Some doctors eagerly embrace every new treatment for their patients. Others, drolly called laggards, wait to see how things go for a while before adopting something new. I’m a laggard.
By JP Sutherland
“Gabapentin,” said Roberta. “How about gabapentin?”
My heart sank a little.
“Gabapentin for what?” I asked, full well knowing the answer.
“You know what,” she said, “It’s a new treatment for bipolar disorder. So, it might cause less side effects than lithium. I want to try it.”
“It’s very new,” I said, “and there’s only been a couple of small trials so far.”
“But it’s been around for years,” she countered, clearly having done some homework.
“It’s been around as a drug for treating epilepsy for years,” I clarified, “but only recently is it being suggested for bipolar disorder.”
“I don’t care, I just need to find a better drug than lithium.”
Roberta had been my patient for many years, and her bipolar 1 disorder had done really well. I first met her in the midst of a florid manic episode, when she had been stopped for speeding at almost twice the speed limit. She had then surprised the arresting officers by talking non-stop, telling them that she was on a mission to save the world, and finally suggesting that they drop the charges, and their trousers, in return for whatever sexual favours they wanted. Unsurprisingly the officers brought her straight to the ER, where I was the on-call psychiatrist that day. Her illness responded well to our first-line medications, and after her recovery she had remained my patient in regular outpatient follow-up.
Once she was well, I got to know her as a pleasant, churchgoing, and highly respectable lady who had used her intelligence and energy to become one of the city’s most successful realtors. I thought that she was wholly well on lithium carbonate, and the fact that she continued to win various sales awards was supporting evidence of her excellent ongoing good health.
However, Roberta was always dissatisfied with her mental state.
“I’m so slow,” she said repeatedly, “and it feels like I’m living in a fog.”
These were concerns to take seriously, because most psychiatric medications can occasionally produce such side effects. However, they only do that in a minority of patients, and there was another possible explanation for what Roberta was describing.
The symptoms of a manic episode in a bipolar illness are based around a change in mood, which is usually euphoric. But alongside that there is an overabundance of energy, a sense that one is performing better than ever before (which we call grandiosity) and an ability to do things faster (though often at the cost of not doing them very well), as well as the sexual disinhibition about which Roberta was now so regretful. If someone has lived with these attractive sounding feelings for a while, then returning to earth and everyday reality can be a huge disappointment. I suspected that Roberta was missing the positive sides of her manic state, even though she acknowledged that she had been dangerous and deluded when ill.
“I don’t want to be manic again, I just want to get some of that speed and clarity back.”
Watching her in the interview I could see no signs of any impairment. The successful businesswoman sat before me, making me feel a little dowdy in my usual jacket and tie, and I could see no sign of the manically excited and disinhibited patient of before. My gaze was interrupted by her phone.
“I’m sorry about this,” she said, reaching to answer the call. “I would normally turn it off, but I’ve got a multimillion dollar deal nearing completion and I daren’t use voicemail right now.”
You only have to say ‘multimillion’ to a psychiatrist for us to instinctively worry about a relapse into mania, so my next questions after she put the phone down were inevitable.
“That sounds exciting. Is it on the internet, can I take a look?”
“Sure.” She said, “Just go to my website and it’s the first listed property.”
Sure enough, there it was at the top of the page, featuring more bathrooms and hot tubs than I thought any one family would ever need. We skimmed through the pictures for a minute before she looked at me from under furrowed brows.
“You’re checking up on me, aren’t you? You thought I might be manic again, and might have imagined it all.”
“Roberta, you don’t miss a trick,” I said, laughing. “See – this is part of the reason why I don’t think you are slowed. That and the fact that you keep winning awards for your work.”
“But I am slow, and I’m sure it’s the lithium.”
“I can see that we aren’t going to agree, but I certainly want to take you seriously. Let me send you off for some cognitive testing. A psychologist can assess your cognition much more thoroughly than the quick screening tests that I’ve done. And they will measure the speed of your answers directly, rather than me relying on my subjective judgement.”
“Thank you. I’ll do it, and then you’ll see what I mean.”
In the late 1920s a new variety of corn was introduced to farmers in the American Midwest. It was adopted slowly at first, but during the following decade it became the dominant hybrid, offering an increase in yield of up to twenty percent over its competitors. This kind of development is always happening somewhere, in some area of agriculture, and as such it wouldn’t merit the attention of people outside the world of farming, let alone those who have as little soil under their fingernails as do psychiatrists. What made the Iowa corn fields story different is that two sociologists, Bryce Ryan and Neal Gross, went out to report on how the new variety was adopted by farmers. They discovered two main findings. Firstly, the rate at which farmers adopted the new corn started slowly, grew into a wave, and then diminished again, leaving a few diehard traditionalists as the only holdouts against the new variety. Secondly, they found that although the innovators at the front of the curve were responding to research findings about the new hybrid, and the efforts of the salesmen to spread the word, most farmers were waiting until their neighbours had some experience of the new corn, and only adopted it once they had seen how it had fared locally. So, for most people the messenger proved even more important than the message.
Deidre had once memorably told me that being depressed was like wading through molasses.
“Escitalopram,” said Deidre, “I want you to prescribe escitalopram.”
This was only one day after my conversation with Roberta about gabapentin, so if there was a spirit who controlled my appointments schedule and decided which patient I saw when, I wondered what I had done to offend them.
“It’s a brand-new antidepressant Deidre, and I would usually wait a while to see how it does before offering it to my patients.”
“But I can’t wait any longer, it’s already been years of suffering like this.”
Deidre had once memorably told me that being depressed was like wading through molasses, and indeed she did move with the speed of someone twice her age, when she wasn’t sitting immobile and slumped in her chair. Although she had been describing her physical activity, her thoughts were similarly treacly, and she gave the impression that completing a full sentence was a major effort. This combination of slowed thoughts and movements is called psychomotor retardation, and is one of the hallmarks of a more severe depression. She had been my patient for at least as long as Roberta and was unlucky in that her depressive illness had not responded to all manner of interventions. Depression is one of the bread-and-butter diagnoses that psychiatrists see all the time, and fortunately it recovers with treatment and remits in a large majority of cases. However, there are a small number of depressive disorders that stubbornly persist, going on to disable people’s lives in a much more severe way than the temporary misery of a major depressive episode.
I looked through Deidre’s chart and saw a list of treatments tried so far. Three SSRIs, two different modalities of individual psychotherapy, an SNRI, two augmentation strategies, and a failed attempt at group therapy. Earlier in the year I had compiled this mournful catalogue, and then offered her a course of electroconvulsive therapy, which we try and reserve for those not responding to other treatments. She bluntly refused that option, which still scares many of the people that it might help. But she did have a point about her long years of suffering.
“Deidre, I’ve got a bit of a problem with escitalopram,” I said. “It is actually the same as citalopram, which you already tried, except that citalopram is a mixture of two forms of the drug, one of them active and the other one inactive. In escitalopram they are just giving you the active molecule.”
“So, it should be better.”
“Well, they are only giving you half the dose, so it seems like the same thing to me. What I would normally do with any new medication is wait a while to see how it fares in early use before offering it to my patients. That way if there are any unexpected effects, we may be able to avoid them.”
“But that would delay any benefit your patients might get from a new drug. I want it now.”
With Roberta I had been unwilling to prescribe gabapentin not only because it was so new, but also because I did not see her being significantly ill or impaired. But Deidre was obviously depressed, and I was all too aware of my inability to help her so far. I didn’t think that escitalopram was likely to help, and I had concerns about how much it was a new treatment rather than a repackaging of an old drug. Nonetheless I felt the need to offer something and eventually agreed.
“Thank you,” said Deidre, taking the prescription from my hand, “but you didn’t have to be so difficult about it.”
Ryan and Gross published their work on the Iowa corn fields in the 1940s, and it helped launch a new scientific discipline called Diffusion of Innovations. The principles behind the spread of a new corn in Iowa turned out to have much in common with the adoption of any new idea or technology. The rapidity of spread depended partly on the idea itself, partly on the methods of dissemination, but some of it was due to the nature of the population being targeted, and their varied social characteristics. The theory became formalised in the 1960s, and was then then applied across many different fields of endeavour. Psychiatrists were very slow to get on board (as we so often are), but an article by Harry Karlinsky in 2004 helped introduce us to the field. The idea resonated with me, and I saw how every individual would have a place on the graph of how quickly they accepted a new innovation. The curve started slowly with a few innovators and early adopters, and then swelled to a peak as most people accepted the new idea. Those before the peak of the curve were called the early majority, and those on the downslope after the summit were the late majority. Finally, those at the tail end of the graph merited a more original name of laggards. I could see that I was either a late majority adopter, or just possibly a laggard. Hence my reluctance to prescribe either gabapentin or escitalopram when they were brand new on the market.
“I can’t believe that you would actually pass me on to someone else rather than make one simple medication change.”
“Roberta, your results from the psychologist are back.”
“And…”
“So, the good news, especially from my point of view, is that you performed well. She couldn’t find any significant sign of cognitive impairment.”
“But there must be, otherwise I wouldn’t feel so slow.”
“And that is the bad news, because it leaves you without a reason for what you’re feeling.”
“Other than what you’ve already told me, that I only feel slowed because I’m no longer manic.”
“That’s right.”
“I’m not making this up you know. I really am slowed.”
“I completely believe that is how it feels, but I wish we could find a more definite reason.”
“Can we change medications anyway? I want to try gabapentin.”
“We can certainly look at another medication change if you want to, there are some of the atypical antipsychotics that we haven’t tried. But I’m not ready to prescribe gabapentin to anyone.”
“Dr Smith does,” she said, naming a colleague of mine from the inpatient unit. “I was talking with one of his patients that I know from when I was hospitalised, and he’s always trying the latest thing.”
“It’s true, he does.” I replied.
If I was almost a laggard on the graph of adopting a new idea, then James Smith was a very early adopter. He was a friend as well as a colleague, and we had talked about our different approaches to innovations. Despite having a lengthy discussion, we ended up as far apart in our opinions as ever, while still respecting each other’s professional abilities, and thus demonstrating how there is more than one way to be an effective psychiatrist.
“If you were determined to try gabapentin then I could ask Dr Smith if he would take over your care.”
Her face fell. “I can’t believe that you would do that.”
“Of course, I would. We have to recognise that some doctor-patient combinations are a better fit than others.”
“I didn’t mean that. I can’t believe that you would actually pass me on to someone else rather than make one simple medication change.” She looked hurt, and beyond that worried. “It’s hard to start over with somebody new, and you are the one who saw me when I was most ill. I don’t want to lose that.”
Some physician-patient relationships never get beyond a limited, transactional, stage. But in the disciplines within medicine where treatment continues over an extended period of time, a deeper level of trust can develop, which is almost always helpful. Family physicians, and psychiatrists, and any specialists seeing patients with a chronic disease know this, and it is usually a part of the job that we value highly. I could see that Roberta was torn between wanting the new drug and not wanting to change physician, and in this case, it really was a clear-cut choice without much middle ground for a compromise. In the end she stayed with me, but our conversations about her slowness and ‘brain fog’ never wholly went away, even as she continued to thrive at work.
Knowing where I stood on the curve of adopting new innovations had given me a deeper insight into my practice, and this was one of the things I had discussed with Dr Smith. We could both see the benefits and drawbacks of our respective positions. If a new medication revealed some previously undetected problems in its early months of use, then his patients might suffer from those, while mine would be spared. On the other hand, his patients might be the early beneficiaries of a new development, while mine might be left waiting, and suffering, until I finally got off the fence and was prepared to act. There seemed to be no ideal position, and this has turned out to be one of the limitations of an otherwise attractive theory. All I could do was offer patients such as Roberta the chance to change doctors, but as she pointed out this isn’t a wholly satisfactory answer either.
In the end, gabapentin was found to be no help for bipolar disorder, and the manufacturer faced legal charges for promoting it so heavily without sufficient evidence of effectiveness. Fortunately, it didn’t seem to cause much damage, and it is still used with good effect for pain and epilepsy, but not for mental illness. I remember telling Roberta and feeling quite pleased that I had spared her a useless trial of medication. However, she still appeared to be unimpressed by my decision.
“Whatever. The point is that I still feel slow. And I still want to keep trying alternatives.”
Deidre looked different at her next appointment. She sat upright in her chair in the waiting room, and on the long walk back to my office I no longer had to pause and wait for her to catch up.
“You’re smiling.” I said, stating the obvious.
“Yes.” She said, and then just sat there for a moment while we both smiled back and forth. But this was no longer the delay of psychomotor retardation, as became clear when she finally spoke, skipping from word to word with a lightness that was wholly normal, but remarkable for her.
“It took a couple of weeks on escitalopram, and I had some early difficulty with an upset stomach. But I remember you saying to try and push through early side effects because they often go away. So I did, and my stomach is better, and I’m eating again.”
Deidre had lost weight during her illness, as often happens in depression, and her renewed appetite was another sign of recovery. I started to move through the checklist of symptoms, and she told me about better sleep, and energy, and finally being able to enjoy her reading again. She still had some days of low mood, and even occasional suicidal thoughts, though these were lessening.
“I feel maybe fifty per cent improved. Will I get the remaining fifty percent?”
“The pattern of improvement fits the time scale for a response to an antidepressant, and so we would expect you to get better still over the next month.”
“So, I was right to make you give me the prescription.”
“I’m very glad that it seems to have worked, even though I still have the same concerns that I told you about.”
She looked at me and shook her head, with a refreshingly normal speed.
“You know, you might try and stay more up to date with your treatments. I bet there are others you could help with escitalopram.”
Looking back on the Diffusion of Innovations now, it seems like just one more chapter in a psychiatrist’s career, similar to so many. An attractive looking theory turned out to offer less than initially promised, and a couple of patients had mixed results from their treatment. Roberta was spared a trial of a useless medication because I was such a slow adopter, but she wasn’t happy about that, and continued to ask for different medication trials, even while retaining her niche as one of the city’s most successful realtors. Deidre benefitted from a new medication, but only after having to push her physician to a decision, thinking along the way that he might have given up on her.
No good outcome was wholly free from disappointments which, all things considered, is often the way things go.
All names and other identifying details have been changed to protect patient confidentiality.
