How much talk therapy do psychiatrists do nowadays!?

[blueadams]

I'm hearing more and more that psychiatrists nowadays are doing nothing more than prescribing medication to patients based on the reccomondations of psychologists working for them that are doing all of the talk therapy.

Personally, I am much more interested in talk therapy than I am in pharmaceutical therapy (and I am currently deciding between becoming a psychologist and a psychiatrist). But I am still very interested in the latter. I want to have all treatment options at my disposal as a mental health practicioner (I would be lying if the difference in pay wasn't a factor either...criticize me for that if you'd like, but I'm guessing that it's a factor for a large enough percentage of you as well).

If I could provide both talk and pharmaceutical therapy, I would love it. But I am hearing that less and less psychiatrists are doing this nowadays. Is there any truth to this!? If there are any exceptions, what are they - private practice!?

Thank you in advance for any help!!

Sincerely,

Blue

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[strangeglove]

You are right that the psychiatrist as psychotherapist is a dying breed. However, there are many psychiatrists who still practice psychotherapy, and a number of the best residencies in psychiatry truly emphasize psychotherapy training. The sad fact is that while a psychiatrist can bill for doing psychotherapy, they can bill even more for managing meds alone. This has to do with the fact that you have to take on a higher level of responsibility when you prescribe medicines.

Some psychiatrists who don't take insurance charge a flat fee for 45 minutes of whatever you need, which could be meds, therapy or some some combination of the two. Their patients tend to be wealthy people who would rather go to the same provider for both treatments, rather than have split treatment. IMHO, combined treatment results in better care.

 

[blueadams]

Interesting...it sounds like it shouldn't be a dying breed then. Is it 'dying' simply because psychiatrists that work strictly with medications make so much more!?

I'm sure this will probably be hard to do...but could you give me a rough average of what the difference in pay is for a psychiatrist who works strictly with medications and one who does both?

Thank you very much for your response and any other future ones!

 

[dl2dp2]

Interesting...it sounds like it shouldn't be a dying breed then. Is it 'dying' simply because psychiatrists that work strictly with medications make so much more!?

I'm sure this will probably be hard to do...but could you give me a rough average of what the difference in pay is for a psychiatrist who works strictly with medications and one who does both?

Thank you very much for your response and any other future ones!

These questions are very hard to answer because it's highly variable depending on the subspecialty, geography, payment structure. The rough number is an average of 200k for any given psychiatrist.

I don't think the increasing move away from strict psychotherapy, especially psychodyanmically oriented therapy is necessarily a bad thing. The Midwestern programs are already largely phasing out psychodynamics, since, one faculty told me "psychiatry vs. psychology is like orthopedic surgery vs. physical therapy." I personally enjoy psychotherapy as well, and I think psychodyanmics is really fun to do, especially on high functioning patients who's willing to pay me $300 an hour for it, but I don't think (1) it's predictably efficacious, (2) doctors should necessarily have to learn to practice it.

I don't think psychiatrists need to necessarily worry about turf war with psychotherapist. The future of psychiatry is in procedures and more targeted therapy, like DBS, TMS, DCS, advanced psychopharm (i.e. pharmacogenetics), advanced neuroscience-guided therapy (i.e. virtual reality exposure, computer assisted CBT), advanced imaging interpretation, and in subspecialties, like detox programs, autism/social function disorders, forensics, etc.

 

[blueadams]

hmm...

so what would you say to a prospective psychologist/psychiatrist like me that would like to do both talk therapy and pharm therapy!? are there still going to be respected residencies that place an emphasis on both in 4/5 years? are there still going to be jobs for practicioners that want to practice both if 8/9 years? etc.

as far as money is concerned, I really don't care. I am sure that I will make less than the typical psychiatrist that does nothing but prescriptions. I am sure that I will still make a little more than the average psychologist who only does talk therapy. I will be doing what I love. I want to have all mental health treatment options at my disposal for my patients!

...also, I noticed that you are an MD/PhD. What, if I may ask, are you getting your PhD in!? And for someone like me, that is really interested in both talk and pharm therapy, would it be a good idea to pursue joint MD-PhD clinical psych programs?

 

[dl2dp2]

hmm...

so what would you say to a prospective psychologist/psychiatrist like me that would like to do both talk therapy and pharm therapy!? are there still going to be respected residencies that place an emphasis on both in 4/5 years? are there still going to be jobs for practicioners that want to practice both if 8/9 years? etc.

...also, I noticed that you are an MD/PhD. What, if I may ask, are you getting your PhD in!? And for someone like me, that is really interested in both talk and pharm therapy, would it be a good idea to pursue joint MD-PhD clinical psych programs?

My PhD is in a neuroscience. I'm going into a career of translational neuroscience research in psychiatry. Clinical psych PhD programs are not eligible for MD-PhD funding. I think if you want to do both therapy and meds in the near term the only pathway is to become a real medical doctor. In the long run if you want to do meds in any significant capacity, you probably will always need to be a real medical doctor. If you want to do any procedures (i.e. ECT, TMS), you probably will always need to be a real medical doctor.

I wouldn't go as far as saying that clinical psychology is not compatible with med school, but there's really very little overlap in terms of career advancement, lifestyle, training, patient population, day-to-day work etc. in these two fields. In an inpatient/hospital situation, you call psychologists for a consult for neuropsychology testing. But psychologists can't staff the psych ER, the impatient units, or get called by the ER to do an admissions, or do C-L consults. NOBODY else in the hospital can except the psychiatrists. It doesn't matter what other training you get, you just can't do this unless you do a residency in psych. In outpatient, you refer your patient for long-term psychotherapy. You staff the psychopharm clinic, the subspecialty clinics, etc. Clinical psychologists run group therapy, counseling services--they don't staff clinics. They also can't moonlight. State hospitals don't hire psychologists for psychiatrists' jobs. Psychiatrists do brief CBT, cash-only psychodyanmics, etc. There's money to be made doing therapy--it's just that you don't have time to talk to people for hours--unless they have the means to pay you a lot of money for your time.

 

[blueadams]

thank you very much for the response.

first...what is CBT? Sorry, but I am not very familiar with medical terms.

...i did not know that clinical psychology phd programs and md programs were so incompatible. i had heard that such a dual program would be a sort of waste of time though - bc if you're really interested in psychotherapy, then you'll get all the training you need in a good psychotherapy oriented residency. would you agree?

...it just seems like such a shame that the psychiatrist as a talk-therapist is dying. that is what i am most interested in doing. providing the best of both worlds to my patients. it sounds like the only patients who will be able to afford me, however, are lawyers and executives (nothing wrong with that I suppose, they need help as well).

...even though they may be declining quickly in numbers, what do you know about those who still do both. are all their clients really very wealthy? do you know of any who I could contact for more specific information?

 

[235750]

first...what is CBT? Sorry, but I am not very familiar with medical terms....it just seems like such a shame that the psychiatrist as a talk-therapist is dying. that is what i am most interested in doing.

I'm not sure how you can say you'd like to do 'talk therapy' when you don't even know what sorts of therapy exist. And as you don't know what sorts of therapy there are, how efficious they tend to be, etc, I'm not how you can lament the direction that psychiatry as taken.

I think you need to step back a bit and start at square one.

SDN is good to get specific questions answered, but starting a thread re: "what is psychiatry, what is CBT, etc" isn't going to be very helpful for your purpose.

For such broad questions, look at the 'stickies' in the top part of the psychiatry forum. Read some articles, check out at least one book, and then get back to us with questions.

Good luck

 

[zenman]

thank you very much for the response.

first...what is CBT? Sorry, but I am not very familiar with medical terms.

Cognitive Behavioral Therapy

 

[la petite mort]

If you can really see yourself being a psychologist, save yourself the stress and debt. I reccommond it.

 

[blueadams]

I'm not sure how you can say you'd like to do 'talk therapy' when you don't even know what sorts of therapy exist. And as you don't know what sorts of therapy there are, how efficious they tend to be, etc, I'm not how you can lament the direction that psychiatry as taken.

I think you need to step back a bit and start at square one.

SDN is good to get specific questions answered, but starting a thread re: "what is psychiatry, what is CBT, etc" isn't going to be very helpful for your purpose.

For such broad questions, look at the 'stickies' in the top part of the psychiatry forum. Read some articles, check out at least one book, and then get back to us with questions.

Good luck

right...i have no future in therapy because i don't know what C.B.T. stands for.

how would anyone that wasn't a psych major...or a psychiatry residency know that!?

 

[Sneezing]

Psssst!!! Wikipedia will give you the bare minimum you need to orient you...

 

[blueadams]

look, i'm not a pre-med student, i'm not a psych major. i did my senior thesis in positive psychology and was very, very intrigued by it. it got me thinking about becoming a psychologist or psychiatrist. i asked some professors about it, they told me that psychiatrists rarely do talk therapy anymore. i asked the board if that was true. it sounds like it is. and it sounds like the rare ones who do both are only able to with very wealthy clients.

all i'm looking for is input about that - do psychiatrists do talk therapy anymore!?

 

[masterofmonkeys]

blueadams, this is really quite a welcoming place and people here tend to be very helpful. Don't get put off by a couple of snide remarks.

I was in your situation not so long ago myself.

Yes psychiatrists do talk therapy. And you can make a very decent living (100k+) taking insurance and doing talk therapy.

http://www.usnews.com/health/family...iatrists-talk-therapy-falling-by-wayside.html

Recent survey for some info.

Here's a short, but far from exhaustive list of reasons for why talk therapy is falling by the wayside. The pharma push and the medicalization of psychiatry. Increased incidence of psychiatric disorders. Increased symptomatic management of same by PCPs who are not trained in psych. Increase in number of psychiatry programs without a strong psychotherapist faculty contingent. Decline in quality of individuals entering psychiatry. Adverse compensation (thank you medicare!). Sociocultural issues regarding psych stigma (if its a biochemical issue you need a pill for, that's not really your fault. If it's a biopsychosocial problem at least partially rooted in your experiences, and reaction to them, and requires work on your part to correct, then it's your fault, you weak person!)

30% is nothing to sneeze at. And I daresay there's no reason the number couldn't be higher. It's just that there's a combination of training programs who don't care about psychotherapy as well as residents who don't care to learn it to go along with societal and economic pressures.

Myself, I still plan on becoming a psychiatrist who thinks of himself as a psychotherapist. I can take a small economic hit, or supplement with some high-paying clients. If I were in it for the money, I wouldn't have gone into psych in the first place lol.

But I will say that a funny thing has happened since I started residency (i'm an intern right now). Namely that I've got a reputation for knowing my psychopharm. Which I actually got annoyed with for a while. Because psychotherapy and lifestyle intervention have been what I wanted to do since I was 15 or so. And then i wasn't so annoyed. Psychiatric disorders after all are BioPsychoSocial, and thus treatment needs to hit all of these areas. It's now become a goal of mine to become as good at psychopharm as possible, because that'll only make me a better clinician.

I'll also say that on the inpatient wards, every patient with insight gets the psychotherapy available in my at the moment limited armamentarium. Whether supportive, motivational interviewing, cognitive-behavioral chunks, or mindfulness exercises.

In short, there is plenty of opportunity for a psychiatry resident to learn plenty of psychotherapy and to do it.

 

[blueadams]

MasterOfMonkeys -

Thank you very, very much. That was a very helpful response (and article). It's great to know that it's still possible for psychiatrists to provide both psychotherapy and pharmotherapy to patients that need the insurance. I would gladly accept a lower salary to do both - not only for the sake of providing better overall care, but also because the talk-therapy aspect of treating patients would be so much more rewarding for me. I wish you all the luck in the world with your career. It sounds like you are going to be one hell of a therapist.

...No offense to those not providing psychotherapy, but to me...someone that knows very little about the field, relatively speaking...it seems almost irresponsible not to. Like you said, in our society, it is so easy to just blame your problems on genetics, and take a pill. There are obviously many, many cases where medication is really needed. But I am of the opinion that drugs should be a last resort. And it seems as though the pharmaceutical companies have succeeded in making them something else.

...For example, I had a roommate a couple of years ago. He got a DUI. His first run in with the law of any sort. Great kid. Great friend. Great student. Very wealthy and concerned parents. They made him go see a psychiatrist to get to the root of the alleged inner issue. My buddy said he went into the guy's office, answered very basic impersonal questions for about 15 minutes, and left with a PRESCRIPTION. Un-real. He didn't want to take any drugs. So, he met with a psychologist instead. He was appalled that medication was even reccomended. After a few one-hour sessions with him, he had never felt better.

 

[HMSPSYCH]

MasterOfMonkeys -


QUOTE]

I too doubted medication management prior to medical school and residency. But experiences taught me not to discount this valuable modality to alleviate patients suffering. Medications like antipsychotic, anticonvulsants, and stimulants- while effective and life saving for many- are powerful medicines which can profoundly affect individuals, sometimes irreversibly. Thereby, it takes a lot of knowledge and training to prescribe safely. It is not as easy as it can seem and time consuming. My colleagues and I routinely order and read labs, ECGs, perform brief PEs on patients taking stimulants/antipsychotics, and record other vital sign to monitor pharmacokinetics and pharamcodynamic properties.

While I respect psychotherapy and have some cases myself, it is less challenging to learn and relatively easy to administer. Many residency programs do teach all modalities of treatment, particularly here in the NE, and do it well. It's up to the individuals to choose which modalities they want to use in their practice depending on needs. Psychiatrists are in short supply throughout the country and many don't have the option to provide therapy. Conversely, therapists (LCSW, PsyD, PhD) outnumber us by a large proportion.

Your friend story sound a bit the exception rather than the norm. Is it possible that your friend was recommended detox treatment, refused, then became upset the MD? He got a prescription after speaking with one of us only in 15 minutes, then went to a PhD, and felt so much better. This sounds scripted. I do not see patients for medication management unless he/she is seen by a therapist.

 

[strangeglove]

The fact of the matter is that people get better in psychiatric treatments because they have a relationship with someone who is concerned about them. We all know that drugs are not miraculous cures in psychiatry, especially for depression. This has a lot to do with the extremely high placebo response rate in clinical trials. Now, it's not as if robots are prescribing these medicines in clinical trials; they are psychiatrists who are trained (hopefully) to show care and concern for their patients.

Is this psychotherapy? Probably not. It has been shown in meta-analyses that the "common factor" of psychotherapies that is most predictive of improvement in symptoms is the therapeutic alliance. In other words, it doesn't matter if you do CBT, DBT, IPT, dynamic therapy, whatever - your patients will get better if you have a stronger therapeutic alliance with them. And this does not just mean being likable.

My point is that even if you imagine yourself doing a "psychopharm only" practice, a big factor in your patients' recovery will be the type of relationship you have with them. There is a lot to say for learning in a formal way how to understand the thoughts, emotions and behaviors of someone who is suffering, especially the ways that they affect their relationships with you and other people who are trying to help them. All psychiatrists - even if they are going to spend their time sequencing genes, scanning brains and stimulating cortices - should be educated in this. Otherwise, we should leave psychiatry to the neurologists.

 

[235750]

right...i have no future in therapy because i don't know what C.B.T. stands for.

I never said you didn't have a future in therapy. I think you should reread my post.

I was merely pointing out that your critiques of psychiatry might be uninformed. I suggested that you could use the vast information that is already at your fingertips on SDN and the internet.

how would anyone that wasn't a psych major...or a psychiatry residency know that!?

Wikipedia or the stickies.

 

[blueadams]

My point is that even if you imagine yourself doing a "psychopharm only" practice, a big factor in your patients' recovery will be the type of relationship you have with them. There is a lot to say for learning in a formal way how to understand the thoughts, emotions and behaviors of someone who is suffering, especially the ways that they affect their relationships with you and other people who are trying to help them. All psychiatrists - even if they are going to spend their time sequencing genes, scanning brains and stimulating cortices - should be educated in this. Otherwise, we should leave psychiatry to the neurologists.

very well said.

 

[strangeglove]

MasterOfMonkeys -


QUOTE]
While I respect psychotherapy and have some cases myself, it is less challenging to learn and relatively easy to administer.

Really? It may be that I am not particularly sophisticated about meds, but it seems like this is really the easy part of psychiatry. Aren't there only, like, 30 different drugs that we routinely use? Compare this to internal medicine, where there are, like, hundreds. I think we make a really big deal about medicines because we are ultimately insecure about the fact that we don't know how they work and are not so confident about whether they actually do much. As a result, we get really hung up on "pharmacokinetics" (much more than internists, it seems, who you might think should be very concerned about this).

 

[HMSPSYCH]

Really? It may be that I am not particularly sophisticated about meds, but it seems like this is really the easy part of psychiatry. Aren't there only, like, 30 different drugs that we routinely use? Compare this to internal medicine, where there are, like, hundreds. I think we make a really big deal about medicines because we are ultimately insecure about the fact that we don't know how they work and are not so confident about whether they actually do much. As a result, we get really hung up on "pharmacokinetics" (much more than internists, it seems, who you might think should be very concerned about this).

With few exceptions, our medications are relatively new, work on the most mysterious organ of the human body, and can have unpredictable adverse effect throughout the body. Thereby, careful thoughts and proper monitoring are needed. PCPs prescribe SSRI routinely as they are considered 'safer' than the other medications but we know can cause SIADH, inhibit platelet aggregation, QTc prolongation, etc. True, they should know but they're not specialists in this field as we are and it would be a disservice to our patients if we do not administer and monitor their usages more carefully. Overall, the cancer meds have the most side effects with our medications playing second fiddle. Most knowledgeable MDs/DOs won't touch either medications without proper training.

 

[dl2dp2]

My point is that even if you imagine yourself doing a "psychopharm only" practice, a big factor in your patients' recovery will be the type of relationship you have with them. There is a lot to say for learning in a formal way how to understand the thoughts, emotions and behaviors of someone who is suffering, especially the ways that they affect their relationships with you and other people who are trying to help them. All psychiatrists - even if they are going to spend their time sequencing genes, scanning brains and stimulating cortices - should be educated in this. Otherwise, we should leave psychiatry to the neurologists.

These are very interesting and good points you are making, but I often wonder if the point of neuroscience is to make psychiatry more like neurology. Is there a fundamental chasm between mental processes and the substrate that psychiatry will always be inextricably tied down to "physician-patient alliance"? In an ideal world, wouldn't we like all medical specialties to be somewhat "robotic" and as "evidence-based" as possible? I have very mixed feelings for both sides of the argument.

Also, I wonder perhaps with the emergence of more brain-based/procedures in psychiatry, the specialty will eventually split, with one specializing in biological psychiatry and the other truly focusing on the psychosocial side of medicine, which should really in itself be its own specialty. But perhaps such split will NEVER happen. In any case, these are very deep questions that currently have no good answers. It's kind of exciting in the field at this time for this reason also I think, since I get the feeling that we are at some cusp that the coming 30 years will be as transformative as the past 30 years in psychiatry.

 

[blueadams]

Also, I wonder perhaps with the emergence of more brain-based/procedures in psychiatry, the specialty will eventually split, with one specializing in biological psychiatry and the other truly focusing on the psychosocial side of medicine, which should really in itself be its own specialty. But perhaps such split will NEVER happen. In any case, these are very deep questions that currently have no good answers. It's kind of exciting in the field at this time for this reason also I think, since I get the feeling that we are at some cusp that the coming 30 years will be as transformative as the past 30 years in psychiatry.

Of everyone chiming in here, I probably know the least, by far - I majored in liberal arts, took about five or six psych courses, and did my senior thesis on positive psych. But I have at least a little bit of additional knowledge outside of academia. I have known a number of people who saw psychiatrists, were convinced that there problems were not a result of their own bad decisions/habits, but heritable/genetic/biological/chemical/etc., were put on medication, and never really got any better. Conversely, I have also known a number of people who instead saw psychologists, worked out their issues, and ended up getting at least a little better...or at least more knowledgable about the actual roots of their problems (whether or not they chose to make adjustments).

From an outsiders perspective, it does seem as if there is a push in psychiatry to make treatment of the brain like any other body part...a broken bone, a failing organ, etc...with concrete procedures and treatments. But like one or more posters have mentioned, the brain is so so much more complex than any other body part. What we know about it...what does what, identifying what isn't doing what it should be doing, and correcting the incorrect aspects...is so so little in comparision to all other parts of the body. And also like one or more other posters mentioned, the drugs that psychiatrists use are so new, and in some cases, not very well proven.

Someday, maybe sooner than later, we will know exactly what does what in the brain. We will be able to identify which part of the brain isn't functioning correctly. We will know which kinds of drugs can correct that problem. But that day is not today. And when these somewhat unproven drugs are used incorrectly, the problems they cause can sometimes be irreversible. THAT is why it seems like drugs should be a LAST RESORT in psychiatry. It seems as though we are so eager to get to the future, that we are screwing up an unacceptable amount of lives with mistakes.

I agree with the poster who suggested that someday, the biological/chemical and social aspects of treating mental illness will be seperated. I think that is true. But that day is not today. Today, it seems like it should be the code of psychiatry to explore all possible forms of non-medical treatment before prescribing drugs. But they way your pay is set up...insurance/pharm companies, thank you...drugs are most definitely NOT prescribed as a last resort. But in many cases, seemingly, a first option (after the usual thirty minutes of consultation).

 

[dl2dp2]

I agree with the poster who suggested that someday, the biological/chemical and social aspects of treating mental illness will be seperated. I think that is true. But that day is not today. Today, it seems like it should be the code of psychiatry to explore all possible forms of non-medical treatment before prescribing drugs. But they way your pay is set up...insurance/pharm companies, thank you...drugs are most definitely NOT prescribed as a last resort. But in many cases, seemingly, a first option (after the usual thirty minutes of consultation).

This kind of sentiment kind of sounds reasonable at first glance, but actually only reflects a lack of knowledge and work in actual day-to-day mental healthcare work. Again this is where the work of psychologist and psychiatrists diverge. The first line treatment of the majority of the patients that an inpatient psychiatrist sees--i.e. schizophrenia, severe anxiety/OCD, severe suicidal patients, manic patients, substance intoxication/withdrawal etc..--is unquestionably meds. It's very dangerous to not medicate someone who's acutely psychotic or acutely manic. In the same vein, it's dangerous and inhumane to not provide antipsychotics to chronic schizophrenics or bipolars. While psychologists RARELY see these patients, and the general public is generally unaware of their existence, this is the real bread and butter psychiatry. Psychiatry is in general not about "working out life problems". While there's often significant "life problems" comorbid for a variety of mental illnesses, I'm not sure that should be part of the physician's job description.

In a similar vein, a large part of improving patient care in internal medicine involves social work, placement, quality control etc., but no internal medicine doctors is trained to perform these duties. And for that matter a lot of IM patient's disorders (i.e. obesity, smoking, etc.) are "life problems" that are often well addressed by psychotherapy. But internal medicine doctors are NEVER expected to train to do therapy, which may often be more effective in "curing" their patients than meds. Instead they are delegated to allied professionals in nursing, social work, dietitians, etc. Insurance, for whatever reason, don't pay the services provided by allied professionals as much, and somehow people are more willing to accept that.

While I concede that therapy is probably much more fun and possibly more challenging than social work/nursing, I'm not fully convinced that it is necessarily REQUIRED per se as part of the training for a doctor. Many residency program directors (i.e. Hopkins/WashU) have pushed this idea to its somewhat disturbing extreme, but I kind of think that this trend will only expand. I think eventually what will happen is those psychiatrists who want to specialize in therapy and high-end med/therapy practices for high functioning individuals with neuroses will do a separate, often very competitive fellowship--and this is already happening with psychoanalytic training institutes. While we should encourage psychiatrists to have some baseline understanding of therapy, I don't think we should necessarily put any stigma on psychiatrists who want to only do psychopharm--it's just a division of labor.

 

[blueadams]

This kind of sentiment kind of sounds reasonable at first glance, but actually only reflects a lack of knowledge and work in actual day-to-day mental healthcare work. Again this is where the work of psychologist and psychiatrists diverge. The first line treatment of the majority of the patients that an inpatient psychiatrist sees--i.e. schizophrenia, severe anxiety/OCD, severe suicidal patients, manic patients, substance intoxication/withdrawal etc..--is unquestionably meds. It's very dangerous to not medicate someone who's acutely psychotic or acutely manic. In the same vein, it's dangerous and inhumane to not provide antipsychotics to chronic schizophrenics or bipolars. While psychologists RARELY see these patients, and the general public is generally unaware of their existence, this is the real bread and butter psychiatry. Psychiatry is in general not about "working out life problems". While there's often significant "life problems" comorbid for a variety of mental illnesses, I'm not sure that should be part of the physician's job description.

I did not realize that these sorts of patients made of the majority of people a psychiatrist treated. But concerning them, I am in complete agreement with you on all aspects.

But let's not get away from the real issue at hand here - what about the psychiatrists that are seeing more highly functional patients...and prescribing them medications after a thirty minute consultation when all other possible treatment options have most definitely NOT been explored. I'm not a psychiatrist. I'm not a medical student. I'm not even a pre-medical student. But don't tell me that doesn't happen. Because I've seen it happen. Several times over.

It seems like the psychiatrists that work ONLY in pharm treatments shouldn't even be seeing functional patients...unless they have been reccomended to them by psychologists that have had at least ten or so hour-long sessions with the patient and determined that some medications would be good for them in addition to his or her reccomended lifestyle changes.

 

[dl2dp2]

I did not realize that these sorts of patients made of the majority of people a psychiatrist treated. But concerning them, I am in complete agreement with you on all aspects.

It seems like the psychiatrists that work ONLY in pharm treatments shouldn't even be seeing functional patients...unless they have been reccomended to them by psychologists that have had at least ten or so hour-long sessions with the patient and determined that some medications would be good for them in addition to his or her reccomended lifestyle changes.

First of all, you are right they mostly don't. Well, if someone is "functional", then by definition they aren't mentally ill, since the vast majority of DSM disorders explicitly include functional impairment as part of the criteria. In which case, you have a physician providing service to someone who's not sick--i.e. cosmetic medicine. While I don't think insurance should pay for anything cosmetic, I think patients should be allowed to choose who and what to pay for. If your argument is that meds aren't effective, then that's false also, because meds are often very effective. We just often don't know when.

Also, to give an example--an investment banker is depressed because he hates his job. However, he is able to function because of his sheer will. Now he asks for an antidepressant so he can get through the day with a little less pain. Obviously the "better" solution is to have him quit his job and do something he actually enjoys. But he made a choice to use medication as a tool to get him where he wants to be. Why should we as practitioners make a judgement of his life goals? That seems kind of ideologic and can be mired in things like racism, institutional biases, etc.

 

[anesthesiarocks]

The future of psychiatry is in procedures and more targeted therapy, like DBS, TMS, DCS, advanced psychopharm (i.e. pharmacogenetics), advanced neuroscience-guided therapy (i.e. virtual reality exposure, computer assisted CBT), advanced imaging interpretation

I couldn't disagree with this more........98% of the psychiatry billing over the next 10 years will be in things not related to that. 95% of pgy-1's in psychiatry not don't plan on making those therapies a staple of their practice.....so how is that the future of psychiatry?

"computer assisted CBT"? GMAFB.........

 

[blueadams]

I wanted to add this on to my last post...but my laptop battery died...

It seems almost as though the psychologist should be to the psychiatrist as the general practitioner is to the specialist.

EMERGENCY: If someone is brought to a large hospital with a potentially fatal gun shot wound (or something similar), he is rushed straight to a surgical specialist of some sort. If someone is brought to a large hospital absolutely out of control because of a mental problem, he is rushed straight to a psychiatrist and given the proper medication asap.

NON-EMERGENCY: If someone notices a potentially cancerous lump (or something similar), they go to their general doctor for a closer inspection, and if necessary, are then recommended to a specialist of some sort. If a functional person is feeling depressed, they SHOULD go to a psychologist for some non-pharm therapy sessions (I would imagine at least ten or so to really get to the root of the problem...couldn't hurt) to determine if drugs would be appropriate/helpful.

If an investment banker is depressed because he hates his job, he shouldn't go straight to a psychiatrist and ask for drugs, and that psychiatrist should not prescribe him drugs after a thirty minute interview. That investment banker should first have ten or so non-pharm psychotherapy sessions...be it with a psychologist or psychiatrist...to identify if the problem is biological and needs drug treatment, or social and needs behavioral adjustments.

If he has a serious chemical imbalance, then yes, he should take drugs of some sort to counteract that. But its more likely that he hates his job because he works 70+ hours a week, feels that it is meaningless, he is constantly stressed out, and he has no time for friends, family or leisure. With such business world experience, he would certainly have other options. Maybe he could take an executive position at an NGO or something. Work less hours. Change the world for the better. Be under less stress. Spend more time with his friends and family. Take some time to see if the difference in money is really worth the difference in lifestyle quality. If he does all that, and he is still having serious depression problems, THEN he should go see a psychiatrist, and THEN he should be prescribed medications.

But in the real world, that's not how it works, is it!? In the real world, that first psychiatrist he sees and asks for a prescription...he is probably going to give him that prescription. And nothing that should really change will really change.

 

[masterofmonkeys]

Please excuse the barely coherent tirade that follows.

It is time for the completely inane mind-brain dualism to die a fast, painless death. I am so sick of hearing about biological psychiatry vs. psychotherapy.

One of my greatest laments is that basic sciences in medical education is biased toward memorization rather than theory formulation and concept recognition. I majored in neuroscience in undergrad, knowing I wanted to go on to do psychotherapy. Why? Because if psychotherapy makes a difference (and it does, with equivalent efficacy and arguably superior relapse rates), then it does so through changing the brain.

Nerves that fire together wire together. The Hebbian synapse. A core principle of basic neuroscience. And a principle that can inform the way we think about how thought patterns arise, are maintained, and extinguished.

What is cognitive-behavioral therapy if not identifying a maladaptive thought pattern, showing it to be false, and then forcibly extinguishing it? Stopping the nerves that wrongly fire together from doing so. What is DBT if it isn't helping the patient to gain awareness over their destructive behavioral responses to emotional distress? And in doing so, extinguish the strength of this synaptic connection?

Furthermore, while a lot of different psychotherapies have been shown to be about as effective as each other for a number of different disorders, and it's been argued that the therapeutic alliance is the common bond, it can also be argued that one thing all of these modalities share is that they teach the patient insight. One could argue since that's a central goal of all psychotherapies, it shouldn't be terribly surprising that they all work.

Psychotherapies ultimately work on the substrate of the brain, and produce their therapeutic benefits through changes in long-term potentiation and synaptic networks. They do this by changing thoughts and improving behavioral/emotional control. Which are products of the brain and its neurons. This should be the null hypothesis, to be disproven, rather than proven. To hold any other position is to essentially invoke Cartesian dualism. Which I am for various reasons not OK with.

Another thing to consider is that most DSM diagnoses are syndromes. I.e. collections of symptoms. Not diseases in and of themselves. Our treatments have been designed to target the relief of these symptoms rather than at specific underlying etiologies. A reduction in symptoms, whether measured by DSM criteria or the GAF (bleh), thus reveals to us nothing but how effective the medication is at relieving symptoms. You can take enough morphine to not feel any pain after you've herniated a disc. Doesn't change the fact that you herniated a disc...

The point I'm trying to make is that while psychopharm works, and psychotherapy works, that in and of itself does not make a very good case for which one is actually fixing the underlying pathophysiology.

As I mentioned earlier, psychotherapies do appear to have better relapse rates than medications alone for depression and anxiety, and we all know that the combination of both is superior. Could the superior relapse rate have to do with therapies, by the development of insight and prevention of maladaptive behaviors, thoughts, and emotional responses, reduce the likelihood of the long-term potentiation and synaptic network changes associated with mood and anxiety disorders? Could it be that combination therapy is beneficial because antidepressants provide symptomatic relief and thus de-stress the brain enough to heal?

What this whole issue shows is a silly bias in the medical profession. If it's delivered through pill or needle, if we physically cut into you and rearrange things, then, it's biological. If it happens through a change in behavior, action, or thought, then it's not. It's that kind of thinking that leads to the loss of empowerment and the medicalization of everyday life.

And to conclude my nonsensical rant, one final thought experiment. If psychotherapy is not a biologic treatment, and it works, then is the illness not biological?

 

[blueadams]

definitely changed my perspective with that post M.O.M.

 

[OldPsychDoc]

......For example, I had a roommate a couple of years ago. He got a DUI. His first run in with the law of any sort. Great kid. Great friend. Great student. Very wealthy and concerned parents. They made him go see a psychiatrist to get to the root of the alleged inner issue. My buddy said he went into the guy's office, answered very basic impersonal questions for about 15 minutes, and left with a PRESCRIPTION. Un-real. He didn't want to take any drugs. So, he met with a psychologist instead. He was appalled that medication was even reccomended. After a few one-hour sessions with him, he had never felt better.

What is this "root, inner issue" you keep referring to?

--A family history of alcoholism, coupled with his own out-of-control alcohol consumption?

--Voices telling him to drive fast to escape the aliens?

--Insomnia caused by flashbacks of sexual abuse by a baby sitter when he was five?

--Unbearable obsessions and anxiety which are only partially and temporarily relieved by alcohol?

--Dangerously high blood glucose levels?

--Untreated mania?

--A poor sense of self, pervasive sense of emptiness and unstable interpersonal relationships, such that he has frequent self-damaging impulsive acts, such as driving recklessly under the influence, repeated parasuicidal gestures, and drinks to soothe his emotional distress?

--Unresolved anger toward his parents?

--Disregard for social norms?

--A brain tumor?

--Being an idiot?

Any one of the above "root causes" can manifest in a DUI arrest, yet each one has a very different pattern of presentation and natural history. In addition, the appropriate first-line treatment for each of these might be quite inappropriate, or even dangerous, for one of the others.

Psychiatric training is about recognizing, usually from the answers to those "basic impersonal questions", which of these root causes is most likely in an individual patient, and knowing which treatment is most important to initiate. Medications will be key for many of these, not so helpful in others. Mandating your minimum of ten 1 hour sessions before referring for meds is just as much malpractice as pulling out the prescription pad after 10 minutes, and neither option accurately reflects how psychiatric care is typically delivered in the real world.

(And FYI in the real world, your stressed-out investment banker isn't going to spend 10 hours chatting with you about his options. He's coming to you for something to help him sleep TONIGHT and feel better so he can get to work tomorrow. How do you propose to figure out whether he has a "serious chemical imbalance" or not?)

 

[blueadams]

What is this "root, inner issue" you keep referring to?

--A family history of alcoholism, coupled with his own out-of-control alcohol consumption?

--Voices telling him to drive fast to escape the aliens?

--Insomnia caused by flashbacks of sexual abuse by a baby sitter when he was five?

--Unbearable obsessions and anxiety which are only partially and temporarily relieved by alcohol?

--Dangerously high blood glucose levels?

--Untreated mania?

--A poor sense of self, pervasive sense of emptiness and unstable interpersonal relationships, such that he has frequent self-damaging impulsive acts, such as driving recklessly under the influence, repeated parasuicidal gestures, and drinks to soothe his emotional distress?

--Unresolved anger toward his parents?

--Disregard for social norms?

--A brain tumor?

--Being an idiot?

Any one of the above "root causes" can manifest in a DUI arrest, yet each one has a very different pattern of presentation and natural history. In addition, the appropriate first-line treatment for each of these might be quite inappropriate, or even dangerous, for one of the others.

Psychiatric training is about recognizing, usually from the answers to those "basic impersonal questions", which of these root causes is most likely in an individual patient, and knowing which treatment is most important to initiate. Medications will be key for many of these, not so helpful in others. Mandating your minimum of ten 1 hour sessions before referring for meds is just as much malpractice as pulling out the prescription pad after 10 minutes, and neither option accurately reflects how psychiatric care is typically delivered in the real world.

(And FYI in the real world, your stressed-out investment banker isn't going to spend 10 hours chatting with you about his options. He's coming to you for something to help him sleep TONIGHT and feel better so he can get to work tomorrow. How do you propose to figure out whether he has a "serious chemical imbalance" or not?)

#1) For the record, he wasn't really driving 'wrecklessly' (though, whenever you are drinking and driving, it is 'wreckless' to some extent). He turned right on red because he didn't notice a no turn right on red sign. He was barely over the legal limit. Still very stupid. But depending on your own personal definition of 'wreckless,' it may or may not have been.

...But, I am not sure which one of those problems he was having. His parents, like I said, are very wealthy, and very concerned, so they pushed him to see someone. He met with a psychiatrist for a very brief impersonal interview and was reccomended a prescription. He didn't feel at all comfortable taking it based on the advice of a doctor that hardly knew anything about him.

*EDIT* - it should be noted that this is precisely the reason so many people that need to see psychiatrists like yourself are so afraid to see psychiatrists like yourself. They hear so much about people being given the wrong medications by psychiatrists that don't take the time to figure out the right treatment option, and they are scared that the same thing will happen to them.

So, he instead saw a psychologist for several sessions, got to the root of something (I don't know what, he didn't tell me, I didn't ask), and felt much better. He was doing great before, now even better. If you are saying that longer, more personal, and more frequent psychotherapy sessions are going to result in worse care...then you are just flat out wrong. I am saying that a more extensive process should be the norm in the field of psychaitry before medications are given. Like you said, there are a lot of different treatment options, and the wrong ones can have terrible consequences. I don't care how great a psychiatrist you are...15-30 minutes isn't going to be enough time to really understand your patient well enough to prescribe him with a mental health medication. It's simply impossible. It happens so frequently because health insurance and pharmaceutical companies have interfered with the way treatments should be carried out.

...as for the investment banker, if he is really interested in feeling better, he should take the necessary time to get better. The only reason he feels as though a quick fix is a possibility (and it really isn't), is because psychiatrists (like you maybe) act as though it is...as though you can talk to a guy for 30 minutes, give him a pill, and all of his problems will be solved.

just my two cents.

 

[OldPsychDoc]

...
just my two cents.

I'd say give those $0.02 to your investment banker, and they might be worth something by the time you're qualified to tell us how psychiatry should be practiced.

 

[blueadams]

I'd say give those $0.02 to your investment banker, and they might be worth something by the time you're qualified to tell us how psychiatry should be practiced.

I've been clear about where I am as a student. If you want to be a dick and ignore all of the points I made...citing nothing but your education in relation to mine as proof...go ahead. No skin off my back. But your ignoral of the opinions of those 'regular non-MD people' (or as you probably consider them, *****s) from outside the profession, its not going to help you in the long-run.

 

[sideways]

#1) For the record, he wasn't really driving 'wrecklessly' (though, whenever you are drinking and driving, it is 'wreckless' to some extent). He turned right on red because he didn't notice a no turn right on red sign. He was barely over the legal limit. Still very stupid. But depending on your own personal definition of 'wreckless,' it may or may not have been.

...But, I am not sure which one of those problems he was having. His parents, like I said, are very wealthy, and very concerned, so they pushed him to see someone. He met with a psychiatrist for a very brief impersonal interview and was reccomended a prescription. He didn't feel at all comfortable taking it based on the advice of a doctor that hardly knew anything about him. So, he instead saw a psychologist for several sessions, got to the root of something (I don't know what, he didn't tell me, I didn't ask), and felt much better. He was doing great before, now even better. If you are saying that longer, more personal, and more frequent psychotherapy sessions are going to result in worse care...then you are just flat out wrong. I am saying that a more extensive process should be the norm in the field of psychaitry before medications are given. Like you said, there are a lot of different treatment options, and the wrong ones can have terrible consequences. I don't care how great a psychiatrist you are...15-30 minutes isn't going to be enough time to really understand your patient well enough to prescribe him with a mental health medication. It's simply impossible. It happens so frequently because health insurance and pharmaceutical companies have interfered with the way treatments should be carried out.

...as for the investment banker, if he is really interested in feeling better, he should take the necessary time to get better. The only reason he feels as though a quick fix is a possibility (and it really isn't), is because psychiatrists (like you maybe) act as though it is...as though you can talk to a guy for 30 minutes, give him a pill, and all of his problems will be solved.

just my two cents.

I've been clear about where I am as a student. If you want to be a dick and ignore all of the points I made...citing nothing but your education in relation to mine as proof...go ahead. No skin off my back. But your ignoral of the opinions of those 'regular non-MD people' (or as you probably consider them, *****s) from outside the profession, its not going to help you in the long-run.

dude, from an outsider's perspective, you're beginning to look foolish. talk about speaking out of your league.

your post reeks of a mind freshly marinaded in a semester of psych 101 at some local community college. maybe after class you smoked a joint and really got those insight juices flowing. but to think you, a PRE-HEALTH student, have any standing on debating the protocols of medicine and mental dysfunction with someone who's spent the better part of their adulthood immersed in the academic and medical mastery of this stuff doesn't speak well for your awareness of your own limitations.

 

[blueadams]

dude, from an outsider's perspective, you're beginning to look foolish. talk about speaking out of your league.

your post reeks of a mind freshly marinaded in a semester of psych 101 at some local community college. maybe after class you smoked a joint and really got those insight juices flowing. but to think you, a PRE-HEALTH student, have any standing on debating the protocols of medicine and mental dysfunction with someone who's spent the better part of their adulthood immersed in the academic and medical mastery of this stuff doesn't speak well for your awareness of your own limitations.

If for nothing else, my perspective as an outsider is valuable because it is just that...the perspective of an outsider...i.e. - your potential patients.

 

[sideways]

If for nothing else, my perspective as an outsider is valuable because it is just that...the perspective of an outsider...i.e. - your potential patients.

no, it's not. your perspective is based on the ignorance of things you have yet to learn. you plan on arguing with all your doctors about their treatment approaches? or just the specialties that you think you sound as if you have some knowledge on because you heard a couple buzzwords growing up (psychiatry)?

you're in over your head on this one. you're like bill maher arguing with maimonides over torah interpretation.

 

[blueadams]

If you think that the common perceptions of your field - from potential patients - are not valuable...

talk about ignorance.

that is all I have to say.

...I may be ignorant about the profession of psychiatry, but if you read through my posts in this thread, you will clearly see that I am not even pretending to know more about anything involving psychiatry than any of you. But at least I am here trying to learn.

...Your high and mighty approach as a doctor...as though the opinions of non-Doctors are completely worthless...IMHO, isn't going to make you the most approachable psychiatrist. I don't know what kind of 'people skills' they are teaching med school students nowadays, but maybe that's something that should be worked on. If you are not warm, accepting, and respectful to your clients...if hold the opinion that what they think is worthless because they did not go to medical school like you...they will not open up to you and tell you the truth about what is bothering them, and you will not be able to give them the best treatment.

 

[sideways]

If you think that the common perceptions of your field - from potential patients - are not valuable...

talk about ignorance.

i admire your perseverance.

 

[blueadams]

i admire your perseverance.

I admire the perserverance of anyone who can make it into the medical profession.

 

[pingouin]

I've been clear about where I am as a student. If you want to be a dick and ignore all of the points I made...citing nothing but your education in relation to mine as proof...go ahead. No skin off my back. But your ignoral of the opinions of those 'regular non-MD people' (or as you probably consider them, *****s) from outside the profession, its not going to help you in the long-run.

Actually, it's really NOT very clear to me where you are as a student.

See, last year, in this thread, you said in your first post that you were a history major as an undergraduate, had traveled extensively volunteering in medical clinics in developing nations, and were concerned that you just weren't sure what specialty to pursue during residency.. later in the thread, you noted that you were not yet a medical student. I have to admit, it sure did imply to me that you'd already graduated.

Not long after that, you asked essentially the same question- just in a different forum. This time we learned you were "no longer satisfied with being a high school teacher"- again, implying that you'd completed college. you also mentioned your freshman year grades- "a long, long time ago".

Then, a couple of months later, you confirmed that you were a history major and added that you weren't getting a minor in any subject. Oh yeah- and that you hadn't graduated yet. And needed to find a post-bacc program. At this point, you said you were planning on doing a few years' volunteer work in medical clinics in developing nations. Is that in addition to the few years you talked about above?

But then less than a month ago, you identified your major as psychology/pre-med, and who wanted to find a shorter route to attaining a career as a psychiatrist. Not to say that people haven't switched before, it's just rare to see that happen a semester before graduation and still see that person only be set back one semester.. By the way, now your age is 22, so I'm guessing those grades from "a long, long time ago" were 3-ish years ago?

but wait! I must be confused because earlier in this thread, you denied that you had a psychology major...

I have no idea why things aren't more clear to me...

 

[blueadams]

Actually, it's really NOT very clear to me where you are as a student.

See, last year, in this thread, you said in your first post that you were a history major as an undergraduate, had traveled extensively volunteering in medical clinics in developing nations, and were concerned that you just weren't sure what specialty to pursue during residency.. later in the thread, you noted that you were not yet a medical student. I have to admit, it sure did imply to me that you'd already graduated.

Not long after that, you asked essentially the same question- just in a different forum. This time we learned you were "no longer satisfied with being a high school teacher"- again, implying that you'd completed college. you also mentioned your freshman year grades- "a long, long time ago".

Then, a couple of months later, you confirmed that you were a history major and added that you weren't getting a minor in any subject. Oh yeah- and that you hadn't graduated yet. And needed to find a post-bacc program. At this point, you said you were planning on doing a few years' volunteer work in medical clinics in developing nations. Is that in addition to the few years you talked about above?

But then less than a month ago, you identified your major as psychology/pre-med, and who wanted to find a shorter route to attaining a career as a psychiatrist. Not to say that people haven't switched before, it's just rare to see that happen a semester before graduation and still see that person only be set back one semester.. By the way, now your age is 22, so I'm guessing those grades from "a long, long time ago" were 3-ish years ago?

but wait! I must be confused because earlier in this thread, you denied that you had a psychology major...

I have no idea why things aren't more clear to me...

let's see...

#1) I have switched my major several times. Started out as a pre-med student. Then switched to History. Then switched to Psychology. Then ended up going with a broad Liberal Arts major. I have not yet graduated. I have completed all of my courses. Still need to give a presentation of my senior thesis (on positive psychology), and pass my comprehensive exams for my major. I do not think that I have ever said that I was a graduate. But for a year or so, I have been saying that I was close to graduating.

#2) I have traveled to several different countries, and volunteered in health clinics in them (and also shadowed several doctors here in the states). This started in high school (when I believed I wanted to be a doctor), and continued on through to about my third year in college (when I switched from Pre-Med to History).

#3) I have also worked as a tutor/after school program counselor at several elementary and middle schools. This started late in high school, and still continues today (very rewarding work). That is why I switched to a History major. Then I later was not satisfied with being a teacher, and started looking to other career areas. That is when I switched my major to Psychology (fourth year of college).

#4) Once I started getting into psychology, I started thinking about becoming a psychiatrist, and thus, medical school...again. That is why I started to look at post-bacc programs. And yes, I am still interested in going abroad and getting some more volunteer experience should I chose that path.

#5) I attend a small-liberal arts school. I have taken a lot of courses in a lot of areas. So much so that I did not even need to commit to one of three potential majors until my last tri-mester (fifth and final year of college). Currently, I am focused on either psychology or psychiatry. If it ends up being psychology, I will probably get a masters in psych, and then a PhD. If it ends up being psychiatry, I will probably go through a post-bacc program, and then med-school. That is why I identified myself as a psychology/pre-med student, because those are the two options I am looking at now...I also did not think it was very important to specify, had I known my background would be researched extensively, I would have been more clear.

now that we have my background out of the way...for those with any interest...can we move back to the issues at hand.

or, alternatively, here comes the psychoanalysis! lol

 

[blueadams]

Maybe I should take a step back here, simply state what I am most interested in, and see what you all have to say...as opposed to getting into the specifics of what I want to be (psychologist, psychiatrist, teacher, etc.), and what I need to do to get there (masters, post-bacc, med school, phd's, etc.).

...More so than anything else in the universe (or beyond), I am interested in the study of happiness, or positive emotion. That is why I did my senior thesis in Positive Psychology (Seligman, Csíkszentmihályi, Fredrickson, etc.) and loved every second of it. Philosophically, I see nothing of greater importance in this life than achieving happiness for myself, and helping others to do the same. So, I want to learn everything there is to learn about happiness, and how to apply it to both my own life, and the lives of others (I'd prefer to do this on a face to face basis as often as possible...I'm more of a people person than a research-oriented professor). And when I say everything, I mean everything - social and biological (if there is a distinction between the two).

...So, maybe I should become a psychologist...maybe I should become a psychiatrist...maybe I should become a neurologist. I really don't know. Maybe I should pursue a combination of all three. I would like to make a good living as well, so the practical side of my brain tells me that if I am going to engage myself in eight or so more years of post-graduate education, at least part of that education should be an M.D.

Any advice/input would be very appreciated

 

[dl2dp2]

What this whole issue shows is a silly bias in the medical profession. If it's delivered through pill or needle, if we physically cut into you and rearrange things, then, it's biological. If it happens through a change in behavior, action, or thought, then it's not. It's that kind of thinking that leads to the loss of empowerment and the medicalization of everyday life.

And to conclude my nonsensical rant, one final thought experiment. If psychotherapy is not a biologic treatment, and it works, then is the illness not biological?

While I think all your points are valid, I think you missed my point. Just because therapy may be more effective in some instances doesn't mean that it should necessarily be part of MEDICINE and practiced by PHYSICIANS. Just as diet and exercise and smoking cessation is probably more effective in the long run than statins and HCTZ, it doesn't mean doctors should all become dietitians and personal trainers. Yes, doctors, esp. PCPs should have some training in diet and exercise, but how much that should be REQUIRED is really up for debate.

 

[OldPsychDoc]

Maybe I should take a step back here, simply state what I am most interested in, and see what you all have to say...as opposed to getting into the specifics of what I want to be (psychologist, psychiatrist, teacher, etc.), and what I need to do to get there (masters, post-bacc, med school, phd's, etc.).

...More so than anything else in the universe (or beyond), I am interested in the study of happiness, or positive emotion. That is why I did my senior thesis in Positive Psychology (Seligman, Csíkszentmihályi, Fredrickson, etc.) and loved every second of it. Philosophically, I see nothing of greater importance in this life than achieving happiness for myself, and helping others to do the same. So, I want to learn everything there is to learn about happiness, and how to apply it to both my own life, and the lives of others (I'd prefer to do this on a face to face basis as often as possible...I'm more of a people person than a research-oriented professor). And when I say everything, I mean everything - social and biological (if there is a distinction between the two).

...So, maybe I should become a psychologist...maybe I should become a psychiatrist...maybe I should become a neurologist. I really don't know. Maybe I should pursue a combination of all three. I would like to make a good living as well, so the practical side of my brain tells me that if I am going to engage myself in eight or so more years of post-graduate education, at least part of that education should be an M.D.

Any advice/input would be very appreciated

Psychiatry is not about "happiness". It is about diagnosing and treating mental illness. That is why my post listed a number of different "root causes" that would have to be taken into account ("ruled out" as we say in medicine) as contributing to your friend's situation.

You admit that you aren't familiar with the breadth of problems psychiatrists handle, nor the wide range of therapies used--yet you fairly confidently declare that your friend was incorrectly treated, and generalize from that case to contend that therapy should always be attempted first, before prescribing meds. You also declare essentially that to do otherwise is to simply be acting as passive tools of the pharmaceutical and insurance industries.

You obviously are at a stage of fascination with a certain school of psychology, which certainly has its place, but you, having handled this shiny new hammer, are swinging it aimlessly at all sorts of tasks for which a different tool is required. My advice and input to you is to put the hammer down and at least listen to people who are familiar with the entire tool box, and most importantly, have some hands-on experience in choosing the correct tool for the job, as well as some skill in wielding those tools.

 

[notdeadyet]

...More so than anything else in the universe (or beyond), I am interested in the study of happiness, or positive emotion.... So, I want to learn everything there is to learn about happiness, and how to apply it to both my own life, and the lives of others (I'd prefer to do this on a face to face basis as often as possible...

...So, maybe I should become a psychologist...maybe I should become a psychiatrist...maybe I should become a neurologist.

Tell a neurologist you're interested in his field since you're pursuing the study of happiness. Curious to see his reaction.

I recommend this book. It's an oldie, but classic for folks who are kicking around many ideas about what to do with their life.

 

[masterofmonkeys]

While I think all your points are valid, I think you missed my point. Just because therapy may be more effective in some instances doesn't mean that it should necessarily be part of MEDICINE and practiced by PHYSICIANS. Just as diet and exercise and smoking cessation is probably more effective in the long run than statins and HCTZ, it doesn't mean doctors should all become dietitians and personal trainers. Yes, doctors, esp. PCPs should have some training in diet and exercise, but how much that should be REQUIRED is really up for debate.

You could make the argument that it's up for debate. I personally think the study and understanding of the body in flux is crucial to understanding health. My belief actually parallels Seligman's move toward positive psychology in that regard. We as physicians are very good at understanding pathophysiology and not very good at understanding health. This leads to failure to intervene before disease becomes manifest, and failure to recognize and correct underlying unhealthy physiology much of the time.

As an example, I don't wait until someone starts complaining of back pain. I screen for poor posture, and if warranted, do a more complete musculoskeletal screening to identify the underlying muscle imbalances that will ultimately lead to disc disease and facet syndrome if not corrected. And will offer a simple routine to fix these imbalances. Unfortunately, there's not a lot of EBM in this area of preventive postural correction. And, equally unfortunately, there won't be until we as physicians recognize its importance.

As another example, after 20 years of research literature indicating interval training is superior to steady-state cardio in terms of fat loss, cardiovascular fitness, BMR regulation, and time efficiency, it is just now starting to percolate into medicine. This is pathetic.

But I'm veering off topic. I guess I'm uncomfortable with the idea that as a psychiatrist, I should only be competent at offering only one of the two treatment modalities we really do. The one that is arguably the more effective for a range of conditions, at that.

 

[Sneezing]

You obviously are at a stage of fascination with a certain school of psychology, which certainly has its place, but you, having handled this shiny new hammer, are swinging it aimlessly at all sorts of tasks for which a different tool is required. My advice and input to you is to put the hammer down and at least listen to people who are familiar with the entire tool box, and most importantly, have some hands-on experience in choosing the correct tool for the job, as well as some skill in wielding those tools.

Eloquent. Nice metaphor.

 

[Sneezing]

While I think all your points are valid, I think you missed my point. Just because therapy may be more effective in some instances doesn't mean that it should necessarily be part of MEDICINE and practiced by PHYSICIANS. Just as diet and exercise and smoking cessation is probably more effective in the long run than statins and HCTZ, it doesn't mean doctors should all become dietitians and personal trainers. Yes, doctors, esp. PCPs should have some training in diet and exercise, but how much that should be REQUIRED is really up for debate.

We definitely should learn these things. These are essential. Ideally, it should be our aspiration to shift from a core of well progressed disease diagnosis and management to focusing on earlier stages of disease.

Diabetes, obesity, and heart disease are greatly linked to diet and exercise. We should be able to fluently discuss how to eat and how to exercise to prevent diseases. What is the first treatment? Remember on tests it isn't medication... but lifestyle changes.

 

[Sneezing]

But I'm veering off topic. I guess I'm uncomfortable with the idea that as a psychiatrist, I should only be competent at offering only one of the two treatment modalities we really do. The one that is arguably the more effective for a range of conditions, at that.

Amen to that. If the tool works I want it in my workshop.