January 7, 2011

Mark Foster, DO
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Bob–

This is the twentieth letter that I’ll be posting on your website. I thought I’d use the occasion to reflect on what I’ve observed over the past six months in regards to mental health care in my practice.

It has been eye-opening to realize just how often I’m dealing with psychiatric issues. I have been keeping track, and I average between three and four cases a day in which the primary presenting issue is of a mental health nature, and another four to five where mental health plays a significant role in the visit. This means I am dealing with mental health more often than I deal with viral infections, hypertension, or pain issues, which are other staples of primary care. This is not a change. It seems that I’m just more attuned now to how often I deal with these things, whereas previously, foolishly, I dealt with them more as background noise. I run a fairly mainstream, suburban family medicine clinic, and I am in no way seeking mental health encounters, so I suspect that my numbers are similar to those of other clinics.

Some of my patients are very complicated with severe emotional or even psychotic disturbances, but those are rare. Most of my patients are suffering from what I would consider mild symptoms. Now, I recognize that from a patient’s perspective, what I perceive as “mild” may in fact seem overwhelming. I’m not trying to diminish their subjective experience of suffering. What I mean is that most patients do not show signs of a pathological disturbance in their mental functioning. Rather, they are sad, lonely, anxious, frustrated, disillusioned, confused, scared–all in all, they seem very human, suffering from some of the mood changes that are endemic to the human experience. In the vast majority of these cases, major social and environmental factors are the clear precipitants of their symptoms: death in the family, job loss, marital struggles, substance abuse.

I sometimes have to ask myself, “Why is this patient coming to my office to seek my help with these problems?” It seems like their problems might best be addressed with a counselor, pastor, social worker, a trusted friend, or even just reassurance and the healing effects of time. But somehow, our society and medical culture has evolved in such a way that these emotional and social disturbances have come to be labeled as biological diseases, and so fall under the purview of medical doctors. Thus, in America, when patients suffer from emotional distress, they come to their doctor’s office for help.

And of course we physicians want to help. It’s in our nature. Now, there is clearly an inherent financial advantage in having patients see us as the fixers of their emotional problems. As most everybody will have significant mood disturbances from time to time during the course of their life, this medical model of psychiatric care taps conveniently into a very large patient population, patients who are willing to pay a lot of money for what they perceive to be our exclusive knowledge and legal prescriptive authority. However, I choose to believe that most physicians selected their career in large part not because they wanted to make money, but because of an innate desire to relieve suffering, to use our skills and knowledge to improve a patient’s well-being. At least that’s what we wrote in our medical school entrance essays, when we were young, naive, and full of hope and energy.

But there remains a vestigial, earnest desire to help those in distress, one that brings with it a perceived burden of responsibility. We think, “These suffering patients are paying me money and I must therefore display my expertise and provide a solution.” Of course, the solutions we’ve been conditioned to provide almost always include a prescription pad. I think that most physicians, myself included until recently, feel utterly convinced by our training (indoctrination?) that the universities and academies and journals who review the studies and craft the guidelines are acting objectively, without bias or self-interest. After all, the guidelines they produce offer discrete, standardizable diagnoses and therapies, things easily digestible and universally applicable. They receive the stamp of presumed authority, and become widely accepted, part of the conventional medical wisdom, the mythical “literature.”

Most physicians are highly intelligent, trained to think empirically and unemotionally, trumpeting the values of evidence-based medicine, driven by the desire to do what is best for our patients. And yet we remain curiously unskeptical about the purported certainties of these standards of care. We believe so completely this officially endorsed version of reality, this biochemical model of psychiatric illness, that when a patient manifests symptoms that faintly correspond with five of the nine criteria for depression in the DSM-IV, we pronounce them physiologically diseased, slapping labels on them authoritatively, and we feel justified. After all, that is what the literature defines as a disease state, in spite of there being no evidence of physiological dysfunction. Then we hand them a prescription for a psychoactive medicine, certain we are providing them with the very best treatment available, even though there is no evidence of its long-term efficacy, and plenty of known risks from prescribing it. Addressing root causes, advising patience and sharing perspective, suggesting non-medicinal alternatives: these things are at best secondary therapies and are mentioned only superficially, because the real problem lies in the physiology. If we didn’t think our pills were necessary and effective, then why would we prescribe them? In this way, we get to witness our fondest aspirations being fulfilled. We have become a vital cog in the great wheel of modern medicine that is improving the human condition. We feel a sense of satisfaction as our patients, prescription in hand, offer us their gratitude, and this encounter is added to our mental database, confirming circularly that what we have done is right because, well, it’s right, right?

And yet we are so wrong. In reality, we are slapping reductionary labels onto patients, oversimplifying complex emotional and social issues that would better be understood as variances on the continuum of normal human behavior. We are giving them brain-altering medications that may provide a short term benefit, but at devastating long-term cost–financial, physical, and mental. This is the truth that exploded out at me from the pages of your book, a practice-altering epiphany that resonated completely with my experiences: the patients I think I am helping are actually getting worse, developing damaged self-concepts, and becoming poorer and all too often disabled.

This is the reality of mental health care in America, and it is dismal, ultimately unsustainable. At the rate we’re going, we’ll all be diseased and disabled in another fifty years. By far the most distressing thing I have observed is in how this destructive paradigm is affecting and disabling our children, a large fraction of an entire generation being raised to believe they are broken and require medicines to be well. I feel for these children who are being iatrogenically disabled, and I feel for the parents who are trusting in medical authorities and have been deceived.

But I haven’t lost hope. I’d like to believe that there is an upward trajectory for the practice of medicine and societal intelligence, and that the truth will win out in the end. I hope that in the long run, with the awareness bred by an abundance of evidence pointing out the inadequacies of the current model, doctors will lead the charge and create the change. This will be “Do No Harm” coming home to rest, putting the brakes on our runaway compulsion to intervene. No, I may not be able to fix you with a pill, but at least I can refrain from making you worse. Or as a wise mentor once put it, “Don’t just do something, stand there.”

Today, I saw an adorable four-year girl who had been doing flips on her bed, fell and broke her arm. She was in a cast, and was very sad about it. As I talked to her, I became aware that she was sad because she thought she would have to wear this cast forever. No, I explained, you’re just going to have to wear it for a few weeks, and then we’ll take it off. She smiled at me. I said, Do you know what is so cool? Your bones are healing right now. You don’t even have to think about it. What was broken and hurting you is coming back together, and when we take the cast off, it will be just as strong as ever, maybe even stronger. She thought this was very cool, and then she wanted a sticker and a sucker.

It is so cool. Our bodies and minds want to heal. They don’t need a lot of help to do that, usually just time. We see so many things on TV and in the news, tragedies of disease, triumphs of medical heroism, and we become deluded that doctors and pills and technology are what save the day. Sometimes we do, and certainly, someday, all of us will succumb to time and age anyway. Some diseases, some mental illnesses, are severe, debilitating, life-threatening. But for most of us, and for most conditions, we hurt and then we heal, we suffer and then we recover. We may need to remove toxic influences that are causing us continuing harm. We may need to use a cast, or a surgery, or a pill for a short while. But the impetus is towards healing and wholeness, and that happens spontaneously, for the body as well as the mind.

Here’s hoping for continued progress towards that healthier paradigm of wellness.

Mark