Viagra, Sage, St. Johns Wort, and Zinc — If patients are singing this tune, psychologists need to be tuned in

By by Martin Tracy, J.D. Our malpractice expert
September 1, 1999



Rarely has a pharmaceutical product seized the headlines like Viagra, Pfizer’s recently approved drug for improving erectile dysfunction.

Anecdotes abound regarding the blue pills given away as party favors, smuggled across the border for black market sale, and distributed free as come-ons by various practitioners. To no one’s surprise, there have already been at least two liability suits filed against Pfizer and the physicians who prescribed the drug to the plaintiffs.

No doubt, psychologists providing marital counseling, treating men suffering from depression, or working with psychiatrists who prescribe drugs (many of which suppress or reduce the libido) will be approached by a patient about the benefits and disadvantages of Viagra.

What is the psychologist’s best response from a risk management perspective?

First, since psychologists cannot prescribe the drug, they must direct inquiring patients to consult their own physicians about the medical indications and contra-indications of its use. Second, because improper use of the drug seems to be spreading, it is wise to remind patients who admit to unprescribed use of Viagra (or any other drug) that non-prescribed use is dangerous. The psychologist should make it clear that he is offering this opinion as a healthcare provider concerned generally with the health of his patients, and not as a physician or pharmacist.

Third, the psychologist can discuss how use of the drug might affect the emotional side of the patient’s relationship with his partner. There is an increasing amount of research about how sudden restoration of potency can upset what was a stable relationship.

The Viagra issue, however, raises broader concerns. How much should a psychologist know about a patient’s medical history? What if a patient says, “my medical history is private; it’s none of your business–you are not my doctor”? A frank conversation with the patient to explain the importance of this information to the treatment plan is required.

A psychologist should know whether a patient has any disease which might affect mental functioning. Further, on-going use of any medication is also relevant to the understanding, diagnosis and treatment of mental illness. A patient who is reluctant to reveal this information should be made to appreciate that common disorders such as diabetes, high blood pressure, and thyroid disease often have psychological manifestations. In the same way, commonly used medications can affect mental status, alertness, concentration, mood and other aspects of mental functioning.

Once the practitioner has elicited this information, and recorded it in the patient’s chart, the knowledge has to be factored into therapeutic decision-making. For example, if a patient is known to be dependent on insulin for the management of diabetes, a noticeable change in the patient’s mood should prompt the psychologist to advise the patient to check with his or her physician.

Further, good risk management has always dictated that a psychologist take a thorough history, and most psychologists do so at the initiation of the therapist-patient relationship. But asking about the use of prescribed or over-the-counter medication at the initial session is not enough.

Patients should be questioned regularly about therapeutic agents they are taking. After all, if a psychologist has followed patients over a number of years, it is reasonable to expect that their physical health will change during the period of treatment. The patient may have had a functioning thyroid when therapy began two years ago, but if she is now being treated for hypothyroidism, the psychologist needs to know that.

Another recurring topic in the media today is the runaway growth of “alternative medicine,” very broadly defined. People from every socioeconomic group in America are looking for alternatives to the standard treatment modalities. (An internet search, using a popular search engine and the words “mental illness alternative medicine” resulted in 1,195,097 web page hits.)

Certain plants (St. Johnswort, chamomile, and gingko to name a few), vitamins (especially B-vitamins), minerals (selenium, potassium, zinc, etc.), aromas (the scent of sage) or “natural compounds” such as royal jelly, are now routinely used by many people who believe they have a therapeutic effect on one or another mental illness. There is widespread belief in the superiority of “natural” agents over “artificial” drugs, and self-diagnosis and self-treatment is rampant in the U.S. population.

Given these realities, a psychologist should ask a patient whether he or she is taking anything to modify moods, to raise energy levels, or to enhance performance, whether athletic, sexual, or academic. Even if the practitioner knows nothing about the particular substance, the fact that a patient is motivated to self-treat can provide useful insight into the patient’s condition as well as the patient’s willingness to comply with the treatment plan.

Further, since there is no question that certain natural agents do have demonstrable effects on certain mental and physical processes (e.g., the morning cup of coffee is perhaps the most common), a psychologist would be well advised to talk to patients generally about substances they ingest or regimens they follow to “help” themselves. While psychologists are not responsible for managing medication or prescribing medication, they are responsible for understanding their patients’ conditions as fully as possible and applying that understanding to their treatment of patients. If knowledge of a patient’s use of alcohol, illegal drugs, or pharmaceutical agents is critical to evaluating and treating mental illness, common sense dictates that the patient’s “therapeutic” use of vitamin cocktails, incense, herbs and minerals can be just as important.

Martin Tracy, J.D. is senior vice president at Professional Risk Management Services, Inc., an insurance program manager in Arlington, VA. He has 13 years of experience in providing professional liability coverage to psychiatrists and other behavioral health professionals. For future column possibilities, Tracy invites questions dealing with malpractice issues. He can be reached at 703/907-3872.

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