Resources often fall short of ideal

Dear Dr. Gott: Recently you answered a letter regarding the antidepressant Paxil. You told the writer that, ideally, a psychiatrist should be the one who administers and monitors those patients who are taking Paxil. While this is ideal, unfortunately it is not the reality.

I practice in an underserved area in central California. We have a shortage of psychiatrists and especially a shortage of psychiatrists for adolescents. I would love to be able to refer all of my depression/anxiety patients to a sub-specialist, but I cannot. I have a feeling this is probably the way it is in many parts of our country, especially with so many uninsured people.

The reality is that in order to properly treat my patients, I prescribe Paxil and other antidepressants routinely, monitoring them very closely during the first few months of therapy. Behavioral health counseling is also encouraged. Generalists such as myself and others have to be able to deal with this and other problems in modern health care today. It is not getting any easier to refer to sub-specialists.

I enjoy your column and I think you give well-rounded and thoughtful advice, but in this instance, reality outweighs the ideal situation.

Dear Doctor: I plead guilty to endorsing the ideal versus the real on some medical issues. This is one such case.

I am aware that physicians’ assistants routinely prescribe drugs – some quite powerful ones. Many general practitioners prescribe birth-control pills. Some gynecologists routinely prescribe antidepressants. In my view, these actions are theoretically not part of these practitioners’ training and specialties.

But, as you pointed out, the realities of good medical practice often have to override the ideals. I accept this. However, were I to need antidepressant therapy, I would choose a psychiatrist – not a gynecologist – to guide me.

Dear Dr. Gott: In a recent column, you indicated that too much thyroid hormone replacement could easily lead to osteoporosis and other unpleasant side effects, such as rapid pulse and nervousness.

I have been taking Synthroid for 10 years because of an underactive thyroid gland. Contrary to my doctor’s claims, I have yet to feel better. Moreover, a bone-density test has shown that my osteoporosis is advancing, despite my regular use of Fosamax.

Dear Reader: You should return to him and request an appropriate blood test to assess your thyroid function. Your dosage of thyroid supplement may have to be altered, because too much can lead to osteoporosis and other subtle consequences.

Correction: In his June 18, 2005 column, Dr. Gott wrote that 400 milligrams of folic acid per day is the Recommended Daily Allowance for adults. The RDA for folic acid is actually 400 micrograms per day for adults. We regret the error.