Bagels, cream cheese, and Xanax 

By Abraham Nussbaum, MD, University of Colorado 

I was headed to the psychiatry unit where I worked but detoured to collect breakfast for the staff and trainees. When I joined the early morning line, I anticipated a quick transaction. 

“Dr. Nussbaum, you were wrong to stop the Xanax. Hydroxyzine doesn’t work as well,” the woman behind the counter said. I shifted in my shoes, thrown into silence before I could settle on which cream cheeses to accompany a baker’s dozen bagels. 

The young woman continued. “When I was in the hospital, you told me hydroxyzine would work as well as the Xanax. It doesn’t.” Sweat began to form in my shoes as she continued. “I know I overdosed on Xanax, but Xanax zeroed my anxiety. Since you switched me to hydroxyzine, I’m anxious all the time. Why did you stop the Xanax?” 

I make mistakes all the time. The ones I regret the most are the mistakes I make during my quick transactions. 

From a medical perspective, swapping a trial of an antihistamine like hydroxyzine for a benzodiazepine, is always the right thing for a patient who has overdosed on Xanax. Physicians prescribe benzodiazepines to one in eight Americans annually and their use is associated with increased mortality. The medical strategy is, after any withdrawal is completed, to switch to a safer medication. Before I could get bagels, the young woman behind the counter made it clear a medical perspective is not enough when prescribing medications. 

Even though most people with mental illness do best on a combination of medicine and psychotherapy, most psychiatrists like me are becoming more like other physicians. We pick a medically indicated medication and prescribe it, sometimes without forming the kind of relationship that helps build patient trust. Over the last two decades, the percentage of visits with a psychiatrist that included psychotherapy has halved. Instead, patients like the young woman at the bagel shop are experiencing psychiatrists as dispensing medications rather than prescribing them in the context of a psychotherapeutic relationship. She felt my prescription after a suicide attempt was just as transactional as buying bagels. 

A few years after the Xanax bagel incident, I was speaking with a fellow psychiatrist, Warren Kinghorn, about better ways to prescribe. We called up friends old and new, who asked us to think less about what to prescribe and more about how to prescribe. They showed us studies where 20% or more of the variance in patient outcomes depends upon whether a patient reports an alliance. They taught us specific skills: from David Mintz we learned to focus on patient alliance instead of their compliance, Francine Conway taught us how to foster mentalizing while prescribing, Kay Redfield Jamison helped us think about patients who stopped medications as engaging in noncordance rather than noncompliance, and Sidney Hankerson taught us how to prescribe community alongside medications for people experiencing depression. In all, we spoke to a dozen psychiatrists and researchers; any of them could have done better by the young woman at the bagel shop than I did. 

To help future clinicians do better than us, we wrote our findings into a little book, “Prescribing Together: A Relational Guide to Psychopharmacology,” a guide to forming collaborative relationships. It has the usual figures and tables which illustrate and summarize its findings, but it also tells stories of the experts with whom we spoke, and more than a little wise counsel. 

One of my favorites came from the Morehouse psychiatrist Glenda Wrenn. Dr. Wrenn spoke with us about prescribing medications with a person who has experienced trauma. She told us, “It’s not just the prescription that you’re giving . . . In everything you are doing, there are so many opportunities to be a part of the healing process for people . . . Whether it’s the smile on your face, the welcome in your voice, or the understanding in your eyes, these are all really powerful interactions.” 

In the bagel shop, I could have used Dr. Wrenn’s counsel. Today, I would hold out for something more. I would ask if we could both step out of the line. I would ask what the change from Xanax to hydroxyzine meant for her. 

Back then, I apologized, picked up one of the prepackaged assortment boxes in my left hand and handed her my credit card with my right. I settled for another transaction. 

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.