The Lesser of Two Evils


After an hour reviewing the recent issues with breakthrough psychosis, the extreme anxiety around the requisite blood draws to check white blood cell count, and the real issue of this being the least stable time of year, I heard Tim’s new psychiatrist say the words that I knew were the right decision, but vex me nonetheless: “let’s leave him on the Clozaril, add 100 mg at midday, and postpone any big medication changes until his impending move to an 18 and over facility in May.”

I hate Clozaril. I hate it like I hate war and The Real Housewives. It’s that level of hate. Reading the insert of the side effects and five – yes, you read that right, five – black box warnings of possible side effects, like abnormally low white blood cell count, seizures, inflamed heart, diabetes, and hypotension with respiratory arrest, makes you wonder how bad the psychosis has to be to be willing to risk all that.

Read the rest at The Balanced Mind Foundation.

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  • ShesAllWrite January 25, 2012 at 3:33 pm

    Oh Chrisa, I know how much you want him off that stuff NOW. I'm so sorry. I hate this with you. And The Real Housewives and war–I hate those too. But I love you! Let me know if I can do anything to help.

  • Jenifer January 25, 2012 at 7:05 pm

    My son has been on Clozril for 2 1/2 months, now at 600 mg per day. The only thing stable is the psychosis, he still has AWFUL mood issues. It is sad, heartbreaking, frustrating and anger inducing. But, he has been on every other anti-psychotic, and this was our last resort before ECT as well. I feel your pain, and get the same judgement you do. I know it's lonely, hang in there.

  • JuliesMum January 27, 2012 at 9:50 pm

    Hi Chrisa, I've been following your blog for several weeks now. I have just received a Liebster award, which gives me the opportunity to choose some more recipients, so I chose yours as one of mine. The details are in my post

  • Dustin January 30, 2012 at 4:47 pm

    I knew patients on Clozaril when I was working as an inpatient PCA… it is scary stuff. The people on Clozaril were always getting sick due to the low WBC… it is scary stuff. But it seemed to work for when everything else failed. I hope he can get off it soon!

  • Anonymous January 31, 2012 at 9:35 pm

    …there's no magic to clozaril despite the claims. . it's the drug of last resort for billing purposes

    NYRB Marcia Angell review of three books on problems with meds

    Like most other psychiatrists, Carlat treats his patients only with drugs, not talk therapy, and he is candid about the advantages of doing so. If he sees three patients an hour for psychopharmacology, he calculates, he earns about $180 per hour from insurers. In contrast, he would be able to see only one patient an hour for talk therapy, for which insurers would pay him less than $100. Carlat does not believe that psychopharmacology is particularly complicated, let alone precise, although the public is led to believe that it is:

    Patients often view psychiatrists as wizards of neurotransmitters, who can choose just the right medication for whatever chemical imbalance is at play. This exaggerated conception of our capabilities has been encouraged by drug companies, by psychiatrists ourselves, and by our patients’ understandable hopes for cures.
    His work consists of asking patients a series of questions about their symptoms to see whether they match up with any of the disorders in the DSM. This matching exercise, he writes, provides “the illusion that we understand our patients when all we are doing is assigning them labels.” Often patients meet criteria for more than one diagnosis, because there is overlap in symptoms. For example, difficulty concentrating is a criterion for more than one disorder. One of Carlat’s patients ended up with seven separate diagnoses. “We target discrete symptoms with treatments, and other drugs are piled on top to treat side effects.” A typical patient, he says, might be taking Celexa for depression, Ativan for anxiety, Ambien for insomnia, Provigil for fatigue (a side effect of Celexa), and Viagra for impotence (another side effect of Celexa).

    As for the medications themselves, Carlat writes that “there are only a handful of umbrella categories of psychotropic drugs,” within which the drugs are not very different from one another. He doesn’t believe there is much basis for choosing among them. “To a remarkable degree, our choice of medications is subjective, even random. Perhaps your psychiatrist is in a Lexapro mood this morning, because he was just visited by an attractive Lexapro drug rep.” And he sums up:

    Such is modern psychopharmacology. Guided purely by symptoms, we try different drugs, with no real conception of what we are trying to fix, or of how the drugs are working. I am perpetually astonished that we are so effective for so many patients.