I enjoy having friends, like just about everyone does. But thats not why Im in thi s business.

When a patient needs help, I will do my best for them every single t ime. And if a few colleagues get bruised egos along the way, so be it. She was a 53-year-old woman, but I dont think she even would have liked to hear m e to refer to her as a woman. Were talking about someone who was short and stout and wore the kind of cap one would expect to see on a newsboy during World War I. She wore a very male looking zipper jacket, and told me she had the name of the other woman to whom she had dedicated her life tattooed on the back of her n eck. Regardless of all this, her face was red and she was crying. She told me she was chronically suicidal and never thought about anything else. Despite being medi cated, her depression seemed to have gotten worse. I reviewed the chart and saw that she had been on Zoloft in steadily increasing doses. She insisted the increasing doses had only made her feel worse. I track ed down more about her history, including a list of all medications. I found o ut that while her Zoloft had been increasing at the mental health clinic, she ha d continued to take medication prescribed by her primary care physician at anoth er clinic. When I tried to speak to her physician, I discovered that he was a decent man. He had put her on Amitriptyline, a tricyclic anti-depressant. He told her that she could get her medications adjusted at the mental health clinic. Well, the mental health clinic did not realize she was already on Amitriptyline. So, she was still taking the Amitriptyline prescribed by her physician of orig in while she was taking the Zoloft. There is an interaction between these two m edications that is well documented. As her Zoloft increased, so did her Amitrip tyline level. People can get into trouble with this class of drugs. In this class of anti-dep ressants known as tricyclics one of the first signs of toxicity is an increase i n the intensity of the depression. I told her immediately I thought this was mo st likely her problem and sent her to the local laboratory for a STAT. That mea nt immediately, on emergency basis, to find her tricyclic level. Somehow, this got everybody at the lab laughing. They had never ordered tricycl ic blood tests before and they said that they couldnt do it. I told them to do i t anyway. They did, but it seemed unlikely we would get anything back the rest of the week. In the meantime, I needed to help her feel better. She would have to get off on e of the two drugs. It seemed to make more sense to continue Zoloft, which was s afer to continue than the Amitriptyline. I knew that any toxic effects she had would not be from Zoloft, which has a therapeutic index that doesnt really requir e blood levels. With Amitriptyline which is a tricyclic blood levels are require d. It was back in my residency that I learned something from Dr. Sheldon Preskorn at the University of Kansas, Wichita. He said that tricyclics simply cannot be prescribed safely without knowing blood levels. He also suggested there was no n eed for a physician to learn about the pharmacokinetic and pharmacodynamic effec ts of tricyclics. The effects of the toxicity were already well known. Increased depression and increased sedation are some of the less dangerous clini cal side effects of toxicity. People also try to kill themselves using tricycli cs, and this chronically suicidal woman told me shed had that thought. And if a person takes a weeks worth of a tricyclic prescription at once, what doesnt kill t

hem could cause considerable cardiac conduction difficulties, possible heart att ack, and more. Since no one on the staff had ever drawn a tricyclic level before, I talked unti l I was blue in the face. They had to send the tricyclic level out of state and told me Id get results in about a week. I talked to this patient and told her that in the meantime, I would deal with he r clinically. The health center I was working in made it so that I could not se e her in less than one week, so we took some telephone appointments. Clinically , she had the signs of toxicity she was a little dizzy and a little woozy. The tr icyclic medications can lead to diminution and alter static blood pressure, so a ll of her symptoms were consistent. I suggested she go home and try skipping that evenings dose of tricyclic. By doi ng this, there were two things that could happen. She could start feeling bette r, and this would be the fastest way to diminish her toxicity. Or she could sta rt feeling quite ill. The sudden severance from tricyclics at a therapeutic lev el will often cause an intractable headache which is resistant to all basic anta lgics like aspirin or Tylenol given for headache. Depending on how she felt, we could consider restarting her on a lower dose the next day. In any event, she called me or I called her every day. I just couldnt figure out a more efficient way of doing this although I did offer her hospitalization whi ch she declined. Shed recently had an electrocardiogram as part of a general annual physical and l ucky for us, there were no signs of conduction reflex. This did not necessarily mean there was no toxicity at all. This meant that the toxicity had not been p owerful enough to affect her cardiac function. The next day, she had no symptoms whatsoever and she was starting to feel better . She said she wasnt thinking about suicide, which was very good news. So I put her on a program of daily calls and monitored her dose. In about a week, the tricyclic levels came back. They showed that her combined total of metabolites was about 50 percent more than we would have expected. Thi s is nowhere near the worst case of tricyclic toxicity Ive seen, but as in so man y things, there is absolutely no correlation between the biochemical severity of the symptom and how the patient presents clinically. So we brought her through and we brought her out of it but there is one curious side effect here. This woman had been a weekly psychotherapeutic patient for at least two, maybe three different interims. She had been marked as someone whos e problems were psychodynamic since anti-depressant drugs had failed her. Psycho therapeutic interns had been sent to the books to read up on and discuss with he r the psychodynamics of lesbianism. Since we had a clear biochemical basis for her diagnosis and she was already get ting better, I decided to go and see the director of the internship program. Sh e was a seasoned therapist who became so angry at me that I probably should have ducked under the desk. She simply refused to believe that medication side effe cts alone could create the level of suicide data which she had seen. She insist ed on continuing the psychodynamic therapy for what she thought was ego-dystonic lesbianism. I can vouch for the fact that this woman was as ego-syntonic as ever I have seen . She looked as if she had been born to wear her cap and her tattoo and her jac ket.

So why treat? We certainly have enough people who really need therapy and who c ould be helped by interns. But as with many situations, securing a patients diag nosis and removing the physical symptoms was not enough to get other people to a bandon their belief systems. Belief, after all, is the strongest force in the u niverse. Even stronger than pharmacology, I think. At any rate, this woman became rededicated to the relationship with her partner, which had been hanging on by a thread. Later on, she told me that it had bloss omed. She asked me what she should do about the psychotherapists. I told her t hat her beliefs were different from mine and only she knew what was helping her and that she could make her own decisions. So she told me she didnt think she ne eded to see them so often. And you guessed it the other psychotherapists were angry at me. Such is my life. The patient got better and my job was done. Im not in this to make friends and Im not in this for ego. Im in this to help people, plain and simple.