Second Guessing the Medical Board II

(Continued from Part I)

Diagnosis and Medication

MQAC provides minimal information about diagnosis and treatment:

• After his initial evaluation in March Dr. Roys diagnosed Major Depression, rule out Bipolar Disorder.
• Dr. Roys stopped venlafaxine because it no longer worked and prescribed lamotrigine.
• In June he prescribed ziprasidone.
• The documents state that in August Dr. Roys "was aware" that the patient "was taking clonazepam" and advised her to taper and discontinue the drug while prescribing mirtazapine.
• During an encounter on August 16 the patient complained of increased anxiety and depressed mood and "was increasingly suicidal." Dr. Roys recommended reduction in lamotrigine dose by half, and prescribed diazepam 10 mg four times daily as needed, a quantity of 120 (a standard one month supply if taken regularly).
• On September 3 the patient took an overdose of "primarily" "all of her" diazepam. Since the document fails to specify whether this meant 120 or 2 capsules/tablets the actual number requires imagination.
• After less than one week in the hospital the patient was discharged back to Dr. Roys' care with a diagnosis of "major depression" on lamatorigine, mirtazapine and trazodone.
• Dr. Roys continued the lamotrigine "along with various other medications."

MQAC criticizes Dr. Roys as follows:

• Inadequate documentation of his rationale for his treatment of her depression.
• "prescribing her Lamictal and stopping her antidepressant."
• Prescribing a large amount of diazepam.
• Failure to document the rationale for treating the patient as "having bipolar depression instead of uipolar depression."

Analysis

Believing as I do that most psychiatric disorders can be adequately treated without benzodiazepines, I applaud Dr. Roys for recommending Patient A stop her clonazepam. But the statement that he was "aware" of her using the drug suggests that she obtained it from another physician or from the street rather than by his prescription. MQAC neglects to address this key question suggestive of noncompliance, mismanagement by another provider, or even an undiagnosed substance use disorder.

I might say that I agree with MQAC's criticism of his decision to then treat Patient A with diazepam. However, the Board appears to regard such prescribing as quite legitimate, provided the amount prescribed remains below some unspecified number of dose units. If the Board agreed with me it would sanction half the physicians in the state. Indeed, MQAC would have us believe that the number prescribed increases the risk of an overdose. Insofar as 2 dose units taken at once represent an overdose how can one argue with that logic? In fact this is a cheap shot, a pejorative ploy to prejudice the reader. Only the patient determines how many pills she actually takes and when. Can MQAC really be so naive as to think that patients always take their medications as prescribed? Even this case gives the lie to that notion. 

The Board would deceive the reader into confusing the risk of overdose with the risk of suicide attempt. In fact he number of pills prescribed does nothing to affect the risk of sucide attempt. How cynical of MQAC to insinuate that the number of doses prescribed caused the suicide attempt while neglecting to propose a "safe" number of doses. Could this be because there is no safe number? Any patient can accumulate a dangerous quantity of any prescription drug unbeknownst to the physician. In fact, one could applaud Dr. Roys for providing the patient with a relatively safe means with which to attempt suicide. But MQAC has covered that base. The documents suggest that combining the diazepam with alcohol or other CNS depressant would increase the lethality of the drug. This is true but entirely irrelevant since there is no evidence the patient did so. Such pejorative, gratuitous statements do not belong in such a document. (Combining diazepam with rat poison would also increase its lethality. So what?) It is perhaps surprising that the Board failed to fault Dr. Roys for not telling the patient that adding alcohol would make for a more lethal cocktail. After all, was it not his duty to provide informed consent thus educating her as to how to kill herself? 

In fact, this patient like all of us had at her disposal numerous and sundry methods for attempting suicide.

Why did Dr. Roys' start diazepam instead of clonazepam during that August encounter. Did he think the latter would be more helpful for the severe anxiety described. Or did the patient imply that she would surely kill herself if he did not provide the requested drug? The Board does not seem to consider that question relevant.

I also wonder about the Board's interest in whether Dr. Roys diagnosed unipolar or bipolar depression. Some authorities believe recurrent depressive episodes represent a variant of bipolar disorder and should be treated as bipolar disorder. Psychopharmacotherapy is a process of auditioning drug after drug, combination after combination, until something works or the patient begins to see the process as futile. There is nothing in the information provided by the board to suggest that Dr. Roys neglected an effective drug or combination or that any of the drugs he prescribed might have adversely affected the patient (provided the patient chose to comply with the ordered regime). Overlake Hospital's psychiatrist seem to have continued more or less the same regimine, only adding trazodone and presumably stopping the diazepam. Kudos to Overlake for bucking the fashion and dropping the bipolar diagnosis, but Patient A needed effective treatment more than she needed the correct diagnosis.

In the documents MQAC claims Geodon (ziprasidone) is "indicated in bipolar disorder" "to help reduce anxiety" Not exactly: Geodon's FDA label approves the drug for treating

"acute manic or mixed episodes associated with Bipolar Disorder, with or without psychotic features" 

MQAC cites no evidence for a mixed or manic episode, in fact describing chronic depressed mood and anxiety rather than mood episodes. The document also criticizes Dr. Roys for "prescribing her Lamictal and stopping her antidepressant" but fails to specify the "antidepressant" to which it refers while also apparently failing to appreciate that psychiatrists often prescribe lamotrigine as an antidepressant. Does MQAC criticize Dr. Roys for discontinuing venlafaxine which stopped working? Does MQAC believe mirtazapine is not an antidepressant?

The documents criticize Dr. Roys for failures in documentation. Medical documentation as an end in itself should only be criticized for failure to serve a purpose in advancing the patient's care. Dr. Roys' putative failure to document rationale for his diagnosis or treatment may damage his ability to defend his choices, but does nothing to adversely affect the patient's care, either by Dr. Roys or any future provider.

In my next installment I address questions surrounding scheduling, coordination of treatment and reimbursement.