I’ll confess, sometimes after I see a patient I ask myself, “was that really necessary??” That’s not to suggest that the interaction was a complete waste of time, or that I regularly provide treatment that is excessive or harmful, but I am frequently reminded of an observation I first made many years ago: we in psychiatry provide a lot of “care” that might be considered unnecessary and, in the long run, wasteful and inefficient.
(Note: I am specifically referring here to certain aspects of outpatient mental health treatment. The same might occur in other medical specialties, but those aren’t my areas of expertise, so I can’t comment. Furthermore, I am NOT referring to regular health-maintenance visits to one’s primary physician, pediatrician, or OB-GYN, in which the “care” consists of an examination and, if necessary, screening tests or preventive measures.)
Consider the following examples of wasteful, inefficient care in psychiatry.
I see many patients (particularly in the community setting) who have been “treated,” often irregularly and infrequently, by a variety of psychiatrists or other physicians who have doled out a half-dozen psychiatric diagnoses and a laundry list of medications. When I see patients like these, their complaints are usually vague and nonspecific, adherence to past treatments has been questionable, and a substance-abuse component is often present. While these patients may indeed suffer from mental illness (or, in many cases, simply face profound psychosocial stressors that the system allows us to call mental illness), it is unlikely that these patients will receive the resources they truly need from conventional psychiatric practice. However, it’s convenient—for us as a society—to shunt them into the psychiatric juggernaut, where they often lose any hope for lasting recovery.
Another example is the patient living in difficult, stressful circumstances who is referred to a psychiatrist by a social service agency or by the criminal justice system “for an evaluation.” Again, these individuals may face huge psychosocial stressors—and may indeed benefit from professional assistance of some sort—but psychiatric care? It’s hard for a psychiatrist to say no. Instead, we give a diagnosis, frequently an “NOS” diagnosis, which, in practice, means “he sort of looks like he might have depression or an anxiety disorder or psychosis, but we’re not sure yet.” This may be justifiable at first, but unfortunately these diagnoses tend to stick—and, interestingly, patients are rarely undiagnosed—locking the patient into a neverending roller-coaster of medication trials and, not uncommonly, a lifetime of psychiatric “disability,” at great expense to all.
Finally, there are those individuals who see a psychiatrist at the urging of their primary doctor or a family member. They may complain of very legitimate symptoms of irritability or mood lability, guilt or sadness over a recent loss, sleep disturbance or anxiety, or chaotic personal relationships—phenomena which we have all experienced to various degrees. Sometimes these symptoms are incapacitating; sometimes not. But we psychiatrists are good at making square pegs fit into round holes; through our DSM-tainted lenses, we give whatever diagnosis “fits best”—often the dreaded “NOS,” discussed above. Furthermore, because many of us are loath to send a patient home empty-handed—and ill-prepared to do anything other than diagnose or prescribe— we give a medication which we think might “work.” (And if it does, we see it as affirmation of our diagnosis, but that’s material for another post.)
These three situations are common in psychiatry. I’m absolutely not saying that patients like these should be denied treatment, “shown the door,” and asked never to return. As a mentor taught me many years ago, no one sees a psychiatrist when everything in his or her life is perfect. But sometimes we fail to recognize that the psychiatrist may approach the patient and his or her complaints in the wrong way.
I believe that, when evaluating patients, psychiatrists should use the tools of scientific investigation: an open mind (although we can use our past experience and intuition, as long as we search for data to support it, too), deep interest and curiosity, a systematic method of analysis, and, most importantly, the lack of bias or predetermined outcome. A significant aspect of this “data collection” is an accurate assessment of the patient’s resources and ability to overcome his symptoms; if his resources can be augmented by psychotherapeutic intervention or by medication, fine, but if not (or if an accurate assessment of his strengths shows that such intervention is unnecessary), then we must have the willingness to say no and back out.
Let me emphasize once again, I am NOT saying that we should be skeptical of patients, or ignore their complaints. But we need to acknowledge we are predisposed (as a result of our training, the nonspecificity of the DSM-IV, and the current treatment paradigm in psychiatry) to see “mental illness” where it may not exist, and prescribe drugs in response. As a result, patients sometimes feel that their complaints “aren’t heard” or are “misunderstood.” Alternatively (and worse, in my opinion), some patients may actually buy into the diagnosis (when in fact it may just be a figment of the doctor’s—or the APA’s—imagination) and use it as an excuse or a rationale for not taking other measures to engage in lifestyle change. To provide truly compassionate and patient-centered care, we must act differently.
I know some psychiatrists will respond, “I always see my patients with an open mind, I’m fair and honest, and I give the patient the benefit of the doubt.” Of course, there are exceptions, but as a product of psychiatric training within the last decade, I can attest to the fact that this approach is rare.
Psychiatrists are taught to look for pathology, not health. And as they say, “seek and ye shall find.”
A more life-affirming and empowering strategy might be for the psychiatrist to (a) first evaluate a person’s strengths and assets, (b) carefully assess the patient’s goals or desires, (c) determine what prevents him or her from achieving those goals, and, most crucially, (d) determine whether the psychiatrist has the means to help the patient achieve those goals (not necessarily to “correct a symptom” or “treat a diagnosis”). Then and only then can treatment commence. Otherwise, we’re spinning our wheels, misleading our patients, wasting our time, and serving no one.