I am an early-career psychiatrist and have been practicing adult, outpatient psychiatry as a part of a hospital-based mental health system in the U.S. for the past five years. I chose to pursue psychiatry because my favorite thing to do is listen to people. I am endlessly curious and interested in the human experience. I had a relative with schizophrenia who was shunned by his family and my heart went out to him and those struggling with similar experiences. I believed that as a sensitive, non-judgmental, and open-minded young woman, it would be an ideal career for me.
I started questioning psychiatry in my third year of residency. I read an article on tardive dysphoria, or antidepressant-induced chronic depression, that intuitively made sense to me. It was just logical that leaving people on these medications indefinitely would cause a person’s system to oppose the drug. I did a presentation on the renal effects of long-term lithium use which horrified me. I was saddened to learn that so many would go on to live with long-term kidney damage after decades on the drug. I also began to understand the risks of antipsychotics and watched their use expand in a way that, again, horrified me. I saw these potent and extremely risky medications being used for everything from insomnia to anxiety to behavioral control. Clinicians were prescribing them without respect or restraint.
Meanwhile, I became intensely interested in psychotherapy, which gave me hope and sustained me. This remains a joy to practice. However, no one is interested in hiring a psychiatrist to perform psychotherapy. I work in an underserved area, and as a concession they allow me to do a small amount of it to lure me to stay. I’ve come to see that employed positions are mainly interested in how much money you generate, which translates into seeing more patients than you can provide quality care for.
After five years as an attending psychiatrist, I have seriously considered leaving the field. It makes me very sad, as I love to practice psychiatry in its truest sense. A practice where I consider the myriad of factors influencing the patient’s emotional state and prescribe very little medication. I am an extremely critical psychiatrist, but I do believe mental illness—although rare— does exist and that medications used selectively, conservatively, and for the shortest duration possible are beneficial. However, 90% of the people who enter my office are not mentally ill. They are having distressing emotional and psychological experiences. I would estimate 80% of these experiences are due to relational trauma, both current (abusive or unsatisfying relationships) and past (trauma inflicted by caretakers). These are very important problems; however, they are not medical problems and should not be medicalized.
Yet patients come to me demanding that they be diagnosed with a psychiatric disorder and are sometimes very angry and offended if they are not. The majority tell me that they have “chronic depression and anxiety,” which they believe are due to faulty brain chemistry and will require medications for the rest of their lives. These patients have no other means to describe their distress than the words depression and anxiety. It’s very sad to see so many people suffering such profound disconnection from themselves due to the promotion of a false narrative. I imagine they grew up with a caretaker telling them that there was something wrong with them when they experienced negative emotion—most likely due to the caretaker’s emotional inadequacy— and now the medical system has retraumatized them with the same abuse.
Patients are even more demanding of psychiatric medication, seeing me as someone to dole out prescriptions with no discussion. I have actually had patients tell me not to ask them any questions about the factors contributing to their distress, as that’s not my role, and to ask only about their symptoms.
In the face of these issues, what has been exceedingly disappointing to me is the reaction of my colleagues. Psychologists and various types of psychotherapists who I anticipated would be like-minded allies have been anything but. I expected these practitioners to discourage medication and promote emotional healing. On the contrary, most of my referrals come from psychologists, who are diagnosing patients inappropriately with innumerable serious disorders including ADHD and Bipolar Disorder.
Just the other day, I had a young woman referred to me by a therapist who had diagnosed her with Bipolar Disorder due to recurrent bouts of racing thoughts and feelings of overwhelm. The patient was a perfectionistic young woman fixated on the diagnosis and anticipating that a mood stabilizer would transform her into an idealized version of herself. I counseled her that she did not have Bipolar Disorder or any other mental illness and that difficult or unusual emotional experiences are normal. I encouraged self-acceptance and exploring contextual factors and ways of coping with her racing thoughts.
She was unsatisfied, however, and told me she disagreed and would be seeking a second opinion. What was most troubling was that I had detailed the negative health effects of “mood stabilizers,” yet she remained unfazed. I have even had a therapist ask me to “blast” a patient with a mood stabilizer due to her frequent trips to the ED for anxiety. This patient was not only not bipolar but also, in my opinion, not mentally ill. In my experience, most therapists are not effective and are ego-driven, tending to interpret their own infectiveness as the patient’s need for medication. It’s all the more maddening, and absolutely frustrating because therapists aren’t implicated in the problems with psychiatry despite the intimate role they play in causing and perpetuating these problems.
Primary-care doctors are generally very good people but, because of their training in the mind (or lack thereof), they prescribe psychotropics freely and inappropriately. In my experience, nurse practitioners are especially dangerous in this regard, particularly in prescribing stimulant medication. They will often message me complaining that a patient isn’t “better” and that I’m not prescribing to them adequately. These patients are often in abusive relationships but refuse to leave. I will not partake in numbing their natural distress, which will call them to leave the abuser.
Medicine in general is creating so much sickness with overdiagnosis and overtreatment. No wonder our EDs and psychiatric hospitals are overwhelmed: We are creating “treatment resistant” patients at a rapid rate because they are not mentally ill.
As there is no one in my field with whom I can discuss my feelings, I feel completely alone. When I started sharing these concerns during my residency, I was met with blank stares. I sometimes post about these issues on a forum for psychiatrists. A few participants will support me, but most will tell me I should simply get over it, pipe down, stop being dramatic, open my own private practice, etc. None of these suggestions will change our field and the damage it is doing to society. On the contrary, if someone posts about how much money they can make seeing the greatest number of patients possible, people are supportive— and no one calls them out on this extremely unethical practice.
So I’m trying to find a way out. I will miss my patients dearly. A few do listen to me and reduce or discontinue medications and explore finding their way to emotional health and self-acceptance. Practicing psychiatry in a sane environment where I have ample time with each patient and no pressure to prescribe would be the ideal scenario, but sadly this is not the standard of care. I’ve read patient stories at Mad in America and I am so sorry for the mistreatment and abuse these people have endured. I see cases like those described fairly frequently. Sometimes I can help, but at other times, it’s too late.
Going into psychiatry as a naïve 25-year-old, I had no idea what I would discover. If I knew then what I know now, I wouldn’t have chosen this field. At the same time, I’ve learned so much about myself and other people and have generally become a more conscious, whole person. I have become more understanding and accepting of my feelings and emotions and have learned to embrace instead of reject my emotional being. I have helped some along the way, but the trends in psychiatry are powerful and I feel as if I’m drowning as I try to swim against them. I’m not sure what my future holds, but until then I need to remain employed –which is why I have not attached my full name to this essay: I would certainly be fired. But as long as I’m still in psychiatry, I’m going to continue to fight the good fight.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.