You're going to say that I made this up.  I am not making this up.  I wish I was, because then I could say,"stop making things up," and everything would be ok.  But it really happened, and I can't stop things from really happening.  So I drink.

This is the conversation I had with another psychiatrist.  He is wearing a Ermenegildo Zegna suit.  It fits him well.

I say, "... so if I have him [hypothetical bipolar depressed patient] on Depakote and Seroquel, once he's stable I try to reduce the dose, or even stop one of the medications."

He shakes his head. "I would never stop the mood stabilizer."

"Why-- wait, which one's the mood stabilizer?"

"The Depakote."

"But how do you know it wasn't the Seroquel?  That's the problem with starting two drugs immediately, you don't know which one worked."

"Well, you need them both.  Especially if you're adding an antidepressant."

"What antidepressant?"

"Seroquel." 

"Seroquel's an antidepressant?"

"In this case it is, you're using it for bipolar depression."

I blink my eyes, to make sure I still can.

"Then what's the Depakote?" 

"The Depakote is the mood stabilizer."

"But how do you know the mood stabilizer isn't the Seroquel?"

"The Seroquel is the antipsychotic."

A voice tells me to stab him.

"Why can't you just use the Seroquel-- the antipsychotic- slash- antidepressant-- alone as a first try?  What benefit does the Depakote give you over the Seroquel?"

He says it slowly, enunciates, because he deduces that I don't speak English.  "Because the Depakote is the mood stabilizer..." 

He looks at me. I look at him. He is wearing a yellow Bolgheri tie.  In my mind it is on fire.

"...Besides, if you use Seroquel off label like that, you'll get sued."  Blaming lawyers, the last refuge of the incompetent.  "And for what?  Why take the risk?"

It's at this point I realize he's not wearing socks.  "If you're going to use that logic, Depakote isn't indicated for mood stabilization, either." 

He looks at me incredulously, then suddenly he realizes something.  "Oh, okay, right, I see what you're saying now... but at least Depakote has FDA approval for Bipolar Disorder."  QED.  He's very happy now.   I can't find the waiter.  Why is my drink empty?

There's an uncomfortable pause.  He wants to show me he's a skeptic, too, that he's carefully pondered these issues.

"I have a theory, have you ever used meclizine (a drug for vertigo) as a mood stabilizer?" 

"No, I had never heard of that."

"I haven't tried it either, but it might make sense: meclizine stabilizes your balance, so perhaps it could stabilize your moods?"

I want to call the State Board of Medicine but realize I'm in a different state and I don't have the number in my phone.  "I doubt the insurance companies would ever cover it."

He slowly, purposefully, nods his head.  "Fucking meddling managed care."

 

I tell people all the time, don't get sick, don't ever get sick, but no one listens to me.