis for her diagnosis and she was already getting better, I decided to go and see the director of the internship program.  She was a seasoned therapist who became so angry at me that I probably should have ducked under the desk.  She simply refused to believe that medication side effects alone could create the level of suicide data which she had seen.  She insisted on continuing the psychodynamic therapy for what she thought was ego-dystonic lesbianism.

I can vouch for the fact that this woman was as ego-syntonic as ever I have seen.  She looked as if she had been born to wear her cap and her tattoo and her jacket.

So why treat?  We certainly have enough people who really need therapy and who could be helped by interns.  But as with many situations, securing a patients’ diagnosis and removing the physical symptoms was not enough to get other people to abandon their belief systems.  Belief, after all, is the strongest force in the universe.  Even stronger than pharmacology, I think.

At any rate, this woman became rededicated to the relationship with her partner, which had been hanging on by a thread.  Later on, she told me that it had blossomed.  She asked me what she should do about the psychotherapists.  I told her that her beliefs were different from mine and only she knew what was helping her and that she could make her own decisions.  So she told me she didn’t think she needed to see them so often.

And you guessed it –the other psychotherapists were angry at me.  Such is my life.  The patient got better and my job was done. I’m not in this to make friends and I’m not in this for ego.  I’m in this to help people, plain and simple.