“The Abilify Doesn’t Work!”

She was in her thirties and had miscarried, again.  Proof that the universe is infinite in its wisdom, she had failed to carry past three months a child conceived while she was hooked on crack.  To say I was relieved was to put it mildly.

She already had two children in her care, aged 9 and 7.  I had sent Child Protective Services to check them out.  Her mom and extended family seemed to be participating in their care.  They seemed to be doing pretty well.

She was not only unhappy; she was angry. I had been so careful.  Taken her off any medications that had a serious chance of causing malformations in an unborn child.  Keeping her on just enough to keep her from hearing voices and “body-slamming” herself into a wall.  Something the voices, she said, told her to do. Not a very good thing for a woman to do who was pregnant, so we kept her on a little medicine.  Always checking with the California Board of Teratogenicity, a wonderful place where both patients and doctors could find out from the published medical literature just how dangerous prescriptions could be to unborn children.  Those who did not believe in abortion could work with their doctor about advantages and risks and being careful and trying to do the right thing. Good God, this was a woman who had used crack.

Now, for one reason or another, she did not seem to be trying to get pregnant.  (She finally admitted it was because her boyfriend was in jail.) Great.  We got her on a good dose of Abilify (arapiperazole). No voices, a stable mood; none of the wild maniacal mood swings we had ignored before.  Her life, and her care for the children she did have with her, sounded pretty good. Now I am not always crazy about Abilify.  It is not an easy drug to get people off, if they are switching to natural treatment.  But in her case, as a patient on the public welfare, it seemed like a decent choice.

She was doing well enough that I spaced her regular visits a little further apart.  We were doing fine until she said, “Get me off the Abilify.  It doesn’t work.”

I repressed my anger well enough to ask her how she decided this. “I don’t feel anything.”

I explained carefully about how the voices telling her to fling herself against the wall were gone, as well as the mood swings.

“I don’t feel anything.” She went on to describe, in a not particularly articulate manner, how good it felt to use crack.  You knew right away you weren’t depressed, because you knew you felt good. This was not a woman who could intellectualize. This was not a woman who was mature enough to get the concept of delayed gratification.  That you could do something now in order to feel better later was just not something she was willing to buy.

I did think of the Mel Brooks school of psychopharmacology. Prescribe two pills.  Put one in each nostril.  You cannot breathe and so you feel terrible.  Then, you remove them.  The air comes in and you feel wonderful and you know right away you are not depressed.

I have told people this for laughs.  I can’t do it any more than I can give out placebos.  Informed consent is a harsh mistress.

I have no drugs that are quick fixes.  Except Xanax (alprazolam), which everyone wants and nobody gets. I sometimes tell them they don’t know from stress, and if I don’t get Xanax, nobody does.

People want on-off switches.  When someone has a mindset and a culture too far from that of the physician, the relationship has trouble working. I have tried literature she ought to be able to “understand” from drug companies, from the state, from anybody.  She does not much like reading, and told me she really did not want to read anything.

She did agree to keep seeing me, so I am going to keep trying. She got a prescription for Abilify, the information it had not been systematically tested with crack, and that no drug has. I will probably see her again.  I don’t know when.  I think some universal force watches out for her because I cannot.