Modern Medicine

Deliberate Consumption

From a recent article in the New York Times, Mind Over Meds:

A psychiatric interview has a certain rhythm to it. You start by listening to what your patient says for a few minutes, without interrupting, all the while sorting through possible diagnoses. This vast landscape of distress has been mapped into a series of categories in psychiatry’s diagnostic manual, DSM-IV. The book breaks down mental suffering into 16 groups of disorders, like mood disorders, anxiety disorders, psychotic disorders, eating disorders and several others.

I’ve sat in on over 200 of these types of interviews, thanks to my work, briefly, at a psychiatric hospital. Though I’m not trained as a physician, I’ve had my DSM-IV at the ready, and took it upon myself to learn the diagnostic criteria, talk with the members of the treatment team (PhD’s, RN’s, MD’s) and learn about the intricacies of mental health, from diagnosis to treatment.

This article, by Daniel Carlat, a psychopharmacologist, details his experience in the field of psychiatry that is different from his father’s (who was also a psychiatrist.) To sum, this shift in education has been away from learning talk-therapy and practicing talk-therapy with patients, and instead, going down a list of symptoms and finding the medication to match the symptomology. The therapy, he says, is then left “to a professional lower in the mental-health hierarchy, like a social worker or a psychologist.”

This was a common complaint from my clients, when I worked outside of the hospital with the court system. My clients (who were all on public assistance) wanted to talk to an MD for not just their medications, but for therapy. What they often got was an ARNP for their prescriptions, and a Masters level therapist, who even then, would not be their major point of contact. (There are still people lower on the food-chain, such as Bachelor and Associate Degree level case managers.) Dr. Carlat writes, “The unspoken implication is that therapy is menial work — tedious and poorly paid.”

Dr. Carlat, though, came to a realization that there is more to treating his patients than simply diagnosing, medicating and referring. He notes that studies show that “about three-quarters of the apparent response to antidepressants pills is actually due to the placebo effect” and that non-biological therapy (talk therapy) can also be an effective treatment.

I’ll let you go over and read the rest of the article – which is full of insight into the way psychiatry is being practiced, including some of his anecdotal experience of changing his routine with his patients. This story is informative not just to other psychiatrists, but to other people practicing medicine. Healing is not just about finding the pill to match the symptom. Sometimes healing is about standing by, bearing witness, listening, and understanding that we don’t have all the answers.

I’d say some of the best medicine is a human connection. That’s not profitable, though, is it?