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Given short shrift at visit to the doctor
August 11, 2010 4:59 AM   Subscribe

My husband recently had an appointment with a new doctor, primarily to discuss issues of mild depression and a mystery nodule in his inguinal region. Depression is not chronic or severe, and husband has never sought treatment for it before, but doctor (a) prescribed Effexor + Xanax right off the bat; (b) did not discuss "discontinuation syndrome" or other potential side effects; (c) did not look at the nodule at all. What would you do?

My husband was looking for a new GP, and recently made an appointment with my GP, whom I'm very happy with. She is part of a small practice with an out-patient surgeon on staff. Even though his appointment was with the GP, it was the surgeon he wound up seeing for the intake appointment.

The main motivation for going to the doctor was to seek treatment for mild depression, and to have the doctor take a look at a hard nodule that had recently appeared in his inguinal region. His depression is not severe, and he has never sought treatment for depression before.

The doctor prescribed Effexor + Xanax for depression, and did not discuss most side effects with him, or really offer any explanation for this choice, discuss alternatives, etc. etc. Basically said it would make him feel better. My understanding is that the Xanax was prescribed in the event that he experienced increased anxiety or agitation as a side effect of the Effexor.

In addition, the doctor did not look at the nodule that my husband mentioned at the beginning of the visit.

It may be relevant to mention that my husband has some issues with alcohol/borderline alcoholic. He is not a super heavy drinker, but tends to drink 3-4 units every night on weeknights and often more on the weekend, over time escalating to as much as 40-50 units a week, at which time he'll eventually attempt to cut back or quit. This is a cycle that repeats itself a few times a year. I don't know if Effexor is any better or worse a choice for someone who historically has a difficult time with maintaining light drinking or abstinence. This fact was mentioned to the doctor.

I feel like: (a) Effexor is not a good choice for a first-time trial of anti-depressants for a case of mild depression, and that it would have made more sense to start with an old stand-by like Zoloft or Lexapro with a less harsh side-effect profile; (c) side effects, and particularly "discontinuation syndrome", should have been discussed; and (b) the doctor should obviously have addressed the other medical concern that my husband was there to ask about.

Now, my husband is a passive person. If it were me, I would have not left the room without discussing the nodule thingie. But he's the type to just not say anything, despite the fact that he is really very concerned about it, and has been talking about it with me rather anxiously for the past several days.

What would you do in a situation like this? Am I right in thinking that the doctor provided inadequate service?

FWIW, he started taking the Effexor 2 days ago and is having a rough time with it. He feels so sick he's taking the day off work today, which is something I've seen him do exactly once before in the 6 years I've known him.
posted by SomeTrickPony to Health & Fitness (16 answers total) 1 user marked this as a favorite
 
Your husband needs a new GP, one who will take the time to listen carefully to your husband, who will take the time to address all of his concerns -- including the nodule that this doctor ignored-- and who will take the time to talk in detail about his options. Doctors' schedules may make them have to squeeze in a lot in a short amount of appointment time, but that's no excuse for dereliction of duty. Effexor, as you mentioned, is notorious for both its side effects and its discontinuation effects, and it's not an obvious first-line choice. I would have your husband taper very carefully off the Effexor and see another doctor as soon as possible.
posted by foxy_hedgehog at 5:07 AM on August 11, 2010 [1 favorite]


Make an appointment, or get a referral to make an appointment, with a psychiatrist. GPs and surgeons are legally allowed to prescribe antidepressants, but it's usually not their specialty. Who knows, he might have just prescribed Effexor because the cute pharma rep had been in the office that week. IANAD, but I would think that the alcoholism that you mentioned is extremely important, since every anti-depressant I've ever been on had strict warnings not to drink. Your husband might ask if a liver function test would be appropriate to determine if his body can handle the anti-depressants.

Also, alcohol is a depressant. It is definitely not going to help him feel better. IANA therapist, but if he's not in therapy or treatment for this problem, you might encourage him to do so. It will be hard to treat the depression while this remains a problem. And therapy + medication is a more effective treatment than just medication anyway.
posted by Colonel_Chappy at 5:39 AM on August 11, 2010 [1 favorite]


I suggest you both go in person to the medical practice's office today. Demand to speak to your GP and say it's an emergency. It is. (Surgeons are all very well in the operating room, but not doing intake appointments and prescribing psychoactive medications.)
posted by Carol Anne at 5:41 AM on August 11, 2010 [1 favorite]


Similar thing happened to my wife. She went in to a new GP with back pain, came out with a prescription for prozac. Good thing she didn't start taking it as we found out several weeks later she was pregnant. Doctors love to write scripts for a pill to fix this, a pill to fix that, and a pill to fix the problems from the first two.

My advice: stop taking the Effexor until you can talk to the GP and/or another doctor. Go with him to the next appointment (or on preview, as Carol Anne suggests, today and ask to see someone).
posted by ish__ at 5:52 AM on August 11, 2010


Seeing a different doctor is definitely advisable. Going to a psychiatrist for the depression portion would be preferable to a GP.

Your husband may benefit from having an advocate - you - in the room, but make sure that's something he wants, as that can also create feelings of being escorted to the doc by Mom.

As a perhaps unwelcome side note: Alcohol and Effexor definitely do not mix. It can create more problems than he started with. Xanax/alcohol don't mix well, either. This is going to be true for pretty much any psychoactive. If he's ready for depression medication, is he also ready to severely curtail drinking? If he is, he could simply start slacking off on the drinking and see if that lifts his mood, since, yeah, alcohol really is a depressant.

Also, every person responds differently to each psychoactive, so when he does get that better recommendation on whether/which meds can help with his depression, encourage him to ask why that specific medication is being prescribed over any other. As an example, Zoloft made my hard-won libido non-existent and left me too zapped to focus at work, Lexapro messed with my language center and didn't really help my mood, plain Effexor gave me horrible nausea, and Effexor XR was just right. And it goes like that for lots of people, so knowing why things are being prescribed will help a lot with narrowing down which meds really can be helpful.
posted by batmonkey at 5:58 AM on August 11, 2010


This is why I don't think that GPs should prescribe psychotropics. Really, it's a TON of work just to be able to stay on top of the literature on what drug is appropriate for whom and for what conditions, what potential side effects are, and what the implications of discontinuing are. This is why you shouldn't make statements like "X drug, often used to treat Y condition, is a bad first-line choice for Y condition," because it depends on many factors. Psychiatrists only have to know these factors for psychoactive drugs. GPs have to do this for all drugs. To be honest, I'm surprised GPs don't forget things like checking nodules more often, given the amount of information they have to track. However, I've had a great GP who was better than my worst psychiatrist, so this generalization can only be taken so far.

I've found that many GPs have never heard of discontinuation syndrome (from SSRIs). From what I understand, it's just recently been recognized by the wider medical community. It's one of those things that a doctor whose job it is to read the literature on the drug you would be taken would know.

However, both GPs and psychiatrists tend to prescribe for everything that walks in their door without even considering therapy because it's what's expected of them. They will lose trust/business if they don't.
posted by emilyd22222 at 6:32 AM on August 11, 2010 [1 favorite]


Your husband may benefit from having an advocate - you - in the room, but make sure that's something he wants, as that can also create feelings of being escorted to the doc by Mom.

I don't know if every practice is as accomodating as mine, but my husband and I frequently schedule our appointments back-to-back and share the exam room. Nobody feels like they are being parented but either of us can chime in with concerns or questions that come up.
posted by Serene Empress Dork at 7:45 AM on August 11, 2010 [1 favorite]


Here's my question: what does your husband think of it?
You weren't there.
Maybe your husband didn't bring up nodule.
Maybe the doctor asked him some questions or he filled out a form that led the doctor to believe that your husband is more depressed than you think.

I was on Effexor for 5 years and Xanax for 8 years. I had zero side-effects except for when I would stop taking it without weaning off.
Effexor has been on the market for quite a long time now. Lexapro actually gave me bad headaches and I had to stop taking it after a week or two.

If HE doesn't feel comfortable with the doctor, then he can chose another one.
posted by KogeLiz at 7:46 AM on August 11, 2010


DTMFA. I had a similar experience with my doc, over-prescribing medication with only a cursory examination. Imagine my reaction when I found he'd done the same thing to others.
posted by MrMoonPie at 8:36 AM on August 11, 2010


What would you do in a situation like this? I'd find another GP, see him/her, then get a referral to a psychiatrist. Then I would go with him. I've been going through about six weeks of this with my mom, who is suffering from depression and who had to be briefly hospitalized. I am her advocate. I ask a million questions, I take notes, and I follow up. You should be his advocate. Also, on preview, GPs and psychotropic drugs are a very bad mix. My mom and her 70-something GP got together and decided she'd quit Paxil cold turkey about two months ago, leading to a near-meltdown. We are still dealing with the aftermath.
posted by fixedgear at 8:42 AM on August 11, 2010


I also think that GP's have no business prescribing psych meds. I am sure that he knows alcohol is a depressant, so that could be contributing greatly to the depression. Maybe he would benefit more from a psychologist than a psychiatrist...
posted by heatherly at 9:08 AM on August 11, 2010 [1 favorite]


If he's on any sort of crazy pills, HE SHOULD NOT BE DRINKING. That is, NONE AT ALL!!!!!!!!!!!!

Not even 1 unit, not even 1/2 a unit.

Effexor is a good drug, and it will take a while to titrate completely, I think it's supposed to be 2 weeks or so, but it might not be the best drug for him.

xanax is a benzodiazepine and is mostly prescribed for anxiety. You should NOT DRINK ON BENZOS!!!!!!!!!!!!!!

It might be best to have him see a therapist first to help determine the best course of action here. He might not need to be medicated. In fact, I'm guessing drinking is part of the problem and that with it out of the way, and better coping mechanisms, he will be able to move forward.

A psychiatrist is, of course, going to say "yes, well he needs to be on this," as that is what they do. They are doctors and they prescribe. I think there is a place and a time for medication.
posted by TheBones at 10:04 AM on August 11, 2010


A call to a pharmacist may help your husband figure out how to taper off the Effexor. With only two days in his system it won't be hard at all (maybe a 1/2 pill for the next day or two, then nothing). Pharmacists are also paid to understand drugs and drug interactions and if this surgeon didn't talk with him about it, no need to call him back. Alternatively, you might be able to call a mental health clinic with psychiatrists on staff and ask them how to taper off. Explain that a GP prescribed and did a crappy job and you just need help with stopping the med so you can find another doc.

I'd also advocate for finding a mental health clinic that has therapists and psychiatrists working together. Usually, you'd see a therapist for the "intake" assessment (lots of questions about what's going on, why you want help, symptoms, etc). A good assessment can take 30 min to an hour easily. They'll ask for any health problems, meds he's currently taking, and about alcohol/drug use. BE HONEST. If he wants to try an antidepressant (nothing wrong with that, but I think talk therapy should go along with it), then the therapist can help set up the appointment and will share the assessment they just did with the psychiatrist. So...give good info on the assessment, get good feedback from psychiatrist.

Regarding the nodule...yep. Find another doctor (or try to schedule with the original GP and refuse to see anyone but that doctor so they won't substitute someone else). See if you can go with him as well to make sure he is being assertive enough in asking for treatment. Another small thing to consider (IANAD, I know nothing more than what you told us here)...drinking can lead to vitamin deficiencies, which can/will make you feel bad. Also, hormonal changes can lead to depression symptoms so while the doc is investigating the nodule I'd see if bloodwork can be done. The nodule may be related to hormonal/thyroid stuff, or it may not. Just something to consider.
posted by MultiFaceted at 10:32 AM on August 11, 2010


I am sure that he knows alcohol is a depressant, so that could be contributing greatly to the depression.

Nope. Alcohol is a central nervous system depressant, meaning it lowers physiological reactivity of things associated with the brain and spinal cord. This is different than clinical depression, which is (crudely) lowering of mood. While I'm sure alcohol isn't helping the situation, physiological depression /= psychological depression.
posted by emilyd22222 at 10:59 AM on August 11, 2010


Serene Empress Dork: we attend each other's appointments, too, but I've known a few folks who balk at that and didn't want to assume everyone's like us, since it can cause friction in an already tense situation.

emilyd22222 is right, which also makes those advising a therapist (clinical psychologist would be a great choice) good advisers, because a therapist can suss out the edges between these two disparate things.
posted by batmonkey at 12:55 PM on August 11, 2010


Quick follow-up:
Thanks for all the input. My husband made an appointment and got seen that same day by a different doctor at the practice (still not the GP that I'd been seeing, but at least a GP and not a surgeon!). The doctor identified the nodule as an abscess, and she partially drained it and then put him on antibiotics to clear up the rest of the infection. He got the head meds switched from Effexor to Zoloft, which he has tolerated well (he was not sure last we spoke about it, last week, whether it's making a difference or not yet). He's continued his sobriety. For the past 6 weeks or so he has been, on an individual basis, seeing the therapist we have been seeing for family therapy for a few years now. I think starting individual therapy was one of the motivating factors in his making an appointment with the doctor in the first place, and asking about anti-depressants.
posted by SomeTrickPony at 7:04 AM on September 7, 2010


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