When asked what makes for good patient care in medicine, a typical answer is that it should be “patient-centered.” Sure, “evidence-based medicine” and expert clinical guidelines are helpful, but they only serve as the scientific foundation upon which we base our individualized treatment decisions. What’s more important is how a disorder manifests in the patient and the treatments he or she is most likely to respond to (based on genetics, family history, biomarkers, etc). In psychiatry, there’s the additional need to target treatment to the patient’s unique situation and context—always founded upon our scientific understanding of mental illness.
It’s almost a cliché to say that “no two people with depression [or bipolar or schizophrenia or whatever] are the same.” But when the “same” disorder manifests differently in different people, isn’t it also possible that the disorders themselves are different? Not only does such a question have implications for how we treat each individual, it also impacts how we interpret the “evidence,” how we use treatment guidelines, and what our diagnoses mean in the first place.
For starters, every patient wants something different. What he or she gets is usually what the clinician wants, which, in turn, is determined by the diagnosis and established treatment guidelines: lifelong medication treatment, referral for therapy, forced inpatient hospitalization, etc. Obviously, our ultimate goal is to eliminate suffering by relieving one’s symptoms, but shouldn’t the route we take to get there reflect the patient’s desires? When a patient gets what he or she wants, shouldn’t this count as good patient care, regardless of what the guidelines say?
For instance, some patients just want a quick fix (e.g., a pill, ideally without frequent office visits), because they have only a limited amount of money (or time) they’re willing to use for treatment. Some patients need to complete “treatment” to satisfy a judge, an employer, or a family member. Some patients visit the office simply to get a disability form filled out or satisfy some other social-service need. Some simply want a place to vent, or to hear from a trusted professional that they’re “okay.” Still others seek intensive, long-term therapy even when it’s not medically justified. Patients request all sorts of things, which often differ from what the guidelines say they need.
Sometimes these requests are entirely reasonable, cost-effective, and practical. But we psychiatrists often feel a need to practice evidence- (i.e., science-) based medicine; thus, we take treatment guidelines (and diagnoses) and try to make them apply to our patients, even when we know they want—or need—something else entirely, or won’t be able to follow through on our recommendations. We prescribe medications even though we know the patient won’t be able to obtain the necessary lab monitoring; or we refer a patient for intensive therapy even though we know their insurance will only cover a handful of visits; we admit a suicidal patient to a locked inpatient ward even though we know the unpredictability of that environment may cause further distress; or we advise a child with ADHD and his family to undergo long-term behavioral therapy in conjunction with stimulants, when we know this resource may be unavailable.
Guidelines and diagnoses are written by committee, and, as such, rarely apply to the specifics of any individual patient. Thus, a good clinician uses a clinical guideline simply as a tool—a reference point—to provide a foundation for an individual’s care, just as a master chef knows a basic recipe but alters it according to the tastes he wishes to bring out or which ingredients are in season. A good clinician works outside the available guidelines for many practical reasons, not the least of which is the patient’s own belief system—what he or she thinks is wrong and how to fix it. The same could be said for diagnoses themselves. In truth, what’s written in the DSM is a model—a “case study,” if you will—by which real-world patients are observed and compared. No patient ever fits a single diagnosis to a “T.”
Unfortunately, under the pressures of limited time, scarce resources, and the threat of legal action for a poor outcome, clinicians are more inclined to see patients for what they are than for who they are, and therefore adhere to guidelines even more closely than they’d like. This corrupts treatment in many ways. Diagnoses are given out which don’t fit (e.g., “parity” diagnoses must be given in order to maintain reimbursement). Treatment recommendations are made which are far too costly or complex for some patients to follow. Services like disability benefits are maintained far beyond the period they’re needed (because diagnoses “stick”). And tremendous resources are devoted to the ongoing treatment of patients who simply want (and would benefit from) only sporadic check-ins, or who, conversely, can afford ongoing care themselves.
The entire situation calls into question the value of treatment guidelines, as well as the validity of psychiatric diagnoses. Our patients’ unique characteristics, needs, and preferences—i.e., what helps patients to become “well”—vary far more widely than the symptoms upon which official treatment guidelines were developed. Similarly, what motivates a person to seek treatment differs so widely from person to person, implying vastly different etiologies.
To provide optimal care to a patient, care must indeed be “patient-centered.” But truly patient-centered care must not only sidestep the DSM and established treatment guidelines, but also, frequently, ignore diagnoses and guidelines altogether. What does this say about the validity, relevance, and applicability of the diagnoses and guidelines at our disposal? And what does this say about psychiatry as a science?
Thought Broadcast 
Dr. SteveB:
EXCELLENT Website you have, doctor, and I find you to be a VERY rare and valuable “Diamond in the rough”.
I admire you becaue you have the b–ls to speak out against the mindless staus quo of modern psychiatry, and I find this a breath of refreshingly clear, sweet air..
What I would like to know is:
As a psychiatrist, are there any set criteria for determining if a patient is delusional or not?
Don’t get me wrong, some people clearly ARE delusional, but what if a consumer makes a claim that is NOT outlandish, is possible, but for whatever reason, the evaluating psychologist or psychiatrist simply doesn’t believe, determines (w/o ANY evidence to either support or refute)that person is definitely delusional… when in fact, the person is NOT, always had GREAT reality testing, and does not lie?
If there is no set criteria for lsiting a person as delusional, except for the personal (fallible) observations, perceptions and biases of the evaluator, SHOULDN’T there be? Either in or both taught in med school in the pscyh rounds or the DSM Committee?
I thank you for your and other readers time in reading this I I would appreciate any insight you can give me on this matter.
As a psychiatrist, my answer about delusional beliefs revolves around function. That is to say, if the patient in front of me is functioning (working, sleeping, eating, generally OK with life,) then it doesn’t really matter what they believe, or whether or not I agree it is valid.
Of course, if someone has a firm, fixed belief that, real or not, does not interfere with function, then what are they doing in my office?
Bottom line – I’m not that worried about the reality (or lack thereof) of my patient’s belief, nor am I really concerned about changing it (tends not to work in Delusional Disorder anyway …) My primary concern is to improve my patient’s functioning in the context of their belief (or delusion.)
What about cases where the person ends up in your office because OTHER people are upset about the delusion and this is the entire reason that the person cannot function. Say someone has a delusion that they have a friend named Harvey. Harvey is a 6 foot tall rabbit, but only Elwood can see Harvey. Elwood does not work, because no one hires people who talk to invisible 6 foot rabbits. So Elwood likes to go to bars and sit with Harvey and talk. He doesn’t really seem to have any other friends, but he is friendly and will talk to other people. He has family members, but their lives are greatly impacted by the delusion. His niece cannot get married, so disturbed by her uncle Elwood are the local suitors. His sister is falling apart, because her social life and chances of ever seeing grandchildren are greatly diminished, because if she brings someone to the house with her they will see Elwood talking to Harvey. It has gotten to the point that Elwood’s sister believes that Elwood must be admitted for psychiatric treatment. He cannot work (a non-issue because he is independently wealthy), so the delusion does interfere with his daily living. And his behavior greatly affects his family.
What do you label Elwood? And do you treat Elwood? Elwood seems fine. It’s everyone else that appears to have the problem…And what if Elwood was not wealthy enough to have this delusion and have it be a nonissue? What if he had to work, but could not because of Harvey? Does that change treatment and how Elwood is viewed as a patient? Does that make him more delusional because he is not wealthy enough for the delusion?
Interesting reply, but NOT exactly what I wasasking.
My question is: IS there a set CRITERIA for determining whether a patient is delusional or not, or does such a determination depend entirely upon the evaulator’s “discretion” w/o any evidence to either verify or deny what the pateint claims, if it’s NOT far-fetched, I mean?
I guess whatI want to basically ask is: what if the shrink makes a mistake, and if the patient tries to clear said mistake up, they are regarded as “:lacking insight””, but may in fact be RIGHT all along?
What about the MArtha Mitchell Effect?
Aagin, I am NOT referring to those cases where the patient is clearly not in reality, but simply during cases where it’s possible, perhaps even reasonable, but the shrink simply doesn’t believe it, and puts said patient down as “delusional mistakenly?
Is there any safeguard diagnostically against this?
Puddytat,
In response to your question, the answer is a big, fat NO. Yes, there are “criteria” for diagnosing all of the major psychiatric disorders, but they are, in most cases, collections of symptoms for which any open-minded observer could find dozens of possible explanations. As Wilyliam’s comment points out, one of the key criteria for all diagnoses (which many psychiatrists ignore– go figure) is that the symptoms interfere with a person’s daily function and (in most cases) reflect a change from the person’s baseline status.
The emphasis on diagnosis (see, for instance, the brouhaha over the DSM-5) and your questions about the evaluator’s subjectivity are, in my opinion, the best evidence for why psychiatry as it’s currently practiced is one big pseudoscience. We have no idea what we’re looking at, and, to make matters worse, we try to do “science” (e.g., clinical trials) when our basic assumptions (who has a “disease”) are probably incorrect. Complete waste of time and money, but enough people buy into it to make for a great market for drugs and docs.
That’s not to say that there’s no place for psychiatry, however. Human, subjective suffering will always exist; people will always look to experts and professionals for help and guidance; and medications DO work much of the time. The framework upon which our profession is built, however (thanks in no small part to the APA), is purely based on the delusion of distinct disease entities and the ability of medications to reverse or at least stabilize progression of these diseases. Stay tuned– I hope to write more about this.
Dr. Balt,
You’ve made this argument several times now. Practicing evidence-based medicine is not the same as following treatment guidelines, and I don’t like when they are equated. EBM always takes into account patient values/resources and clinician judgement, in addition to the science at hand. Everyone is different, but that does not mean you shouldn’t be informed by quality evidence.There is no evidence for starting a treatment plan that you and a patient know full well cannot be followed, paid for, or agreed upon. Doing so just because it is in a guideline and then saying using evidence to inform clinical decision-making is poor care or not “patient-centered” conflates the issues.
As for the validity of psychiatric diagnoses, that has always been questioned. This is why the DSM endeavor shifted to a reliability model of diagnosing in order to side-step the validity issue. For some reason, though so many mental health professionals, doctors, policy makers, insurers, courts, etc., all believe and/or insist that diagnoses are valid or are supposed to be valid. They aren’t. This doesn’t make them useless if symptom clusters are shown to frequently co-occur and responsive to particular interventions. However, more often than not now the defining of criteria for a diagnosis is a political process, not a scientific one, and added to the issue of insistent validity of these diagnoses, people diagnosed can be terribly harmed and stigmatized by labels that actually have little basis to exist, and that lack any effective treatment.
I agree that there are lots of problems with current treatment guidelines and diagnoses, mostly because of the corrupted science that informs them, the belief that diagnoses are valid and have particular etiologies, and the use of treatments that lack strong evidence are included in the guidelines. I’ve come to learn Psychiatry is not at all science, in that there are so many clinicians like yourself who don’t seem interested in basing their decisions on systematically gathered evidence and the considered scientific base of psychiatry is actually pretty baseless.
To me though, this means that care provided is not at all “patient-centered,” because there is no good rationale for intervening. There are all sorts of things a potential patient could do that aren’t based on evidence that might better fit their needs/values/expectations/preferences, but they from many angles (physicians, media, social services, etc.) are told that psychiatric intervention is what is supposed to be helpful. I suppose being set up to expect benefits from medical help may help align patients and doctors in finding a “treatment” that will be helpful, but seems pretty messed up when based on what comes down to propaganda. If you can’t develop and appropriately utilze an evidence-base to inform treatment that is predictability more and/or more often beneficial than what patients can do themselves (or nothing), than you are not practicing medicine or helping your patient in meaningfully helpful ways, just taking credit for successes and disavowing failures when you just shoot from the hip.
Okay, that takes care of the first 30 seconds, when a psychiatrist comes to a diagnosis and treatment plan.
What about listening to the patient to see if treatment has an adverse effects? What about being able to recognize adverse effects, and change treatment to minimize them?
That’s not part of being “patient-centered”??
Sigh. My Dad is old enough to remember when even really poor people could afford to have the doc come to your house. Ever read any James Herriot novels? He was a vet long ago, (1930s?) and he could help the pets of even the poorest people. I needed my hamster put down. It didn’t happen. 110 dollars to put her down, 55 dollars for exam. I love the James Herriot story where a poor family has a dog that needs surgery, but none of the vets in the area are qualified to perform it. However, there was a really wealthy, highly trained vet who did it for free. James takes him the dog, the dog gets treated, and James stares in awe at the high tech practice. This was obviously not just a “family pet” vet. But it seems like in the James Herriot stories, no pet goes untreated because a family can’t pay. He makes his house calls, and sometimes very wealthy people use him (and pay him well). And sometimes people on public assistance have him come over and he treats the animal no charge.
My point is, its really sad that doctors can’t just help people anymore (or pets). Can’t afford the money to put down a hamster? Too bad! No mercy killings here. On a side note, did you know that hamsters are considered exotic animals? That’s why it’s so expensive to put them down and get them care. Weirdly, putting down your dog is cheaper. It’s actually really expensive to perform hamster surgery or perform hamster sick care. Well hamster visits are pretty good at 55 dollars…Anywho, whatever happened to the days when your doctor really got a sense of who you are, your family, your home life, your pet, etc? Why are doctors no longer allowed to see the individual? I don’t know why. But I sure do wish it could go back to that. I wish doctor’s and vets could better tailor treatment to the individual. They could work to make sure all in their communities could be well served. They could think up unique treatment plans that are not necessarily dictated by an insurance company. Alas…
The NYTimes just published an article on “patient-centered care” here: Afraid to Speak Up at the Doctor’s Office http://well.blogs.nytimes.com/2012/05/31/afraid-to-speak-up-at-the-doctors-office/
“….Now a study published in the most recent issue of Health Affairs has begun to uncover some of that perspective, and the news is not good. In our enthusiasm for all things patient-centered, we seem to have, as the saying goes, taken the thought of including patient preferences for the deed…..
The participants responded that they felt limited, almost trapped into certain ways of speaking with their doctors. They said they wanted to collaborate in decisions about their care but felt they couldn’t because doctors often acted authoritarian, rather than authoritative. A large number worried about upsetting or angering their doctors and believed that they were best served by acting as “supplicants” toward the doctor “who knows best.” Many also believed that they could depend only on themselves for getting more information about treatments or diseases. Some even said they feared retribution by doctors who could ultimately affect their care and how they did.
The findings fly in the face of previous optimistic assumptions about shared decision-making that were based mostly on studies that examined physicians’ intent, but not patient perceptions. “Many physicians say they are already doing shared decision-making,” said Dominick L. Frosch, lead author of the new study….”
So interesting, Alto! The accounts of the participants in the study have mirrored my own in the past. I wonder if psychiatrists read too much into people’s lack of assertiveness or assertive attempts to be more collaborative, instead of perhaps recognizing doctor-patient relationships across the board suffer from this power difference. Doctors may not get it because they may think they are offering choice or asking meaningful questions, but patients treat them with overt reverence but keep their actual concerns to themselves or to people not in direct provider roles.
Me, too, Nathan. But I’ve found in active belittlement, psychiatrists have been the worst.
There is a great lacking in informing patients of risks and choices other then meds, maybe careful monitoring and therapy would be good first choices, some people just want listened to! How about less on the spot diagnosis? How about believing “anecdotal” issues, they may be true. Isn’t that how treatments were first found to begin with? Akethesia is real, how bout all docs warn about this, and this nonsense of lifetime treatment for depression, how about as needed! Do you and your fellow Dr’s know the correct way to wean your patients from these very addictive drugs? Do you tell your patients of this possibility? 6mns seems like long enough to be on any drug before a taper begins, they will suffer a rebound depression and if they know that they will know it is temporary and will pass, then let them live awhile and let it be their decision to go back on the drug or not. EBM is ok to a point, when common sense has to take over, get rid of the dogma. The DSM actually isn’t the Bible,use what you learned in school,research, do what is best for your patients with their full consent. More doctors need to get out of the rut and get with it! American’s are loosing their faith in you even if they show up at your office they are hoping they will be the exception and be one of the few that gets good care, we want to believe but it is getting harder and harder, We need some good faith practice from you guys!
Funny how often weaning off drugs comes up in these discussions. Yep, it’s definitely a big gap in doctor knowledge. I wish they would learn how to do it.
Dr. Steve:
Thank you for your honest reply. I honestly didn’t think there was one, as I have known pleny of consumers who were falsely listed as delusional when they were not.
I would like to, if I may, take this opportunity to call on any and all the mental health professionals who may be reading this to ALWAYS give the consumer the benefit of the doubt, ESPECIALLY of they have great reality testing, and the said account in question is at least possible and non-far fetched, evven if you do not nec. believe the account.
Fair, professional, and objective enough?
As always, very insightful for the mental health professional. As you mentioned, patient’s expectations are a big determinant on outcome. I ask the question: “How do you think we can help you the best?” and get VERY different answers everytime. To throw a thought-provoking contribution on delusional disorder, I’d like you to remember (or watch) “the last temptation of Christ” (based on the Kazantzakis book were Jesus is depicted as, well, another delusional prophet. I don’t mean to question religion dogmas, just pointing out that in that particular time claiming that God talked directly to you and going around preaching salvation or condenmation was quite popular. and what about scientology? http://www.youtube.com/watch?v=T7EEOMbBIO8 … I don’t mean to be politically incorrect just promoting perspective.
The more we learn about different cultures and beliefs, the less we hold on to the fact that we have the absolute truth. Unfortunately, in some cases acting like we do has negative implications, such as what happened with Hong Kong and eating disorders. http://www.nytimes.com/2010/01/10/magazine/10psyche-t.html?pagewanted=all
I ask myself the question you end your post with very frequently. You are brave enough to ask it to the public.
lol. That was a great South Park episode. I liked their Mormon episode too. I really want them to do Islam again. Only I want them to go into the story behind it (like with the Mormons and the Scientologists) and not just the controversy about depicting prophet Mohammad (pbuh and/or saws).
Hi, Basic Patient / Lay Person here: This was one article I could wrap my head around, as I certainly understand how it feels to walk into the psychiatrist’s office, and walk out with my Rx moments later. You wrote:
“Unfortunately, under the pressures of limited time, scarce resources, and the threat of legal action for a poor outcome, clinicians are more inclined to see patients for what they are than for who they are, and therefore adhere to guidelines even more closely than they’d like. This corrupts treatment in many ways. Diagnoses are given out which don’t fit (e.g., “parity” diagnoses must be given in order to maintain reimbursement)”
Yes – we patients are seen as a particular group of symptoms requiring specific pharmaceutical responses. I realize that’s oversimplifying – my first psychiatrist was great – she took time with me and understood that I needed to proceed at my own pace – however, it does seem at times that once you get your ‘label,’ that’s basically it. I have one diagnosis, for instance, that is not shown in my record, because the med I’m taking for it is “off-label.” Since her departure, my care has been very hit or miss.
This dilemma reminds me of practicing law – you are given a set of laws, or rules to follow, and then you try to apply those to your client’s facts. Sometimes the fit is perfect, most times, you have to MAKE the law and facts work together. Sometimes it works, sometimes it doesn’t. You also have the human factor present in all professions – learning how to deal with judges, court personnel and opposing counsel isn’t taught in law school. Neither is learning what to say to a shrink – No, I won’t REALLY “jump out a window.” It’s a figure of speech! You also learn in the clinic setting, not to become too attached – because the docs don’t stay too long. I’m currently treading water, waiting for the permanent doc who is supposedly coming in this Summer. The 15 minute “med check” is a pit stop, much like getting your BP checked or something. It doesn’t allow much time to even go through how the meds are working or not working, let alone talk about your feelings about it or other things.
Dr. Balt mentioned that .”we admit a suicidal patient to a locked inpatient ward even though we know the unpredictability of that environment may cause further distress;” One of the folks I’ve seen online, aek, has been saying this right along, and advocating for a better way to handle suicidal people – I am happy to see it mentioned here in this blog. But what to DO about it?
How do a lot of concerned folks, scientific and lay alike, band together to actually CHANGE the trajectory of how psychiatry is practiced, prehaps making it a bit more ‘old school’ than it is now? Can we go back to the days when folks “talked about it,” or am i looking forward to just stopping by for my 15 minute med-check and prescription, much like a car being brought into the shop for its periodic oil check?
Sorry for the long post, but this article got to me. I would like to think that I will actually LEARN something as I continue on my ‘journey’ with psych meds and psychiatry – that although the pills might make me feel “better,” there is more to it. Because … there IS.