Is it reasonable for me to be frustrated with my psychiatrist?
January 27, 2017 2:56 PM   Subscribe

I take stimulant medication for ADD. My psychiatrist will only prescribe Vyvanse. It is expensive and my insurance company will not cover it. Is it reasonable for me to be frustrated here?

Due to depression and anxiety, my drinking spiraled out of control and about a year and a half ago I sought help from an addiction psychiatrist. I no longer drink alcohol and my depression/anxiety is being very effectively managed by a combination of medication and ongoing therapy. I feel better than I have in ages.

I still see my addiction psychiatrist, who I REALLY like and trust. He is, understandably, VERY VERY conservative about medication with abuse potential. This is usually 100% fine with me as I am not interested in developing a new substance dependency.

However, the only ADD medication he'll prescribe for me is Vyvanse, which he believes has lower abuse potential than Adderall or Ritalin. I like all three medications just fine, but Vyvanse has no generic and the out-of-pocket cost just rose to almost $400/month. So...

1) I have appealed twice, including an appeal where my psychiatrist had to get on the phone with a doctor and explain why Vyvanse is my only option. This was unsuccessful and my insurance will. not. cover. Vyvanse on the grounds that there are cheaper equivalents like Adderall and Ritalin. To be honest, from my perspective as a layperson patient who views these medications as essentially interchangeable, the insurance company's position is reasonable.

2) I CAN afford it, but I am frugal by nature and have some non-trivial anxiety about spending money, especially when I feel that there are very reasonable alternatives to this $400 expense. Managing anxiety is a big part of caring for my mental health and I do not want to add a new source of anxiety to my life.

3) I have taken some form of stimulant medication (Adderall, Ritalin, etc.) on and off for almost 30 years. I am extremely careful about it - I only take the prescribed amount or less, I take frequent days off so that it doesn't build up in my system, etc. Because of my anxiety, abusing stimulants holds no appeal for me.

4) Having a functioning and productive brain is essential to avoiding a depressive cycle and protecting my mental health. Please assume that I've tried other methods of controlling my ADD and that not taking a stimulant medication is off the table.

In my more ungenerous moments, I feel like my psychiatrist is riding his own hobbyhorse about medication to the detriment of my mental health needs. I am in an anxiety therapy group that has lots of people who have tried to manage their anxiety by abusing depressants, and they are prescribed Adderall and Ritalin no big deal.

I feel like I'm stuck between a rock and a hard place. Am I being unreasonable? Is my therapist being unreasonable? If so, how can I approach this with him? I really like this guy and don't want to switch psychiatrists, but I'm pretty frustrated here.
posted by anonymous to Health & Fitness (8 answers total) 2 users marked this as a favorite
Absolutely time to have a talk with the psychiatrist about this. The key points are
- You agree that less addicting is better and, all other things being equal, you would prefer Vyvanse.
- He knows, because he helped you, that you have appealed this twice, there is not way to get insurance to pay for it.
- Taking Vyvanse instead of Adderall or Ritalin is going to cost you $X per year because Vyvyanse is $400 a month and the others are $y per month. $X is a lot of money. (Do the math to get the annual figure - doctors may not be aware of the cost difference and/or not fully appreciate how it adds up over time. $400 a month sounds different from almost $5000 per year. Don't comment on whether you can afford it or not, just say that it is a lot.)
- Remind him that you have a past history of taking simulates carefully, including the details you mentioned above.
- "I know you don't like prescribing these other drugs, but given the circumstances, isn't there a way we could work together so I could be taking the more affordable medication in a way that minimized the risk of addiction?"
posted by metahawk at 3:08 PM on January 27, 2017 [4 favorites]

really i would just find a new doctor for this particular aspect of your medical treatment. the fact that he seems more concerned with his own hangups wrt medically valid stimulant treatment of a legitimate medical issue than with your own ability to continue functioning in a good and healthy manner is... i want to say it's troubling to me but honestly it's just fucking obnoxious. i've had similar struggles in the past and at the end of various exhausting interactions my only success was to find a new doctor willing to prescribe both ritalin (and later adderall after the ritalin side effects became suboptimal) and to steadfastly not discuss that aspect of my treatment with those who were stubbornly evangelizing against it.

there is a lot of stigma against stimulant prescriptions for ADD/ADHD/etc in the medical world, and also right here on metafilter, and it's hugely disheartening to hear that kind of tiresome crap when it's your own mental health at stake. my current prescribing doctor is not a psychiatrist or therapist, but a neurologist who specializes in ADD/ADHD, and he has been far more willing to help me experiment with which medications/doses are right for me than anyone i've ever seen in the psych meds community.
posted by poffin boffin at 3:14 PM on January 27, 2017 [15 favorites]

Can you go to your regular doctor and ask them for a prescription, instead of seeing the psychiatrist, since you know what works for you?
posted by The corpse in the library at 3:54 PM on January 27, 2017

I'd get a new prescribing doctor. You're not going to change this one's mind, and it does sound to me like he is prioritizing his concern (or liability) with regard to addiction over your overall welfare.

We could both be wrong of course; but at the very least, if you do shop around and find that other doctors say the same thing, you can remove "I have a responsibility to stop wasting this money" from your list of worries and shift it into the "unavoidable life tax I can't do anything about" category of expenses.
posted by fingersandtoes at 4:05 PM on January 27, 2017 [2 favorites]

Honestly? Your doctor is being an ass.
posted by xammerboy at 4:27 PM on January 27, 2017 [4 favorites]

I'm a pharmacist and I am frequently surprised by how utterly unaware of cost doctors are. I agree the insurance company's position is probably reasonable, and if I were you I'd look for another doctor.
posted by selfmedicating at 6:48 PM on January 27, 2017 [1 favorite]

I think you're being very reasonable and have tried to work within your constraints. The danger, as you probably know, with changing doctors is that you'll likely be accused of med-seeking even though you already are on a stim. Especially since you really are seeking a controlled med and not getting it is the dealbreaker in your current arrangement (though for legit reasons). Is there someone on your treatment team that will vouch for you with a new doctor? Or can you get a printout from insurance/a pharmacy of the cost difference to bolster your case? I'm sure there are folks here who've been on the other side of the desk and can help you avoid getting dismissed as a med-seeker, should you decide to find a new prescriber.
posted by mermaidcafe at 11:16 AM on January 28, 2017 [1 favorite]

The guy is getting a kickback for prescribing this drug. Find another doctor. Good luck!
posted by cartoonella at 11:46 AM on January 28, 2017 [1 favorite]

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