Prescribing psychotropics to family members

Recently, I put up a post on our main Shrink Rap blog titled, "Is it okay to shrink your sister in an emergency?" Given how difficult it can be to get an appointment with a psychiatrist, I wondered about the ethics of prescribing psychotropics to a distressed family member when other options are limited.

First, I created a fictional scenario. Sister Lucy was treated for panic disorder 5 years ago. She took a benzodiazepine for a few weeks, an SSRI for a year, and went to psychotherapy. Her symptoms resolved, and she was able to terminate treatment with the blessing of her psychiatrist. Last year, Lucy moved to a new state and, being generally healthy, she has not yet established relationships with primary care providers. So with no physician, in a new state, Lucy had a recurrence of her panic disorder. She was initially seen in an emergency department, given a small supply of Ativan (lorazepam), and instructions to see a psychiatrist.

Lucy called around, and the earliest appointment she could get was 6 weeks away. She tried a handful of psychiatrists, but she did not call every psychiatrist in town. Most of the ones she tried were not taking new patients, and the voice mail systems of each mental health group were time consuming and frustrating, some cut her off, and no one had any more immediate response than to go to the ED if it were an emergency, and Lucy had already done that. Her brother, a psychiatrist in another state, came to visit for the weekend, and he witnessed several of her panic attacks. He had no more luck finding a psychiatrist for her. Lucy visited an urgent care center, where she was restarted on the SSRI and given more of the Ativan. But at the drugstore, she noticed she was given a 2-week supply and this would not last until the scheduled appointment.

So I asked our blog readers if it was okay for the brother to write prescriptions to hold his sister over until her scheduled appointment. The other options would have been for her to continue to suffer, to see if she could find another form of treatment more quickly, to return to the urgent care center on a continual basis and hope they would provide more medication, or to find a new primary care doctor who could prescribe in the meantime. Lucy didn’t know if this would be any easier. The psychiatrist who saw her 5 years ago before she moved would not be comfortable resuming medications without seeing her, but just in case there was any doubt, he retired, moved to North Korea, and died in a freak accident where he was swept up by a street cleaner so that option was not on the table (fictional characters can lead interesting and tragic lives).

Readers wrote in with a variety of thoughts. One psychiatrist empathized; she had a very depressed relative, and she debated providing medication samples in the interim while the relative waited to get in with a mental health professional. Another psychiatrist had seen too many patients become addicted to prescription benzodiazepines and suggested that this might start a cycle where Sister Lucy would pester brother psychiatrist for more medication in the future. Most of the psychiatrists felt that if a reasonable effort were made to obtain care and the barriers were valid, then it was a tough situation, but ultimately they felt it was okay to resume medications that previously had worked and been tolerated, for a limited period of time, since Lucy was symptomatic and this constituted an emergency.

The patients who wrote in were less forgiving, overall. Several insisted it was easy enough to find a primary care doctor within days, and a primary care doctor would certainly prescribe the medications. I was told that all one has to do is call one’s insurance company, so, curious, I called mine and got two names. The first one had a message saying staff was not in on Wednesday and the caller should try back tomorrow. I didn’t. The second one instructed me to leave a message that would be returned within 24 hours. It wasn’t. I e-mailed my own primary care doctor to ask when the next new patient appointment was – this physician charges a practice fee (too low to be considered "concierge," but high enough to enable a lower caseload). The response I received is that the practice is full. I e-mailed a friend who is a wonderful primary care doctor but takes no health insurance and has opted out of Medicare, and he had an opening the following week. I, however, had insider knowledge that a random newcomer to town might not have, and the insurance companies would certainly not be referring urgent cases to this out-of-network doctor. And all this assumes that any doc will do; there is no allowance here for the idea of waiting for a psychiatrist or internist who might come highly recommended or have subspecialty training.

I was left to say that it wasn’t easy to find a psychiatrist or a primary care doctor on demand when one is new in town and in a state of emotional distress. Again, I was told otherwise! I learned about a service called ZocDoc.com where you can make a next day appointment with a physician, simply by giving your Zip code, insurance, and specialty desired. Interesting, as I do this all the time with an App called OpenTable to schedule reservations at restaurants. Why not doctors’ appointments?

So it was late, and I tried to schedule a next day appointment with a primary care doc. It worked! Only I didn’t really want the appointment; what I wanted was information to write my article for Clinical Psychiatry News this week. I dialed the doctor to cancel the appointment, and instead of getting an office machine, I got the actual doctor – and he even sounded like a nice guy. He couldn’t cancel my appointment, but I then realized that, like OpenTable, there was a button to push to cancel the appointment, and I did that. I looked for psychiatrists, and there weren’t many with next day appointments – perhaps one – nearby, but if I would drive 30 miles or so to the next major city, I could get an appointment very soon, and certainly within a couple of weeks. Interesting. I learned something new!

So I wondered about Sister Lucy, and I decided she lives in Boise, Idaho, a place I’ve never been to and whose availability of medical care I know nothing about. The ZocDoc site there is not active, and so poor Lucy is back to her original problem, and I am left to the original question: Should her brother prescribe her medications?

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: the Johns Hopkins University Press, 2011).

Recently, I put up a post on our main Shrink Rap blog titled, "Is it okay to shrink your sister in an emergency?" Given how difficult it can be to get an appointment with a psychiatrist, I wondered about the ethics of prescribing psychotropics to a distressed family member when other options are limited.

First, I created a fictional scenario. Sister Lucy was treated for panic disorder 5 years ago. She took a benzodiazepine for a few weeks, an SSRI for a year, and went to psychotherapy. Her symptoms resolved, and she was able to terminate treatment with the blessing of her psychiatrist. Last year, Lucy moved to a new state and, being generally healthy, she has not yet established relationships with primary care providers. So with no physician, in a new state, Lucy had a recurrence of her panic disorder. She was initially seen in an emergency department, given a small supply of Ativan (lorazepam), and instructions to see a psychiatrist.

Lucy called around, and the earliest appointment she could get was 6 weeks away. She tried a handful of psychiatrists, but she did not call every psychiatrist in town. Most of the ones she tried were not taking new patients, and the voice mail systems of each mental health group were time consuming and frustrating, some cut her off, and no one had any more immediate response than to go to the ED if it were an emergency, and Lucy had already done that. Her brother, a psychiatrist in another state, came to visit for the weekend, and he witnessed several of her panic attacks. He had no more luck finding a psychiatrist for her. Lucy visited an urgent care center, where she was restarted on the SSRI and given more of the Ativan. But at the drugstore, she noticed she was given a 2-week supply and this would not last until the scheduled appointment.

So I asked our blog readers if it was okay for the brother to write prescriptions to hold his sister over until her scheduled appointment. The other options would have been for her to continue to suffer, to see if she could find another form of treatment more quickly, to return to the urgent care center on a continual basis and hope they would provide more medication, or to find a new primary care doctor who could prescribe in the meantime. Lucy didn’t know if this would be any easier. The psychiatrist who saw her 5 years ago before she moved would not be comfortable resuming medications without seeing her, but just in case there was any doubt, he retired, moved to North Korea, and died in a freak accident where he was swept up by a street cleaner so that option was not on the table (fictional characters can lead interesting and tragic lives).

Readers wrote in with a variety of thoughts. One psychiatrist empathized; she had a very depressed relative, and she debated providing medication samples in the interim while the relative waited to get in with a mental health professional. Another psychiatrist had seen too many patients become addicted to prescription benzodiazepines and suggested that this might start a cycle where Sister Lucy would pester brother psychiatrist for more medication in the future. Most of the psychiatrists felt that if a reasonable effort were made to obtain care and the barriers were valid, then it was a tough situation, but ultimately they felt it was okay to resume medications that previously had worked and been tolerated, for a limited period of time, since Lucy was symptomatic and this constituted an emergency.

The patients who wrote in were less forgiving, overall. Several insisted it was easy enough to find a primary care doctor within days, and a primary care doctor would certainly prescribe the medications. I was told that all one has to do is call one’s insurance company, so, curious, I called mine and got two names. The first one had a message saying staff was not in on Wednesday and the caller should try back tomorrow. I didn’t. The second one instructed me to leave a message that would be returned within 24 hours. It wasn’t. I e-mailed my own primary care doctor to ask when the next new patient appointment was – this physician charges a practice fee (too low to be considered "concierge," but high enough to enable a lower caseload). The response I received is that the practice is full. I e-mailed a friend who is a wonderful primary care doctor but takes no health insurance and has opted out of Medicare, and he had an opening the following week. I, however, had insider knowledge that a random newcomer to town might not have, and the insurance companies would certainly not be referring urgent cases to this out-of-network doctor. And all this assumes that any doc will do; there is no allowance here for the idea of waiting for a psychiatrist or internist who might come highly recommended or have subspecialty training.

I was left to say that it wasn’t easy to find a psychiatrist or a primary care doctor on demand when one is new in town and in a state of emotional distress. Again, I was told otherwise! I learned about a service called ZocDoc.com where you can make a next day appointment with a physician, simply by giving your Zip code, insurance, and specialty desired. Interesting, as I do this all the time with an App called OpenTable to schedule reservations at restaurants. Why not doctors’ appointments?

So it was late, and I tried to schedule a next day appointment with a primary care doc. It worked! Only I didn’t really want the appointment; what I wanted was information to write my article for Clinical Psychiatry News this week. I dialed the doctor to cancel the appointment, and instead of getting an office machine, I got the actual doctor – and he even sounded like a nice guy. He couldn’t cancel my appointment, but I then realized that, like OpenTable, there was a button to push to cancel the appointment, and I did that. I looked for psychiatrists, and there weren’t many with next day appointments – perhaps one – nearby, but if I would drive 30 miles or so to the next major city, I could get an appointment very soon, and certainly within a couple of weeks. Interesting. I learned something new!

So I wondered about Sister Lucy, and I decided she lives in Boise, Idaho, a place I’ve never been to and whose availability of medical care I know nothing about. The ZocDoc site there is not active, and so poor Lucy is back to her original problem, and I am left to the original question: Should her brother prescribe her medications?

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: the Johns Hopkins University Press, 2011).

Recently, I put up a post on our main Shrink Rap blog titled, "Is it okay to shrink your sister in an emergency?" Given how difficult it can be to get an appointment with a psychiatrist, I wondered about the ethics of prescribing psychotropics to a distressed family member when other options are limited.

First, I created a fictional scenario. Sister Lucy was treated for panic disorder 5 years ago. She took a benzodiazepine for a few weeks, an SSRI for a year, and went to psychotherapy. Her symptoms resolved, and she was able to terminate treatment with the blessing of her psychiatrist. Last year, Lucy moved to a new state and, being generally healthy, she has not yet established relationships with primary care providers. So with no physician, in a new state, Lucy had a recurrence of her panic disorder. She was initially seen in an emergency department, given a small supply of Ativan (lorazepam), and instructions to see a psychiatrist.

Lucy called around, and the earliest appointment she could get was 6 weeks away. She tried a handful of psychiatrists, but she did not call every psychiatrist in town. Most of the ones she tried were not taking new patients, and the voice mail systems of each mental health group were time consuming and frustrating, some cut her off, and no one had any more immediate response than to go to the ED if it were an emergency, and Lucy had already done that. Her brother, a psychiatrist in another state, came to visit for the weekend, and he witnessed several of her panic attacks. He had no more luck finding a psychiatrist for her. Lucy visited an urgent care center, where she was restarted on the SSRI and given more of the Ativan. But at the drugstore, she noticed she was given a 2-week supply and this would not last until the scheduled appointment.

So I asked our blog readers if it was okay for the brother to write prescriptions to hold his sister over until her scheduled appointment. The other options would have been for her to continue to suffer, to see if she could find another form of treatment more quickly, to return to the urgent care center on a continual basis and hope they would provide more medication, or to find a new primary care doctor who could prescribe in the meantime. Lucy didn’t know if this would be any easier. The psychiatrist who saw her 5 years ago before she moved would not be comfortable resuming medications without seeing her, but just in case there was any doubt, he retired, moved to North Korea, and died in a freak accident where he was swept up by a street cleaner so that option was not on the table (fictional characters can lead interesting and tragic lives).

Readers wrote in with a variety of thoughts. One psychiatrist empathized; she had a very depressed relative, and she debated providing medication samples in the interim while the relative waited to get in with a mental health professional. Another psychiatrist had seen too many patients become addicted to prescription benzodiazepines and suggested that this might start a cycle where Sister Lucy would pester brother psychiatrist for more medication in the future. Most of the psychiatrists felt that if a reasonable effort were made to obtain care and the barriers were valid, then it was a tough situation, but ultimately they felt it was okay to resume medications that previously had worked and been tolerated, for a limited period of time, since Lucy was symptomatic and this constituted an emergency.

The patients who wrote in were less forgiving, overall. Several insisted it was easy enough to find a primary care doctor within days, and a primary care doctor would certainly prescribe the medications. I was told that all one has to do is call one’s insurance company, so, curious, I called mine and got two names. The first one had a message saying staff was not in on Wednesday and the caller should try back tomorrow. I didn’t. The second one instructed me to leave a message that would be returned within 24 hours. It wasn’t. I e-mailed my own primary care doctor to ask when the next new patient appointment was – this physician charges a practice fee (too low to be considered "concierge," but high enough to enable a lower caseload). The response I received is that the practice is full. I e-mailed a friend who is a wonderful primary care doctor but takes no health insurance and has opted out of Medicare, and he had an opening the following week. I, however, had insider knowledge that a random newcomer to town might not have, and the insurance companies would certainly not be referring urgent cases to this out-of-network doctor. And all this assumes that any doc will do; there is no allowance here for the idea of waiting for a psychiatrist or internist who might come highly recommended or have subspecialty training.

I was left to say that it wasn’t easy to find a psychiatrist or a primary care doctor on demand when one is new in town and in a state of emotional distress. Again, I was told otherwise! I learned about a service called ZocDoc.com where you can make a next day appointment with a physician, simply by giving your Zip code, insurance, and specialty desired. Interesting, as I do this all the time with an App called OpenTable to schedule reservations at restaurants. Why not doctors’ appointments?

So it was late, and I tried to schedule a next day appointment with a primary care doc. It worked! Only I didn’t really want the appointment; what I wanted was information to write my article for Clinical Psychiatry News this week. I dialed the doctor to cancel the appointment, and instead of getting an office machine, I got the actual doctor – and he even sounded like a nice guy. He couldn’t cancel my appointment, but I then realized that, like OpenTable, there was a button to push to cancel the appointment, and I did that. I looked for psychiatrists, and there weren’t many with next day appointments – perhaps one – nearby, but if I would drive 30 miles or so to the next major city, I could get an appointment very soon, and certainly within a couple of weeks. Interesting. I learned something new!

So I wondered about Sister Lucy, and I decided she lives in Boise, Idaho, a place I’ve never been to and whose availability of medical care I know nothing about. The ZocDoc site there is not active, and so poor Lucy is back to her original problem, and I am left to the original question: Should her brother prescribe her medications?

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: the Johns Hopkins University Press, 2011).