Ridiculous Study of the Week: Irritability
Did you know that there was “qualitative study comparing the way family medicine and pediatric vs specialty care providers evaluate and treat school-aged children who present with irritability”? Yes, it’s true. Money was spent on this. The study sample included 17 family medicine, pediatric, and psychiatry care providers from a single facility who participated in in-depth interviews from June to August 2016 about how they differentiate normal from abnormal irritability in children and adolescents in clinical practice.
Umm, isn’t every teenager is irritable? I was irritable then and I am irritable reading this now. You will be too:
Despite the resource limitations for primary care physicians and the absence of a true gold standard assessment tool, “the psychiatry respondents expressed a wish for PCPs to be more involved in assessing and treating irritability, while family medicine and pediatric providers expressed a wish to learn more about assessment and treatment,” according to the authors.
So, we have no time and no gold standard for this crap but make sure you assess and treat irritability. Yeah, right.I know, let’s create a metric so we can penalize family docs for not assessing irritability. Sounds reasonable.
Why are we physicians responsible for EVERYTHING?
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I recommend all my phycian colleagues to read the book “THE TYRANNY OF METRICS” by Jerry Z. Muller. The author blows a big hole in the “MBA BRAIN” that says to be successful we must quantify human performance, publish the results, and divide the rewards based on the numbers. They have become fixated on the measurements them selves. Measurement for the sake of measurement so the MBA’s can get paid more for improving the metrics. Buy the book and have some Rolaids available to manage the heartburn.
Hm, I don’t know. As someone with a family history of Bipolar I, it would have been terrific if we could have had a head’s up before the teens who became floridly manic did so. I think we need to stop giving a crap about the the metrics and the ridiculous ways we are being “judged” and be more curious about learning what we might be able to do differently to help our patients. PERIOD. The name of the game is how can we help? Screw the people judging us, but be curious and open to what psychiatrists have to say about how we might urge bipolar prone youth their way for evaluations and periodic monitoring before their world crashes around them. Also, the “irritability” that comes with hypomania has been misdiagnosed more than once in my family as ADHD and guess what? Stimulants given by Family Medicine doctors was like adding gasoline to the fire. Not blaming anyone, but it would have been great to have bypassed those tramatic episodes in our family.
I agree that I see a lot of people who have bipolar disorder who have been misdiagnosed with ADHD and have been prescribed stimulants instead of mood stabilizers. Then I frequently see people who have been diagnosed with combination of ADHD, bipolar disorder and anxiety disorder (which I really argue that if you read the DSM-IV it is not possible to have both since ADHD is a diagnosis of exclusion) and are prescribed (by psychiatrists) a cocktail of amphetamines, benzodiazepines and mood stabilizers. It seems that once a patient is diagnosed with ADHD it remains (rather than being suspected as a misdiagnosis) and diagnoses are stacked rather than revised. I also often see patients who complain of “anxiety” and when I question them deeper it becomes apparent that they are actually having mania. Of course these patients are often prescribed unopposed SSRIs which is a huge error in treating them. When I was trained it was de rigueur to rule out bipolar disorder before prescribing an antidepressant to a patient; these days I commonly see patients who are obviously bipolar being routinely prescribed antidepressants without a mood stabilizer.
You must admit though that there seems to be a trend to make average human behavior pathological in the eyes of the physician. I mean it seems to me that every veteran who has even had a whiff of a combat zone has has been diagnosed with PTSD these days.
Also ADHD seems to be a diagnosis that is very popular because there are medications for it and because the schools get extra money for a student when they are diagnosed (they get placed in special ed). I remember a few years ago seeing a teenager at the request of his teachers because of his bad grades and his family was told that the school thought he had ADHD and after about 3 minutes of questioning in my office it was obvious that he had dyslexia. Another student who I evaluated with a similar referral from the teachers who thought he had ADHD because he was struggling in science class but who had spent hours and hours successfully teaching himself to play guitar.
There’s an ICD-10 code for irritability so it must be a legitimate medical diagnosis. On the other hand, I have yet to see an advertisement on TV asking if your kid has symptoms of Adolescent Irritability Syndrome (AID) and to ask your medical provider about treatment…so maybe not.
Also I wonder why the psychiatry people get off telling the PCP’s what to do? Why don’t they get off their lazy arses and develop a plan to assess and treat “irritability” then get out their and beat the bushes for patients just like everybody else. I am sure they would have people beating down their doors if they could deliver on the promise of curing adolescent irritability (that is without turning every teenager into a benzodiazepine/amphetamine/anti-psychotic doped up zombie).
What I like about the study is how it pathologizes a normal human state involved with feelings and expression. We might all say that computers are better than people because they are not irritable or fussy or sad. They might perceive; they never reflect. Computers, in our fantasies, bear the mask of sanity. So do psychopaths, and we are smitten with them in our culture.
You’ve never seen my office the morning after the IT people push out an “enhancement” or “upgrade”. It seems like the computers all throw an all day tantrum at having a new version of the operating system or emr or whatever they have installed.