“It is really quite incredible to me that some . . . are willing to denigrate the 8 years of training that it takes to become sophisticated about pathophysiology of the whole body, understand the intricate play of medical and mental problems and really master complex diagnosis, pharmacotherapy, and psychotherapy, as I feel I did in my training”. – A psychiatrist colleague, personal e-mail communication, 4/2/12
This blog, and many to follow, will try to analyze why we are in this “incredible” state of affairs and what to do about it.
The Siege on Psychiatrists
In many ways, this situation has been building over many years. We can start with the middle of the last century, when psychologists and social workers started to provide more and more of the psychotherapy that psychiatrists like Freud had developed. And, wouldn’t you know it, and just as Freud had predicted, not only have their results have been pretty good, but they helped develop more evidence-based psychotherapies like Cognitive-Behavioral Therapy. So, it turned out we don’t really need psychiatrists to purely do psychotherapy, do we?
Then, around 1990, the promising new wave of psychopharmacology provided a new direction for psychiatrists. In fact, with Prozac for clinical depression, it all seemed so easy and safe that primary care physicians soon became the major prescribers of psychiatric medications. Just pop a pill like you might a daily vitamin. Patients seemed to like that, too, as it seemed less stigmatizing to go to your general doctor instead of a “shrink”.
More recently, the book by Robert Whitaker, Anatomy of an Epidemic, strongly suggested that we may have been led down a path mined with unexpected risks for long-term use of most of these new medications. Convincing evidence, which seemed to fit my own personal experience, was presented about how some of our “thought leaders” in psychiatry may have been swayed by pay from the pharmaceutical companies.
To top this all off, a colleague just advertised two jobs for a psychiatrist and/or nurse practitioner, as if there wasn’t any difference between the two professions. Similarly, not a week goes by that I don’t have a patient ask what the difference is between a psychiatrist and a psychologist. Hint (if you don’t know the answer): psychologists can not yet generally prescribe medication. Adding to this confusion, although anyone with a Ph.D in any field can call themselves a “doctor”, only psychiatrists are medical doctors specializing in mental disorders. Besides confusing psychiatrists with psychologists, “psychiatry” is often confused with all mental healthcare. Technically speaking, “psychiatry” should just refer to what psychiatrists do.
Outside of our profession, scientologists have led an anti-psychiatry movement for decades. More gently and helpfully, many of our patients have formed a consumer movement to achieve more of a voice and remind us that recovery is more than just taking a medication.
We psychiatrists also do not get paid nowadays nearly as much as one may imagine. How about $25 from Medicare or Medicaid to do a medication review for the most seriously symptomatic, a reimbursement which doesn’t compare well to what many plumbers make.
Psychiatric Advances and Retreats
Fortunately, our current state of affairs hasn’t always been the case, otherwise the profession would not have developed and continued to serve a societal need in the first place. A highly selective view of some of psychiatry’s glory days, followed by retrenchments, would include the following.
Back in the 1800s, in the early days of state psychiatric hospitals, inmates with mental illness were able to leave jails and prisons to receive “moral treatment” in attractive new facilities. Imagine how proud these early psychiatrists must have been to be able to increase the dignity and safety of these patients. Unfortunately, over time, these state hospitals started to become overpopulated and in need of repair.
Then, the theories of Sigmund Freud seemed to promise a new way to treat mental illness. Just think of what made this so exciting in the early 1900s. The pride and promise to disclose unknown and unconscious conflicts! Unfortunately, though as Freud himself anticipated, the psychotherapies derived from his theories have major limitations, especially for the most seriously mentally ill.
There is more. The promise of mental healthcare for all with the federally-funded community mental health centers, supplanted by cost-cutting for-profit managed care systems. Therapeutic communities and housing led by such psychiatrists as Loren Mosher, only to give way to scores of homeless mentally ill. But you get the picture by now. One wave of promise supplanted by another, and not one way necessarily complementing and being integrated with the other. Two steps forward, then one step back.
Stepping Into an Integrated Future
Fortunately, all of these prior treatments and settings are alive and partially well in one way or another. And therein lies the hope for the future: integrating the best of the past in new ways. If we accept constructive criticism, we should be poised to take another two steps forward. One of these emerging new paths leads to clinics that integrate psychiatrists on-site with primary care physicians. It is here, given enough time, where there is the best potential to make accurate diagnoses and more carefully prescribe psychiatric medication when it is needed.
Who has the best potential to lead this advance? By now, you should know the answer. It is still only psychiatrists that have the most comprehensive education and training in all aspects of mental health and mental illness. In the loving spirit of Shakespeare, let us count some of the many ways they can add unique value to those in need.
-Psychiatrists, alone among all the mental healthcare professionals, still take some version of the Hippocratic Oath, dedicating ourselves to the patient first and foremost.
-Psychiatrists, alone among mental healthcare professionals, have worn the white coat of medicine, which forever will infuse our professional identity.
-Psychiatrists, alone and unlike any other mental healthcare discipline, have had direct responsibility for life and death decisions in medical school and internship.
-Psychiatrists by far have the longest and most comprehensive education, with at least 8 years of graduate school.
-Psychiatrists have studied the brain extensively, and know why it is by the hardest organ to study in the body, let alone how the brain may differ from our “mind” and “spirit”.
-Psychiatrists know that deficits in the frontal lobes of the brain can cause a condition called Anosognosia, which leaves many prospective patients unable to even realize and accept that they have a mental problem in the first place.
-Psychiatrists, by our medical school training, are best equipped to make sure that an underactive thyroid gland or brain tumor is not causing one’s anxiety, depression, or psychosis.
-Psychiatrists know best that people with psychiatric illness have much poorer overall health than the general population, and why.
-Psychiatrists are leading the way in understanding that disorders like PTSD and Major Depression may turn out to be not just brain diseases, but whole body illnesses.
-Psychiatrists best understand the medical language of other physicians.
Sure, we have “bad apples” among us, just like any other profession. And we, too, are subject to social forces that limit what we can do. Nevertheless, one might heed the advice of another hard-hitting and truth-finding investigative journalist, Mike Wallace, who just recently died. He had a serious suicide attempt and suffered periodic depressions. When asked once what advice he would give others suffering from depression, he simply recommended to find a “good psychiatrist”. Note that he did not say, find any psychiatrist. How to find that good psychiatrist will be the subject of future blogs. If you have any recommendations on how to do so, let us know.