Lawrence Mass is a shithole. I grew up about twenty miles away from there. It is a former Industrial Revolution town that rose and fell and rose again during WWII and fell again.

It's nickname is the Immigrant City and dozens of different blue collar ethnic peoples have all come together over the decades to live and to work or collect welfare and to kill each other off in a relatively small area.

"Luis Serrano, building superintendent at the nearby Rita Hall assisted-living complex, said that about 9:30 p.m., he heard a loud gunshot near Santo Domingo Liquors, about two blocks south of the apartment complex at 490 Hampshire St.

"I didn't pay no mind," said Serrano. "You hear that all the time."

When I was a young adult I worked at a carnival that moved all around New England for a summer season. Lawrence was the only place where our rides got vandalized in the middle of the night and there was an attempt to smash the ticket box but there was no money in it and the window was made of plastic.

If you look up crime stats in Lawrence both violent crime and property crime are considerably higher than the median for the rest of Mass. It was that way when I was a kid and it still is.

Times must be getting pretty tough if seroquel is preferable or cheaper for getting sleep than smoking a joint and chasing it with some shots.

I work as a psychiatrist in a community psychopharmacology clinic in an urban community in California. Our patients are, for the most part, low-income, minority residents with Medicare or Medi-Cal.

One of our full-time physicians sees upwards of 40+ patients a day (new and returning) and for at least half of his patients, regardless of diagnosis (of course, what kind of "diagnosis" can you give in a 5-10 minute initial evaluation?), he routinely prescribes Seroquel XR
300-600 mg/d and Abilify 20-30 mg/d. Occasionally, he'll add on Ambien CR 12.5 mg/d for good measure. The prescriptions are usually given for a 30-day supply with 5 refills, and he asks them to come back in 6 months.

(BTW, can you guess which drug reps bring lunch to the office most frequently? Yeah, I thought so.)

I frequently see these patients when they return to the clinic and he's not available... For more than half, they're no longer taking their meds, and I need to do an entirely new evaluation. Patients are typically in mild to moderate distress (often due to financial, family, and/or legal problems, or drug/alcohol abuse-- not to mention obesity, diabetes, and general poor health) and DO need attention, but I find the best thing to do is supportive care, referral to a PMD, and advising the patient of available community resources.

I can't imagine how much Seroquel & Ambien we're putting on the streets of our community, nor how much money we're costing California & the US govt for indiscriminate Rx'es. The problem is, the system works IN FAVOR of this doctor; he argues that, like it or not, it's the "standard of care" for this population, and besides, he has a mortgage to pay!! (I should mention we're paid on a per-visit basis--- we get paid the same whether it's a 45-minute supportive therapy visit or a 5-minute prescription of these powerful meds.)

It has made me incredibly disillusioned about psychiatry, and about health care in general, but I feel impotent to change the situation.

PJ,

You're not alone in this, but try to out them and you'll find that new job hard to find. As you note, you'd have a hard time proving a standard of care claim. The foxes guard the hens.

It's a hard decision. Some hide in academia, others in suburbia, others sell out, some retire or get out and do something else. We need people on the inside to expose what's done in practice, not just what the DSM says we should ought do. It's not just happening in community clinics - it's happening in regional hospitals, teaching hospitals, everywhere. I'd start collecting evidence to protect yourself. Eventually, you'll make a decision and its nice to have something in your back pocket - just in case.

Paul, thanks for the support. What's interesting about your post, however, is that it's not what the DSM says we ought to do, it's what Astra-Zeneca, BMS, Sanofi-Aventis, Eli Lilly, et al, say we should do!!

In fact, I appreciate the DSM (recognizing, of course, it's a RESEARCH tool with limited clinical applicability). It helps me to think about patients and their symptoms-- or lack thereof-- and also to appreciate the differences among patients, particularly with respect to psychosocial background, current stressors, etc.-- everything the DSM does NOT include. In short, it helps me to recognize depression or anxiety, but more importantly how two people, both with depression, are DIFFERENT from each other.

It's when the drug companies tell me that ANY diagnosis of "X" requires drug "Y" at dose "Z", regardless of cost, side effects, other meds, other interventions, etc., that I get p***ed off. I didn't go to medical school to take directions from a salesperson who doesn't even see my patients, much less get to know their stories.

The MD I wrote about above is, I fear, exactly what the drug companies want us to become: machines who ignore everything we learned about personalized care, bedside manner, attention to detail, etc, and simply label our patients and prescribe the drug du jour to get them out the door (and put money in our pockets).

I knew Rob, and he was a good man. His story shows how bad these meds really are. They should of pulled this medication long ago after they found out its addictive nature. It has also been known to cause diabetes. The drug puts you into such a stupor that's its easy to use as a means to escape reality. Don't blame the drug dealers, blame the drug companies for releasing this highly addictive medication to the masses. In the begging they handed these out like candy to everyone with low to moderate anxiety. Now they are harder to get. The drug companies made millions of addicts with these meds, and then cut the supply. Then they act surprised when people are committing crimes, and dying to get more of there drugs. Things really need to change.

PJ,

Point taken. I've come to see the DSM as a reflection of combined pharma/APA commercial interests - this really limits it's utility as a clinical tool in my mind. It's more an insurance billing code reference than anything else as far as I'm concerned.

You can see outward signs of the influence of pharma when you look around the office and see the various freebies promoting this, that, or the other thing. What patients don't see are the lunches, dinners, and other things...

Sales reps know you CAN read the package insert. I think they count on most MDs not bothering to and will rely on being detailed so they don't have to be bogged down by minutiae. It takes time to separate the wheat from the chaff - at 40 patients a day I doubt much of that goes on.

I think this is an area of major concern because of psychiatry's heavy reliance on pharma and vs. It's ripe for the sort of corruption you point out, but also disease mongering.

As a therapist, I worked with hard core heroin addicts in a methadone program for several years. Seroquel and the benzodiazepines (Valium, Klonopin, Xanax, Ativan) were some of their favorite drugs. Most of my clients had purchased and sold or were purchasing and selling these medications in parking lots, alleys and other places of illicit exchange. They also engaged in a lot of drug seeking behaviors in medical offices and emergency rooms for these drugs. They then mixed them with the methadone they were being administered, sometimes in amounts that absolutely stunned me.