Psychiatry a good career?

[skpsycho]

Data on this long-term prognosis? And are you acknowledging the efficacy of meds then?
I guess my question is this-- can you show me the data that the long-term prognosis is better for someone receiving other psychiatric interventions without medications, compared to those that receive the medications?

There were, I think, four wide NIMH-sponsored studies in the seventies that specifically addressed this issue. I can give you the exact names when I get home next week. They all showed that medications help end a psychotic episode quicker, but in the long run the patients who never took meds tended to be much less prone to repeated hospitalizations; in fact, something like two-thirds of them were not hospitalized again after I think 3 years, while about two-thirds of the treated patients were back to the hospital within a year. Moreover, even a relatively short course of a drug was enough to produce the effect. These are very interesting studies. Nothing like this is being done today, for whatever reasons.

So yes, of course I acknowledge the efficacy of the medications. It would be stupid not to. But I maintain two important points: first, you pay a price for their help, and second, they don't even come close to addressing the cause, even the official one. The levels of neurotransmitters that the drugs act upon in a treated brain differ from the normal by an order of tens. Some speculate that the medications act as a terrible stressor for the brain, which in response puts forth its best effort to survive the attack. So yes, they work in many cases, but because we know so little about them, they must be used as a last resort, that's all. And choosing to use them when other options are available is no less than a moral choice that everyone must make for themselves.

Unfortunately you cannot force someone to change. You can only offer them the means to do it. If someone is absolutely determined to kill themselves, attempted and failed but still determined, then I can hospitalize them against their will for 17 days, even get a court-order forcing them to take meds while in the hospital, get counseling for their family, have family meetings, social work interventions, and all the psychotherapy offered to them, but if they don't choose to take advantage of those services and choose to kill themselves once they leave the hospital, then I cannot change that. And that happens.

I agree. Here is a side thought about suicide. Should we continue exchanging quotes? Camus said that the most important question in life is whether or not to commit suicide. Why is it that suddenly everyone thinking about suicide is 'clearly out of his mind'? I mean, this is an age-old question. One requires serious counseling in this situation, by people who really understand the issue deeply, and instead the question is pushed away, and tends to be simplified and ridiculed.

You see, essentially, my problem with biological psychiatry is this: when you try to explain every human soul movement by means of chemistry, you do nothing but engage in good old denial. Yes, in some cases the problem is really organic; if you have syphilis of the CNS, you might safely disregard the psychological side of the problem. But by persuading everyone that their misery is chemical you effectively turn a blind eye to the real causes of distress. In many cases a problem is not only purely psychological in nature, but can be helped or even cured by psychological means, even if the chemical changes are involved. Not allowing this to happen, and concentrating on altering the brain chemistry from without, is, I think, dishonest. Sorry, I got wandered away a bit.

I don't take things in isolation. <...>
Usually we're a little more detailed than that. If you continue to take an extremist oppositional approach to the use of medication, then you'll be dismissed the same way I dismiss biologic reductionists-- short-sighted and inflexible.

I didn't mean you did. I used 'you' in general sense. And I hope very much not to be dismissed; at least, we have a common enemy - reductionism.
I don't want to sound simplistic, really. Yes, I dislike medications, but I agree to use them in a last-resort scenario. And the medications, however hot the topic is, are only a part of the problem. But again, I don't want to judge anyone in particular or the nation as a whole. Perhaps I don't understand a lot of things about America. I am just trying to figure out whether I may be able to practise psychiatry here, or will I become depressed very soon I appreciate your help in verbalizing these complicated issues.

And Eschylus said "Exiles feed on hope." It's what keeps them going and trying new things despite overwhelming adversity. Hope does not imply passivity, but rather a motivation for actions in general. If I told you to be hopeful that driving down the street would make you meet your soulmate, that doesn't mean you're going to sit and not drive down the street.

Yes, but only if you are really talking about action. Because taking meds is not an action; it is passivity. It is allowing one's self to be acted upon. Other than that I of course agree with you. If you can use medications to help you motivate people to take some kind of real action, you have my blessing.

Now you make a good point that many pt.'s think meds are their only solution, and that starts to touch on a whole other aspect of western culture and psychiatry, and that none of us pretend meds will really help -- personality. Personality, from types to dysfunction, and our systemic inability to properly treat it or choose not to treat it, is a discussion for another day.

Yes *sigh*. And a discussion on why even your personality is not you, and what follows, is hardly possible on a forum like this at all...

------------
skpsycho (http://skpsycho.wordpress.com/)

---

Members don't see this ad.

 

[skpsycho]

Reading Socrates? I understand what you mean about the psychiatrist's attention to great thinkers... but while you can read Aristophanes and other satirists, Xenophon and Plato, and Aristotle, and even Kierkegaard and Peter Kreeft in order to understand Socrates ... you can't read Socrates .

Good point )) This makes my argument bulletproof They really don't read Socrates, do they?

-------------
skpsycho (http://skpsycho.wordpress.com/)

 

[Faebinder]

Skpsycho.

I think you have a valid point but you are too quick to accuse everyone/many of mishandling something when their hands are tied in many occasions. Perhaps you would change your mind once you are the captain of the ship... I hope you don't and honestly, the current push is towards this but the resistance comes from the law and patient's families. I hope you stand strong if you discharge a patient with no meds and he kills himself and his family comes after you. No there is no sarcasm in my writing.

 

[skpsycho]

Skpsycho.

I think you have a valid point but you are too quick to accuse everyone/many of mishandling something when their hands are tied in many occasions. Perhaps you would change your mind once you are the captain of the ship... I hope you don't and honestly, the current push is towards this but the resistance comes from the law and patient's families. I hope you stand strong if you discharge a patient with no meds and he kills himself and his family comes after you. No there is no sarcasm in my writing.

Thank you. I am really not accusing anybody, and I try not to make judgments. I am just describing what I see. We have to see things in their totality. If stars are lit than it must be needed by someone, said a famous Russian poet. If something happens, it happens for a reason, and the reason is society as a whole. I truly believe that the majority of the mental health professionals are good people whose hands are tied. If you think about it, it only makes matters worse, because it means that the forces that shape psychiatric practice are powerful, and I might very soon find my hands tied just as firmly. For example, in a scenario like the one you described.

-----------
skpsycho (http://skpsycho.wordpress.com/)

 

[TheWowEffect]

I disagree. Your hands are not tied. You can do pretty much what you want as a free individual but you must be ready to face the consequences.

If inappropriate care is what you want to render, so be it. Just go ahead and do it. Of course, it is another matter that you will have done tremendous damage to a patient and violated your hippocratic oath. I wish philosophy could treat our patients but the fact is that it does not.

So keep your thoughts on what various poets and thinkers say to yourself and focus on treating the patients the way modern medicine wants you to. Believe me, it is the right approach, no matter how many counter-arguements you can come up with.

 

[skpsycho]

I disagree. Your hands are not tied. You can do pretty much what you want as a free individual but you must be ready to face the consequences.

If inappropriate care is what you want to render, so be it. Just go ahead and do it. Of course, it is another matter that you will have done tremendous damage to a patient and violated your hippocratic oath. I wish philosophy could treat our patients but the fact is that it does not.

So keep your thoughts on what various poets and thinkers say to yourself and focus on treating the patients the way modern medicine wants you to. Believe me, it is the right approach, no matter how many arguements you can come up with it.

Wow. You know, this is... WOW! The hours spent in this thread have paid off. I now have this post of yours. I will have it printed out in large friendly letters and posted on the wall, to read whenever I get too optimistic about America, the Psychiatry and Everything.

I am now withdrawing from the discussion. Thank-you everyone (especially nitemagi - my pleasure talking to you).

------------
skpsycho (http://skpsycho.wordpress.com/)

 

[TheWowEffect]

I am glad that this one post has made a modern psychiatrist out of a Socrates disciple

 

[Anasazi23]

Thanks a LOT TWE. NOW look at what you did!

 

[TheWowEffect]

 

[OldPsychDoc]

Wow. You know, this is... WOW! The hours spent in this thread have paid off. I now have this post of yours. I will have it printed out in large friendly letters and posted on the wall, to read whenever I get too optimistic about America, the Psychiatry and Everything.

I am now withdrawing from the discussion. Thank-you everyone (especially nitemagi - my pleasure talking to you).

------------
skpsycho (http://skpsycho.wordpress.com/)

I hope you will post a follow-up after your intern year.

 

[Anasazi23]

I hope you will post a follow-up after your intern year.

Two words:

Eggs - actly.

 

[ApolloDok]

This is a great topic. I just wanted to thank everyone for participating. I know it's been heated at times (ie in many of the above excerpts), but I suppose sometimes it takes a hot fire to forge something rather sturdy There is good insight born from such conflicts!

 

[l0st1]

Well, I have been fervently reading about a career in psychiatry, pros & cons, academic and opinion pieces on the future of the field and my place in it, essentially doing a lot of soul-searching before committing to the pursuit of a residency in psychiatry. I have to say that this thread and specifically skpsycho's thoughts have put some major doubts in my mind. While some of the arguments against his were quite convincing, I found that his were not without merit. I've just read on his linked blog post that he has left his residency program and is no longer practicing

 

[Dharma]

Well, I have been fervently reading about a career in psychiatry, pros & cons, academic and opinion pieces on the future of the field and my place in it, essentially doing a lot of soul-searching before committing to the pursuit of a residency in psychiatry. I have to say that this thread and specifically skpsycho's thoughts have put some major doubts in my mind. While some of the arguments against his were quite convincing, I found that his were not without merit. I've just read on his linked blog post that he has left his residency program and is no longer practicing

I admittedly haven't read through the entire thread, but my advice is to come to conclusions yourself while on rotations, through your own experiences working with patients. If that 'something' is there, I doubt you will be swayed much by the negative perspective of others.

 

[Dharma]

I think your logic has difficult consequences. A great many of the scientific and medical discoveries happened without first understanding the mechanism, only afterwards were we able to then abstract from it and use the developed understanding to further science. An easy example is the cowpox/smallpox vaccine.

As for psychiatry and meds, efficacy vs. placebo, side effects vs. none, I think there's many points to be made.
1. Medicine is largely a field of maintenance and doing the best with the tools we have. How many specialties actually FIX a problem. I could argue almost none, without causing their own problems. Surgery seems like a quick fix except for those lifelong adhesions and abdominal pain. Antibiotics might seem like a fix but really we're just restoring a balance temporarily, often for individuals with recurrent infections. Psych is no different. It's a field of weighing risks and benefits, and when someone comes in suicidal and says help me in some way or I'm going to end my life, and you have tools that might help --- then saying let's wait to give something to keep this person from dying until we understand every intricacy of the brain is frankly LUDICROUS and unethical, especially when there IS data that medications can help.
2. Depression is at least the 4th highest cause of disability worldwide - https://content.nejm.org/cgi/content/extract/338/20/1475
Not attempting to use any and all means of helping individuals that are suffering is sad. And I'm not just talking about medications. I know of few psychiatrists who believe that giving medications will fix every problem in those with mental illness. There are many levels, including environmental, philosophical, and otherwise, all of which ideally we should aim to improve in some way.
3. Depression may have benefit for some people, but not all and not always. I'm very in favor of Frankl's logotherapy and recommend it often to patients, but that doesn't mean that they will have the energy, motivation, or insight to be able to utilize it properly at the time. It's a tool and a direction to maximize the state, but is not the only valid perspective on depression. It's like those arguments from the scientology community that all depressed people really need to do is just exercise. I love exercise, and I think it helps my mood for sure. But how many people in a full blown major depressive episode do you think you can motivate to exercise daily? Maybe with a multi-system approach of meds, environmental changes, psychotherapy, then they'll be functional to add in exercise, but unlikely to happen alone.
4. Antidepressants may be overprescribed or misprescribed, but I think it's inappropriate to blame psychiatrists for that. I believe it's a tool again, but that most psychiatrists use it appropriately. I think a large problem is that PCP's are often burdened trying to manage depression, much of which may not require antidepressants, and much of which is band-aiding of difficult social situations put on PCP's attempting to do whatever they can to help a patient.
5. 40% of ALL medications effects (psychiatric and otherwise) is placebo. Does that mean don't give the meds because they're only a little better than placebo? No. I'd give someone a jolt-cola enema if I believed it was a tool that would help improve their mental illness. As physicians we should be using all the tools at our disposal, including medications.

It's easy to critique psychiatry from the sidelines. And there's plenty to critique, throughout all of medicine. But work in it for a little while before you badmouth it. Either that or pick up a torch and work hard to make changes in the world, rather than just dismissing practices outright.

Since this thread has arisen from the depths, I thought this quote above was worth reeling to the surface as well for new eyes it may fall upon.

 

[Ibid]

How are we to understand your widely drawn and inflammatory generalizations as anything but criticism? Perhaps it is a cross-cultural misunderstanding on your part, but these do not come across as a call to open dialogue! Instead you make statements which are both false and unjust, and I would frankly dispute that they truly reflect the practice of psychiatry where you claim to work. If they truly reflect the practice where you intend to do residency, you will be very unhappy there also.

However, if you can adjust your preconceived notions about the practice of psychiatry in this country today, I believe you will find places (such as in my practice, I hope), where everyday behavior is normalized, mental issues begin to be explored, people are put on the appropriate medications for their symptoms with careful concern about side effects, the research is based on carefully gathered evidence (CATIE? STAR*D? STEP-BP? Have you heard of these? Can you honestly call this "for profit and laughable"?????) , and psychiatrists are well-rounded compassionate individuals. Your definition of "reality" is quite at odds to the real world in which we practice.

Just out of interest where do you feel the best place for people who have alternate points of view best congregate.....ie both sides of the conversation....

In my experience i've found over time I have been able to have some very constructive conversations with people on this forum... not always though.... I take my share of the blame for that....

In the bricks and mortar world ive found that you can sometimes have a good discussion but its always riddled with the same difficulties that plaque conversations on here... generally the conversation leads to or starts out with misunderstanding and lots of talking at cross purposes.....

There is a view that if you don't like psychiatry or you have been harmed by it..... then the answer is to just walk away, reject diagnosis, taper off medication, find work or what ever, mostly find work and that is the route to salvation.

For some people that works but for some people who have difficulty with the practice of psychiatry walking away is not a realistic option.