What’s the Proper Place of Science in Psychiatry and Medicine?

On the pages of this blog I have frequently written about the “scientific” aspects of psychiatry and questioned how truly scientific they are.   And I’m certainly not alone.  With the growing outcry against psychiatry for its medicalization of human behavior and the use of powerful drugs to treat what’s essentially normal variability in our everyday existence, it seems as if everyone is challenging the evidence base behind what we do—except most of us who do it on a daily basis.

Psychiatrists are unique among medical professionals, because we need to play two roles at once.  On the one hand, we must be scientists—determining whether there’s a biological basis for a patient’s symptoms.  On the other hand, we must identify environmental or psychological precursors to a patient’s complaints and help to “fix” those, too.  However, today’s psychiatrists often eschew the latter approach, brushing off their patients’ internal or interpersonal dynamics and ignoring environmental and social influences, rushing instead to play the “doctor” card:  labeling, diagnosing, and prescribing.

Why do we do this?  We all know the obvious reasons:  shrinking appointment lengths, the influence of drug companies, psychiatrists’ increasing desire to see themselves as “clinical neuroscientists,” and so on.

But there’s another, less obvious reason, one which affects all doctors.  Medical training is all about science.  There’s a reason why pre-meds have to take a year of calculus, organic chemistry, and physics to get into medical school.  It’s not because doctors solve differential equations and perform redox reactions all day.  It’s because medicine is a science (or so we tell ourselves), and, as such, we demand a scientific, mechanistic explanation for everything from a broken toe to a myocardial infarction to a manic episode.  We do “med checks,” as much as we might not want to, because that’s what we’ve been trained to do.  And the same holds true for other medical specialties, too.  Little emphasis is placed on talking and listening.  Instead, it’s all about data, numbers, mechanisms, outcomes, and the right drugs for the job.

Perhaps it’s time to rethink the whole “medical science” enterprise.  In much of medicine, paying more and more attention to biological measures—and the scientific evidence—hasn’t really improved outcomes.  “Evidence-based medicine,” in fact, is really just a way for payers and the government to create guidelines to reduce costs, not a way to improve individual patients’ care. Moreover, we see examples all the time—in all medical disciplines—of the corruption of scientific data (often fueled by drug company greed) and very little improvement in patient outcomes.  Statins, for instance, are effective drugs for high cholesterol, but their widespread use in people with no other risk factors seems to confer no additional benefit.  Decades of research into understanding appetite and metabolism hasn’t eradicated obesity in our society.  A full-scale effort to elucidate the brain’s “reward pathways” hasn’t made a dent in the prevalence of drug and alcohol addiction.

Psychiatry suffers under the same scientific determinism.  Everything we call a “disease” in psychiatry could just as easily be called something else.  I’ve seen lots of depressed people in my office, but I can’t say for sure whether I’ve ever seen one with a biological illness called “Major Depressive Disorder.”  But that’s what I write in the chart.  If a patient in my med-management clinic tells me he feels better after six weeks on an antidepressant, I have no way of knowing whether it was due to the drug.  But that’s what I tell myself—and that’s usually what he believes, too.  My training encourages me to see my patients as objects, as collections of symptoms, and to interpret my “biological” interventions as having a far greater impact on my patients’ health than the hundreds or thousands of other phenomena my patient experiences in between appointments with me.  Is this fair?

(This may explain some of the extreme animosity from the anti-psychiatry crowd—and others—against some very well-meaning psychiatrists.  With few exceptions, the psychiatrists I know are thoughtful, compassionate people who entered this field with a true desire to alleviate suffering.  Unfortunately, by virtue of their training, many have become uncritical supporters the scientific model, making them easy targets for those who have been hurt by that very same model.)

My colleague Daniel Carlat, in his book Unhinged, asks the question: “Why do [psychiatrists] go to medical school? How do months of intensive training in surgery, internal medicine, radiology, etc., help psychiatrists treat mental illness?”  He lays out several alternatives for the future of psychiatric training.  One option is a hybrid approach that combines a few years of biomedical training with a few years of rigorous exposure to psychological techniques and theories.  Whether this would be acceptable to psychiatrists—many of whom wear their MD degrees as scientific badges of honor—or to psychologists—who might feel that their turf is being threatened—is anyone’s guess.

I see yet another alternative.  Rather than taking future psychiatrists out of medical school and teaching them an abbreviated version of medicine, let’s change medical school itself.  Let’s take some of the science out of medicine and replace it with what really matters: learning how to think critically and communicate with patients (and each other), and to think about our patients in a greater societal context.  Soon the Medical College Admissions Test (MCAT) will include more questions about cultural studies and ethics.  Medical education should go one step further and offer more exposure to economics, politics, management, health-care policy, decision-making skills, communication techniques, multicultural issues, patient advocacy, and, of course, how to interpret and critique the science that does exist.

We doctors will need a scientific background to interpret the data we see on a regular basis, but we must also acknowledge that our day-to-day clinical work requires very little science at all.  (In fact, all the biochemistry, physiology, pharmacology, and anatomy we learned in medical school is either (a) irrelevant, or (b) readily available on our iPhones or by a quick search of Wikipedia.)  We need to be cautious not to bring science into a clinical scenario simply because it’s easy or “it’s what we know,” particularly—especially—when it provides no benefit to the patient.

So we don’t need to take psychiatry out of medicine.  Instead, we should bring a more enlightened, patient-centered approach to all of medicine, starting with formal medical training itself.  This would help all medical professionals to offer care that focuses on the person, rather than an MRI or CT scan, receptor profile or genetic polymorphism, or lab value or score on a checklist.  It would help us to be more accepting of our patients’ diversity and less likely to rush to a diagnosis.  It might even restore some respect for the psychiatric profession, both within and outside of medicine.  Sure, it might mean that fewer patients are labeled with “mental illnesses” (translating into less of a need for psychiatrists), but for the good of our patients—and for the future of our profession—it’s a sacrifice that we ought to be willing to make.

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33 Responses to What’s the Proper Place of Science in Psychiatry and Medicine?

  1. Keris says:

    Great post! I’m in total agreement that the training for MD’s needs the inclusion of “communications” to enhance patient engagement. All the science (or lack there of on occasion) does not have the predictive power of improvement in mental health outcomes than a good doc-patient relationship. Yet that receives the least attention in a doctor’s (psychiatrist’s) training– hmmm???

  2. aek says:

    Are you familiar with the Harvard School of Public Health global medical education change initiative? The Lancet published a white paper about it, and there is an active resource website.

    http://healthprofessionals21.org/docs/HealthProfNewCent.pdf

    Your assertion that psychiatrists are unique because of practicing both art and science is incorrect: all helping professions are considered hybrid art and science practices. To the extent that both are critical in both assessing/understanding patient problems and devising treatments based on those assessments, your assertions about emphasizing the patient’s experience/environment is accurate.

    • mara says:

      Hey aek. I just checked out your blog. I don’t think I have ever witnessed someone who was that openly suicidal and feeling so alone and disconnected online. It’s not something I witness in life outside the computer either. I’m not sure whether to applaud you or not. I think it’s a positive that you have the guts to talk about it like that. Though obviously the fact that you are feeling THAT suicidal, desperate, and alone would be a negative…

      You are exactly the kind of person to be posting on sites like this. And I read your comments differently now. I applaud you for your effort in battling your thoughts of suicide “upstream” as you put it. Hang on! There are a lot of people on Dr. Balt’s site who I am sure would love to keep reading your comments. I could see why you feel alone, because I could see mental health professional freaking out about your feelings (obviously you are not sure whether you are going to do it or not) and people in your regular life might be overwhelmed by something like that. But I recommend you keep going!

      Who knows…maybe one day psychiatry will improve? And in the meantime your mind is still sharp and your comments are welcome.

      • annalaw81 says:

        The voice of a mental health ‘consumer’ here. I put my 2 cents in on this and similar blogs because I am NOT like many of the other posters – mental health or other health care professionals, many of whom talk about what ‘the patient’ feels, does, wants or needs. First of all, good article! You wrote:

        “Instead, we should bring a more enlightened, patient-centered approach to all of medicine, starting with formal medical training itself. This would help all medical professionals to offer care that focuses on the person, rather than an MRI or CT scan, receptor profile or genetic polymorphism, or lab value or score on a checklist.”

        Amen. But will it happen any time soon, in a profession that, as the article itself notes, prides itself on its scientific orientation? In a profession that has essentially stopped talking to their patients, and instead, focuses on what ‘cocktail’ or combination of meds is ‘efficacious?’ I’m not holding my breath. I’m now going on my 4th psychiatrist in a year and a half (that’s what happens when you are in a clinic setting w/o health insurance.), and I’m at the point of saying …’whatever.’ If it’s Tuesday, it must be Dr. Whomever, and s/he’ll give me X meds but won’t be there next month.

        I agree w/ aek that ‘all helping professions are considered hybrid art and science practices.’ And yes, I have seen that a good psychiatrist, in addition to his or her knowledge of what meds to give you, also listens, talks, intuits, and understands – the ‘art’ portion of the process. He or she will see you as more than a prescription or a set of symptoms.

        Mara – I’ve gone to aek’s blog and at first, felt as you did. However, I wanted to understand what she was saying so I kept going back. I think aek has important things to say, not just about how suicide is handled in this country, not just about her own story and the pain she has clearly suffered, but also about her own and other professions, notably the mental health/ psychiatry professions, too.

        I applaud her, like you, for having the guts to be honest about her own experiences and also for her upstream struggle. I see that struggle as a positive because the more I read and reread, the more I came to realize that it is a ‘call to arms’ of sorts for those who have the power and ability to make the changes she speaks of, changes that might help others feeling the kind of pain she felt. I may be assuming, here, but that’s what I got from it, and found it worthwhile reading, although I’ve just started – it’s rich in resources to check out as well.

  3. I personally don’t see science and humanism as an “either-or” issue. I think they complement each other rather nicely.

    And I use my medical training all the time to distinguish what used to be called “organic” symptoms from psychological symptoms as best we can (e.g., delirium from dissociation), not to mention the fact that psych medications (which when used appropriately save lives and alleviate severe suffering – if you don’t believe that, why prescribe them at all?) interact with every other organ system, disease state, and medication in the PDR. This is why psychologists should not get prescribing privileges.

    • Puddytat Cat says:

      “… [I]f you don’t believe [psych meds are effective] why prescribe them at all?

      Uhhhhhhhh… for all your sarcasm aside, maybe he prescribes them because he is simply UNSURE if they work, perhaps simply a chance, apart from your either-or question.

    • Duane Sherry says:

      Dr. Allen,

      Re: “If you don’t believe that, why prescribe them at all”

      Do you believe psych meds save lives?
      If yes, based on what?

      Has there been a reduction in the number of suicides since these drugs hit the market?
      If so, show me the numbers.

      The numbers aren’t there, are they doc?
      No.

      So you believe in something that doesn’t exist.
      You believe in a myth.
      A delusion.

      Duane

  4. mara says:

    A really long time ago, Moviedoc told some pre-med student with dreams of becoming a psychiatrist who practices psychotherapy on another site that she should get into a good MFT program and then become an NP. He said he thought she would be less ridiculed. But in reality…he’s right that this is really all the training she needs (I don’t know about the ridicule part). The average psychiatrist doesn’t even look for other causes. Insurance companies won’t allow it. At least mine won’t. If there is a suspected issue that is not psychological then the psychiatrist just has to recommend that you make an appointment with your primary care doc. You could probably get by as a well trained PA or NP who practices psychotherapy.

    Actually that would be a good route for a psychologist who wants prescribing privileges. Once they get the PhD in psychology, they can enroll in PA school. I think it’s 3 years if you already have a BA or higher. That way they could still screen for physical causes.

  5. Nathan says:

    I am uncomfortable with art/science and humanist/reductionist dichotomies. think science is being used in this blog as the accumulated knowledge of physical/biological processes.To me, science is a methodology, the process in which you shape and nuance knowledge through syestematic inquiry and falsification, not the knowledge itself. I know many doctors have undergraduate backgrounds in elementary “hard sciences” (physics, chemistry, biology), but the premed requirements do not teach you how to do/understand scientific process and research methodologies. There is a difference between what is learned in a “science” class and scientific inquiry. Filtering clinical experience through a knowledge base of biochemical/physical phenomena and trying to make it fit is not the same as doing/understanding/utilizing science. That would be more like filtering clinical experience through an analytic knowledge base and just trying to make it fit. Neither is science. Even folks who concentrate in the hard sciences I find do not have strong research methodology training/skills as folks who study more human sciences (psychology, cognitive science, quantitative sociology, etc.). Especially when studying people, their behavior, thoughts, and feelings, a “hard science” background I don’t see quite as helpful for designing, conducting, analyzing, interpreting, and applying research in human/clinical sciences.

    You can also use scientific inquiry to make predictions about treatment effectiveness applied in different situations and make choices about how/what/why to treat. You don’t have to reduce/objectify a patient in order to make treatment decisions given limited information and high variation that maximize clinical outcomes.Treatments/interactions can be shown to effective and have limited risks without having to have a biological disease present. You can study how people interact with each other relate to clinical outcomes without pathologizing people.

  6. amcunningham says:

    ” “Evidence-based medicine,” in fact, is really just a way for payers and the government to create guidelines to reduce costs, not a way to improve individual patients’ care.”

    EBM is about improving the health of populations. Resources are scarce. How do we best allocate them? EBM is a solution. But it seems that we are approaching a crisis of faith in the RCT.

    What then?

    • stevebMD says:

      EBM is a great idea. But just as a person is not simply a collection of cells, tissues, and organs, a population is not simply a collection of individuals. And by seeing it as such, we end up doing things that sometimes don’t make a lot of sense. Unfortunately, as we have less and less time to think (and are actively encouraged NOT to think, thanks to our EMRs, decision support systems, and everything else that takes our autonomy away from us), we end up giving the same mediocre care to everyone. We might save money, but everyone loses.

      Speaking of resources, in community psychiatry I see resources wasted every day. It’s a joke, but not a funny one. No one seems to care. Actually, I wonder if anyone even notices. To me, community psychiatry is ripe for a major change, perhaps a revolutionary one. I’ll write more about that when I can.

      • Nathan says:

        Much of the problems of evidence medicine is the failure to actually identify work towards substantially beneficial outcomes for patients. When the end goals/outcomes are not well thought through, not able to change when needed, and resources/time/skill/interest is not invested in assessing if those outcomes occur and figuring out why they are not if they aren’t, then yes, lots of thoughtless decisions are made for senseless reasons. The massive infrastructures and useless EMRs many physicians/insurance companies use collect a lot of unnecessary and distracting data, take too much time, and are more burdensome than helpful.

        Reducing cost is one of the motives/goals of EBM, but is a secondary one, and must do so by gaining greater understanding of what kind of care is unnecessary or harmful, supporting risk-reduction or prevention work, and implementing care practices that have shown to be superiory helpful in engendering the kinds of outcomes sought. Basically, EBM supports quality, efficient care, where quality comes first, and efficiency is factored by how accessible, affordable, and timely quality care is delivered. Even if costs stay the same, increasing quality of care, which EBM should help do (and the practice of utilizing EBM will let you know if you are not increasing quality of care), means that healthcare is more efficient.

        I can understand how frustrating it is to see people hail evidence based medicine when what people actually practice is only designed to cut costs and reduce liability. I don’t think these are bad goals in themselves, there is a lot of waste and irresponsibility in healthcare especially mental health care. But all other tenets/goals of practicing EBM are secondary to the goals of supporting people in being “healthier.” I

        I find EBM bashing a little hard to hear though, especially from doctors, because I find the alternative, non-evidence based medicine, to be wrought with more problems like: inconsistent quality of care, no infrastructure to determine to quality of care in order to make decisions about increasing quality of care where needed most, lack of scientific inquiry or patient outcome focused researched but just more “treatment as usual,” some people receive much better care because of its high cost is only affordable to a few, people are more likely to be exposed to potentially harmful healthcare, etc.

        EBM should not bind doctors into being automatons (unless you can build a case that not doing so leads to poorer health outcomes than doing so would, which in some instances may be the case), but allow people to make more informed and reasoned decisions about their health, something I think we mostly believe is better for our health/wellbeing across our lifespans and at the population level than less informed and less reasoned/irrational decisions.

      • stevebMD says:

        Nathan,

        I keep having to remind myself that I’m a psychiatrist, and psychiatry is, in many ways, different from other branches of medicine.

        For example, you write that NON-evidence-based care is “wrought with more problems like inconsistent quality, no infrastructure to determine quality, … [and] people are more likely to be exposed to potentially harmful healthcare.” I will concede that if you follow even the most rudimentary guidelines in primary care/pediatrics/OBGYN, you may end up with inconsistent care, but the end result will be better than nothing.

        In psychiatry, all such bets are off. I am convinced that our evidence-based guidelines (and yes, we have them) end up hurting people more than they help. Paradoxically, in psychiatry at least, people receiving evidence-based care actually ARE exposed to “potentially harmful healthcare.” And no, it’s not because of the DSM-IV or overmedication or those big, nasty drug companies, although that’s certainly part of it. No, it’s because the system in place to enact those guidelines is horribly, horribly broken and– at least as it stands right now– fails to recognize the humanity of the people we serve.

      • aek says:

        This is in response to both your and Nathan’s comments about EBM.

        Instead of EB medicine, I’m going to refer to evidence-based clinical practice. That translates to basing diagnoses and plans of care on evidence. So the question then becomes which evidence is important – signals, and which is background noise. Since every patient is the research subject equivalent, however rough the analogy of an n=1, the evidence must include the environmental, social and cultural factors which are salient. Since those most often do not get incorporated into extant clinical guidelines (we all have beaten the pharma/surgical/invasive treatment horse to death, so let’s bury the carcass), it is up to the clinician to apply knowledge from the social sciences and humanities to bring to bear appropriate and acceptable treatment options to present for the patient’s consideration. But in order to achieve gaining the “right” evidence, a professional caring relationship must have been built and nurtured on a firm foundation of trust, honesty, partnership and beneficence. In my dealings with psychiatrists and mental health providers as both a healthcare provider (clinician and administrator at varying times) and patient, I have found, with a single exception, that the relationship is built on the provider gaining and holding onto power, control, and forcing/selling treatments based on dishonesty, deception, coercion and sometimes outright assault, battery and incarceration. There is neither anything therapeutic nor beneficent in that.

        There is an out of print book called Nursing: The Finest Art, which really covers the clinical art aspect well both literally and figuratively. http://www.amazon.com/Nursing-The-Finest-Art-Illustrated/dp/032305305X

        Physicians and other clinicians will easily be able to see their own professions in the presented collection. Medical humanities courses which emphasize clinical narratives and creative writing also support this. Patients are well represented, too.

        I’ll end on this challenge to psychiatrists about psychiatric education and practice: why is it that people with extreme psychological distress do better by all extant measures in undeveloped or developing countries and cultures? Doesn’t that send up antennae that social and cultural factors are in play? And that perhaps there isn’t an app, a pill or an EBM guideline for that?

      • Nathan says:

        Dr. Steve,

        I really don’t believe that in psychiatry, all bets have to be off. The problems I see is that the evidence-base for clinical practice in psychiatry is currently deeply flawed. Research is highly suspect, outcomes sought are not that meaningful, and assessment of potential risk/harm is poor. I don’t believe EBP guidelines in psychiatry are that helpful right now because the science is so shoddy for what has been considered important (diagnosing and treatment with drugs/psychotherapy) and quality research informing other aspects of clinical practice/treatment (modes of interaction, social/environmental factors of patients, patient lifestyle/resources) are so limited/non-existent. So not just the the science of psychopathology and pharmacotherapy is flawed, but even the study/evaluation of clinical practice is just so skewed.

        You seem to be saying that despite any basic and clinical research in
        done in psychiatry, the money spent to do that research and to train clinicians in ways based on that research in order to maximize patient outcomes, nothing psychiatry has studied is helpful in making rational decisions when engaging with patients. I understand that people are complex, and all individual patients are different. If there really is no helpfully systematic way as of yet to assess folks and engage them in ways that are meaningfully helpful to them, that is sad. I really don’t like believing that when a patient sees a psychiatrist, their choices now are to follow current EBP guidelines that are pretty blunt and are based on suspect evidence or has to rely on deeply informed clinician judgement/assessment which I think is wrought with all sorts of coercive power, bias, and irrationality. Perhaps I’d be more ok with it psychiatrists were better at evaluating their own practices (which would mean collecting and analyzing data related to patient outcomes and the efficiency of those outcomes being achieved), but they just don’t.

        If as you say , practicing using current EBP standards is better than not systematically consulting/utilizing evidence, then that is actually an evidence based decision in practicing. You can actually compare to different kinds of clinical practice and the outcomes they engender, and in doing so, generate support/evidence. If the current standards (and I don’t eve believe EBP should ever be so rigidly standardized as it to be come so difficult to apply new evidence or make reasoned clinical decisions where evidence is lacking) are worse than what many psychiatrists actually do, we can study what those psychiatrists do so well and build a case that parts of their practice can be really helpful across the specialty. I guess I just find your dismissiveness of EBM in psychiatry to be based only on some of the ways it is been implemented, and I say that what you describe as EBM is not so at all. It’s a sad state for psychiatry to be practicing without evidence in support of much (theories of psychopathology, validity of diagnoses, robustness of outcomes compared to other kinds of interventions, safety of intervention, etc.), but doing patient-centered research that intents to assess what makes patients experience the best/most robust outcomes they can and then applying that research in clinical settings I do believe improves wellness/health. Not doing so means doing the same old thing which I think we all agree has had limited effectiveness and at great risk. r specific purposes, how social/environmental factors moderate patient outcomes, but also of other aspects of clinical practice and administration that may effect outcomes.

      • Duane Sherry says:

        Re: “.. a revolutionary change”

        It’s happening, as we speak.

        Each and every physician, psychologist, licensed social worker, and person who’s been labeled with a psychiatric disorder who is a reader on this site needs to take a look -

        http://www.madinamerica.com

        The revolution has begun!

        Duane

  7. Hawkeye says:

    I endorse the thrust of some comments above as I understand them: use evidence in a way that is consistent with its limitations. To do this med students need to be better scientists not necessarily better humanists. For example, when prescribing an atypical how many docotors will completely discuss the metabolic dangers of the drug they are prescribing. How many will completely discuss the ambiguities of the bipolar/unipolar dichotomy and the dangers of making a mistake?

    Here is my medical profession reform. I am not a doctor and would not have survived this test. You want to be a doctor: at age 20 you take a subject and cognative ability test. People are lined up according to performance and the off the wall personalities are maybe weeded out. You enter the profession pretty much according to your test scores.

    AND EDUCATION IS FREE.

  8. Puddytat Cat says:

    Dr. Steve: RIGHT ON!!!

    I just wish there were more psychiatrists like yourself… ones who actually see PEOPLE instead of a walking, talking list of “symptoms”, as most psychiatrists do.

    I don’t mind sharing here that I’ve had some rather unpleasant, in fact TRAUMATIC experiences in the psych e.r. sadistic security guards, giving the atmosphere one of apenal/ounitive, rather than safe place.

    Actually, I wen there on my own simpky for someone to talk to about a family crisis; I WAS NOT dangerous, and responded clearly NO when they asked if I was… never-the-less, I was kept overnight (they did this w/ALL patients, rgeardless of the reason), and I LATER discovered from my own doc THIS WAS AGAINST THE PROPER PROTOCOL!!!

    But… thye needed the rtevenue an overnight generated, and I was treated in a MOST degrading, abusive manner from male security personnel, who seemed to control the unit, NOT the RN or MD’S on duty.

    Look, if someone who goes in 4 help on their own si treated as a criminal as a matter of course, then guess what??! Some time for an ACTUAL psych emergency, people who found the unit/experience abusive will NOT, I repeat, NOT go back!!!

    Sorry to seemingly vent w/ you (you actually seem like one of the rare psychiatrists who are human and nice), but something MUST be doen about certain places and the type of “care” (or lack thereof) given.

    And… I strongly suspect that there would bMANY people who would not of otherwise have gotten into the anti-psychiatry movement, had they simply gotten human, non-degrading, non-abusive care.

  9. Duane Sherry says:

    Steve,

    The role for psychiatrists ought to be to look for underlying physical conditions that are often the root cause of “mental illness” -

    http://discoverandrecover.wordpress.com/category/root-causes-of-mental-ilness/

    The role of providing therapy, counseling is better done by those who have no pre-concieved notion of “lifelong, incurable brain disorders” and treat their clients as equals.

    Until psychiatrists begin to act like real doctors, they are likely to get very little respect, because they are causing more harm than good: with marginalizing labels, toxic drugs, etc…

    And if the (false) diagnoses were not enough, there are the prognoses, which are even more harmful.

    Duane

    • Duane Sherry says:

      If your profession plans on staying around, the few of you who are ready to make a paradigm shift better do so… quickly.

      Or the profession is going to die.
      One-way, or the other.
      It makes no difference to me.

      I support those of you who are ready, willing, able to make the shift…

      As for the others, oh well…. it couldn’t have happened to a nicer bunch.

      Duane

      • doctorz says:

        Thanks, Duane, for your Jack Nicholson imitation, as well as your sterling admonition to our profession. I had no idea that the future of psychiatry was predicated on your prognostications. Sorry that you’ve obviously had some bad experiences at the hands of some of our practitioners, as have many others, but you’re preaching to the choir on this site, which, as I appreciate it, is to serve as a nexus for civil discourse. The good Dr. Balt has done an excellent job IMHO of not only honestly confronting the problems in psychiatry and offering solutions, but also being a receptive ear for input from all comers. You may find your discontented energies better expended through a Big Pharma rant forum; e.g., http://www.mcrh.org/Alternative-Medicine/skeptics_forum_just_doing_they_told_PHARMA_2010119.htm

    • herb says:

      Dear Duane,

      “The role for psychiatrists ought to be to look for underlying physical conditions that are often the root cause of “mental illness”’ – Duane Sherry

      Excuse me but “Wow!!!” You’re confusing me. Isn’t this statement of yours a major departure from your pharmaceutical and psychiatric diatribes as well as your very persistent and strong advocacy for talk-therapies only as you most often attribute “mental illness” to situational issues?

      Are you now acknowledging that there can be physical causes for mental illness?

      Yes, I am in agreement with you that as part of a very careful and intensive initial evaluation the psychiatrist should try to ascertain and rule out if there are any detectable physical ills as well as any situational/psychological issues as best one can.

      I don’t know how many psychiatrists you’ve consulted with but from my experiences with a number of psychiatrists attending to my spouse through the years they not only “act like real doctors” they are doctors. Personally, I find many of your generalizations unprofessional and way of base (politely stated).

      By the way, I’m curious if you are a parent and if so, are you a parent to a child exhibiting hyperactivity, distractibility, impulsivity, destructivity and/or suicidal behaviors?

      Warmly,
      Herb
      vnsdepression@gmail.com
      http://www.vnstherapy-herb.blogspot.com

      • vnstherapy says:

        Dear Duane,

        Thanks for the informative reply. Now I have a better understanding of your perspective on several issues and where you’re coming from which only leads me to ask more questions of you.

        Who better to know one’s offspring than his/her parents or in another case one’s own spouse? From the article you directed me to I am reminded of a friend of yours who gave her young daughter a psychotropic medication for bed-wetting and based upon her writings she originally didn’t know the name of the drug or that it was a psychotropic, had no knowledge of the prescribing information and just administered the drug to her daughter. In her narrative additional psychotropic medications were administered and the situation seriously deteriorated. In her diatribes she refuses to answer questions regarding her actions as a parent.

        So I’ll similarly ask questions of you.

        How did you decide upon a psychiatrist for the symptoms your son presented?

        Did you know the name of the medication, its prescribed intended use and were you knowledgeable of the potential side-effects at the time you administered it to your son?

        Didn’t you and/or your family carefully observe your son during the treatment and the ensuing detrimental changes taking place in your son’s behavior(s)?

        Why didn’t you immediately insist upon withdrawing the drug before complicating the matter further by adding additional medications to the initial treatment regimen instead of re-establishing a baseline?

        Why did you wait seven or more months to finally come to the realization that something was not working and/or amiss?

        I am truly sorry to read about your family experiences and similarly those of others that encounter challenges similar to the nature you’ve described. At the same time there is responsibility in these matters to be shared by all. That is all the more reason that I advocate for patient and/or support person education while encouraging hope and persistence as well as enlisting a trusted, caring, knowledgeable and licensed health care professional. Unlike you I’ve not spent my time laying blame simply because I find it to be counter-productive to our goals and energy draining. My efforts were spent in careful observations, data and record keeping, and collaborations in order to achieve our goals. Through the years we ran into challenges from medications but we were able to circumvent issues through advanced knowledge, preparedness and medical collaborations. Unlike you and some of your cohorts I didn’t slam any particular medication or treatment or profession knowing full well that others benefited while we did not. I also added the information pertaining to side-effects and detrimental experiences of others to my knowledge base. So when I am questioned I share our experiences and appropriately caution others regarding potential serious side-effects.

        Based upon the article, in my opinion, I can agree with you that your son was improperly diagnosed and treated. Since this article was written some 5 years ago I certainly hope your son is long past these issues and doing well for himself as I also wish the same for you and your family.

        Warmly,
        Herb
        vnsdepression@gmail.com
        http://www.vnstherapy-herb.blogspot.com

      • Duane Sherry says:

        Herb,

        I feel like I’m being asked questions by a prosecutor, grilled.
        Our son was experiencing irritable bowel syndrome, and was placed on Paxil. He subsequently had a “manic episode”.

        This, I would later find out, is quite common (see #6) –

        http://www.madinamerica.com/2011/11/bipolar-illness/

        I took him to a psychiatrist who was highly recommended by my general practitioner, who spoke highly of him. (Later found out that he was in trouble with the Texas State Board of Medical Examiners).

        We were told he needed to “stay on the medication” by his psychiatrist, and I thought he knew what he was doing. He was after all, a specialist in this area.

        When I saw him drift away into a zombie state, I took action. I had no idea where to go, or what to do, so I started reading, as much as I could.

        I took matters into my own hands.
        And I would encourage any parent to NEVER give the keys to your child’s brain to a psychiatrist… In fact, I would encouarge any/every parent to NEVER allow your child within a thousand yards of a psychiatrist – NEVER!

        I learned a lot over these past seven years, Herb.
        Did I do everything right?
        No.
        Not even close.

        Did I say my kid’s life, the best way I knew how?
        Yes.

        I put my website together for one purpose, and one purpose only… To help answer two questions:

        1) If psychiatry doesn’t work, what does?
        2) Where do I start.

        I did the best I could along the way, and continue to do my best, with all of this.

        It has been a tiring battle.
        Am I always politically correct?
        No.

        But, I never claimed to be, Herb.

        Re: Our son, Brian.

        He’s been off psychiatric drugs for almost seven years.
        He willl take his finals at the University of North Texas next week, as he completes his sophomore year in college, on the Dean’s list.

        He is a gifted soul.
        A writer (masterful writer),a musician (more insturments than I can count); he is a polite young man, engaging, curious, respectful, and well on his way to being a much better man than his dad… which was my goal the moment he was born.

        My best,

        Duane

      • Duane Sherry says:

        correction (used a broad brush)…

        Some psychiatrists are good at working with children/adolescents… the common denominator is that they don’t use drugs, and don’t label children…. but, there are very, very few… It’s like finding a needle in a hay-stack.

        IMO, is much better to stear-clear of conventional psychiatry (unless you can find an MD who meets these criteria), and look for a good LMFT and/or good doc who will search for underlying physical conditions.

        My apologies, Steve for the number of comments.

        Duane

      • vnstherapy says:

        “I feel like I’m being asked questions by a prosecutor, grilled.” – Duane Sherry

        No Duane, I’m not a prosecutor but asking questions is a very simple and basic technique I learned a long time ago as a both a support person and health care advocate as well as an executive/ entrepreneur in aiding me in trying to make the best reasonably informed decisions possible whether collaborating with physicians or dealing with life’s issues.

        Most importantly is what I now read about your son, the fact he is doing well. You as a parent have much to be proud of as well as his accomplishments.

        You never addressed the first and main issue in this odyssey; his “irritable bowel syndrome and anxiety”. Has the issue been resolved and if so, how?

        I do thank you for sharing some of this information with me. As I stated elsewhere it does give me a better perspective of where you’re coming from and your position on a number of issues.

        With this knowledge I believe your position and many of your statements relating to psychiatry and psychiatrists as well as treatments are seriously tainted by your past decision making and unfortunate experiences and that you have a distorted disregard for those both having benefited and befitting from these same entities.

        While I shall respect your opinions, better knowing the basis for your conclusions, I shall also respectfully disagree with many of what I consider your dogma and grossly distorted statements.

        Thank you for the dialogue.

        I wish your son, you and yours continued wellness.

        Warmly,
        Herb
        vnsdepression@gmail.com
        http://www.vnstherapy-herb.blogspot.com

      • Duane Sherry says:

        Herb,

        Thank you.
        My best to you and your family as well.

        Duane

  10. Duane Sherry says:

    Dr. Z,

    From your website:

    Do I prescribe Ritalin and Dexedrine to hyperactive, distractible, and impulsive children? Yes, but only after a reasonable evaluation process to rule-out other clinical syndromes or diagnoses, which cannot be easily remedied with an indiscriminate medication intervention. My evaluations often include a consultation request for psychological testing, which can be an invaluable tool for diagnostic clarification in perplexing cases. ADHD, by virtue of its ill-defined and all-encompassing nature, should be considered a diagnosis of exclusion for the aforementioned reasons. It’s time to stop putting the cart before the horse!

    My comment:

    It’s time we stopped putting kids on amphetamines! -

    http://www.madinamerica.com/2011/11/children/

    Duane

  11. Sincered says:

    As an outsider I can’t help feeling students should be choosing psychiatry, not choosing medicine then ending up in psychiatry. This does not seem like equality for the mental health system and its long-suffering denizens and outcasts; treating it as just another narrowed specialty when if anything it’s broader than general medicine, requiring the most humanly divergent skills and understandings and experiences. But yes I see the point that maybe general medicine itself needs to broaden out.

  12. Peter C. Dwyer says:

    Dr Balt,

    Thanks for another thoughtful and insightful post – and for the courage to take a controversial position.

  13. mara says:

    what an interesting way of promoting spam

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