What do you guys hate about psychiatry?

[Achillees]

it is true that institutional racism pervades all institutions but there is alot more racial tension in psychiatry. African Americans who are mentally ill are more likely to be incarcerated, less likely to seek care, more likely to have a pathway of care involving emergency services, the police, and the criminal justice system, have psychopathology influenced by racial injustices and social inequalities, and more likely to experience coercive practices including so-called "assisted outpatient treatment" (outpatient commitment). African Americans with psychosis/schizophrenia are more likely to be perceived as violent and dangerous as their white counterparts despite, if anything, the white schizophrenics being more violence-prone (that is a big if though). The APA has never had an African American President (the AMA and the other APA on the hand both had their first black President 20 years ago or so). There is alot of racial tension within the APA and the Black Psychiatrists Caucus has taken the administration to task for failing to speak out on wider issues affecting African Americans they feel are relevant to mental health.

This btw, makes it even more important, imho that more African American medical students go into psychiatry. Unfortunately, medical students from minority backgrounds seem to be less likely to go into psychiatry for various reasons.

Speaking as an African American medical student, I am no stranger to stigma. I have battled the so called, "imposter syndrome" 3/4 years of med school. The stigma that Psychiatry carries only serves to reinforce this (both intrinsic and extrinsic) feeling. I imagine my peers either genuinely lack affinity for Psychiatry and/or they feel they must prove themselves by chasing more "prestigious" specialties.

This dichotomy in healthcare towards African Americans/minorities isn't unique to Psychiatry. I've witnessed this in other rotations.

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[whopper]

Seeing someone that definitely doesn't have bipolar disorder, schizoaffective disorder, psychosis, or what have you.

Then wondering why the previous psychiatrist diagnosed them with that disorder.

Then asking the psychiatrist why they put the disorder down that you don't think is valid.

And then that psychiatrist even admits it's not valid but that they were under pressure or gives some other completely BS response such as "well you know."

So then I ask them, "What benefit are you trying to achieve by diagnosing this kid that really has (insert here-narcissism, antisocial PD, borderline PD) with a medication that could cause serious side effects (insert here-typical antipsychotic, atypical antipsychotic, mood stabilizer) and a diagnosis that you don't even believe in?

Then they tell me, "well you know," while smiling.

Oh geez how many times have I seen this happen! Makes me want to poke those doctor's eyes out.

 

[whopper]

Psychiatrist's who seem to be attempting some sort of Guinness world record for 'fastest diagnosis of a mental illness'. Mood instability? Bingo, it's Bipolar Disorder! - Hearing Voices? Schizophrenia, come on down!

Patient could afford to lose 5 lbs. Everyone on his dad's side of the family over age 50 has diabetes, so he's taking extra efforts to eat healthy and exercise. He must have hypochondriasis. He needs an SSRI with Abilify added even though it's for depression augmentation, not for hypochondriasis.

Patient had a one time hypnopompic hallucination of his father talking to him, so he must have schizophrenia and need an antipsychotic.

Patient loves his kids but sometimes they drive him nuts. He must need some lithium.

12 year old kid yells back at parents, likes to stay up at night, and would rather be watching a horror flick instead of being in class. He must need an antipsychotic, mood stabilizer, SSRI and a stimulant altogether!

I sometimes wish I had a license that let me go to other psychiatrists that diagnose and treat like this and slap them around and then poke their eyes like Moe from the Three Stooges.

 

[OldPsychDoc]

Patient could afford to lose 5 lbs. Everyone on his dad's side of the family over age 50 has diabetes, so he's taking extra efforts to eat healthy and exercise. He must have hypochondriasis. He needs an SSRI with Abilify added even though it's for depression augmentation, not for hypochondriasis.

Patient had a one time hypnopompic hallucination of his father talking to him, so he must have schizophrenia and need an antipsychotic.

Patient loves his kids but sometimes they drive him nuts. He must need some lithium.

12 year old kid yells back at parents, likes to stay up at night, and would rather be watching a horror flick instead of being in class. He must need an antipsychotic, mood stabilizer, SSRI and a stimulant altogether!

I sometimes wish I had a license that let me go to other psychiatrists that diagnose and treat like this and slap them around and then poke their eyes like Moe from the Three Stooges.

16 year old girl stays out all night and <gasp!> has SEX. With a boy! Start lithium!

 

[smalltownpsych]

The last couple of posts reflect what we all see too much and makes me think that what I hate is the lack of research on the negative findings and also effects of prescribing on non-clinical population. I have felt for years that prescribing a med for kids in bad situations just exacerbates their feelings of impotence and learned helplessness. For a percentage of my patients, healthy change starts when they stop looking for a solution from medications. They are always afraid, leery, embarrassed to tell their doctor or NP though and probably most often "I don't want to hurt their feelings because they are really trying to help me."

 

[F0nzie]

16 year old girl stays out all night and <gasp!> has SEX. With a boy! Start lithium!

Adjunct with Naltrexone to cut the cravings

 

[WingedOx]

16 year old girl stays out all night and <gasp!> has SEX. With a boy! Start lithium!

How about some QID xanax to help you with the anxiety of starting a heroin treatment program?

/saw this one from a BC addiction psychiatrist last year.

 

[doctorpilgrim]

The pressure to get a diagnosis and the medication for that diagnosis has increased gradually and has led to current situation. The diagnostic criteria are fulfilled easily. So it is not entirely the community psychiatrists who are misdiagnosing/over diagnosing and the over treating patients. The cultural expectations and the system based on medicalization of psychiatry has some responsibility for that. It is hard to resist the pressure to diagnose in 15 minute followup or 45 minute intake and separate the psycho-social issues and behavioral problems. I am not saying that misdiagnosing patients is ok. Often it takes multiple visits to convince a patient that there is no pill for their problem and that they need therapy and behavioral change.

 

[OldPsychDoc]

How about some QID xanax to help you with the anxiety of starting a heroin treatment program?

/saw this one from a BC addiction psychiatrist last year.

 

[OldPsychDoc]

Adjunct with Naltrexone to cut the cravings

Risperdal typically works better for those urges.

 

[Doctor Bagel]

So is the prescribing pressure coming just from us, or do you see it a lot from other non-prescribing mental health professionals? I feel like I do. I get referrals for someone with "anxiety and depression" with a ton of other psychosocial and addiction factors going on with a feeling of an expectation that I'm supposed to come up with some psychiatric treatment (separate from a psychosocial type of treatment, btw, because again the referral is from this person's psychologist or social worker) that will alleviate their symptoms. I'm often left with the feeling that I'm doing it wrong if I don't prescribe or if I even take away medications. Of course maybe they believe we have this magic because we've been trying to sell them on this all along.

 

[l0st1]

The previous few posts really hit hard for me. They are at the core of what has been holding me back from applying to psychiatry and I don't think it's any small issue. It's not at all a minor problem with current practice in the field like some of the other points raised, this seems to be more of an epidemic and has caused a backlash that is now prevalent among patients and even other medical fields who often refer to practitioners as merely "pill-pushers", a term that I as a prospective applicant take offense to.

How does one reconcile these pressures to prescribe, the easily met diagnostic criteria and the overmedicalization of patients with an honest and fulfilling career in medicine? Is the only solution to go against the grain and practice good psychiatry by spending more time with each patient, or by trying to convince patients/parents that they don't need medication, and consequently be the lowest paid psychiatrist in the area? Or do you just have to close an eye, enjoy the great hours while swallowing the bitter pill that is current trend in the practice psychiatry?

How do you do it? What do you tell a medical student that has become disillusioned with the field?

Looking back at splik's list of 30, it almost seems as if most can be linked back to this very nature of psychiatric practice as the core problem.

 

[st2205]

I'd like to add more to this thread later. For the past few posts, this is indeed a reality. It's also a reality in the rest of medicine, they're just not insightful enough to recognize it. Regardless of what specialty you go into, you'll be seeing the same patients. Instead of treating the personality disorders with mood stabilizers, benzos and antipsychotics, you'll be treating them with norco, flexeril, Zofran, neurontin, Metformin, Simvastatin, benzos, tramadol, Omeprazole, Ambien, Zyrtec, et. al. You'll have a different, more medicalized diagnosis for axis II pathology and you'll continue to throw meds at every symptom. You will face this in most fields. Except pathology and radiology.

 

[slappy]

1. this ridiculous quest people have to make psychiatry sound more 'scientific' and technical than it is or ever should be
- "or ever should be"? Really?

3. the generally poor standard of alot of mental health care in the community
- You must refer to "health care."

8. people using the term "med management" - makes them sound like pharmacists
- Many fields use that term.

9. the artificial divide between psychiatry and medicine
- This is now internally inconsistent. You want psychiatry and the rest of medicine to be considered together but you don't want psychiatry to pursue "scientific" and "technical" inquiry like the rest of medicine does?

13. disparaging of evidence-based practice
14. the overselling of evidence-based practice
- Hmm.

10. the challenges of providing basic medical care to patients as a psychiatrist
- Unlike, say, orthopedics who fluently manage hypertension and diabetes in their clinics all the time.

15. the obsession in some quarters for measurement-based practice with silly things like the PHQ-9
- I've long said this: HAM-D is to depression what serum sodium levels are to hyponatremia. Comparably valid.

19. the promotion of the myth that mental illnesses are "brain disorders" - which has been shown to increase the stigma of mental illness
- Those studies were poorly designed. And even if the findings were valid, they are likely short-term effects. Do you honestly believe people would be more embarrassed to admit their son has encephalitis than schizophrenia?

21. the obsession with "objectivity" and finding biomarkers
- Yes, identifying VGKC-Ab, NMDAr-Ab, Anti-GAD Ab, etc were all such a waste.

I've run out of time. I'll respond to the others at a later date.

 

[hamstergang]

Is the only solution to go against the grain and practice good psychiatry by spending more time with each patient, or by trying to convince patients/parents that they don't need medication, and consequently be the lowest paid psychiatrist in the area?

I don't see how being paid less is a consequence of being a good psychiatrist.

 

[heyjack70]

is it considered indirect eugenics to crank the dose of prozac to the point the libido is non-existent, then add risperdal to boost the pro

I don't see how being paid less is a consequence of being a good psychiatrist.

I think spending more time per patient leads to lower pay.

 

[WingedOx]

The previous few posts really hit hard for me. They are at the core of what has been holding me back from applying to psychiatry and I don't think it's any small issue. It's not at all a minor problem with current practice in the field like some of the other points raised, this seems to be more of an epidemic and has caused a backlash that is now prevalent among patients and even other medical fields who often refer to practitioners as merely "pill-pushers", a term that I as a prospective applicant take offense to.

How does one reconcile these pressures to prescribe, the easily met diagnostic criteria and the overmedicalization of patients with an honest and fulfilling career in medicine? Is the only solution to go against the grain and practice good psychiatry by spending more time with each patient, or by trying to convince patients/parents that they don't need medication, and consequently be the lowest paid psychiatrist in the area? Or do you just have to close an eye, enjoy the great hours while swallowing the bitter pill that is current trend in the practice psychiatry?

How do you do it? What do you tell a medical student that has become disillusioned with the field?

Looking back at splik's list of 30, it almost seems as if most can be linked back to this very nature of psychiatric practice as the core problem.

Take some perspective here...

Assuming everyone else is like me, you're seeing the complaints of people who love/like what they do and chose this field for a reason. Every specialty has its own breed of bullsh-t. Ours is just its own unique breed. And some of us just like to complain.

 

[WingedOx]

I'd like to add more to this thread later. For the past few posts, this is indeed a reality. It's also a reality in the rest of medicine, they're just not insightful enough to recognize it. Regardless of what specialty you go into, you'll be seeing the same patients. Instead of treating the personality disorders with mood stabilizers, benzos and antipsychotics, you'll be treating them with norco, flexeril, Zofran, neurontin, Metformin, Simvastatin, benzos, tramadol, Omeprazole, Ambien, Zyrtec, et. al. You'll have a different, more medicalized diagnosis for axis II pathology and you'll continue to throw meds at every symptom. You will face this in most fields. Except pathology and radiology.

It would really help if our field didn't produce steaming piles of flaming hot garbage like this, but agreed that we aren't unique in dealing with that. I'm not sure how people in a Rheum clinic get through the day without their eyes permanently rolling back into their heads.

 

[Ceke2002]

How about some QID xanax to help you with the anxiety of starting a heroin treatment program?

/saw this one from a BC addiction psychiatrist last year.

I'll go you one better

How about we increase this patient's already high dosage of Xanax to a maximum dose of 16 mgs a day, because with the patient starting on a Methadone taper program it's far more preferable that she just pill herself out on a daily basis thereby reducing her risk of scoring heroin.

I was the patient. I am no longer on Heroin, Methadone, or Xanax, and the hardest of all those drugs to come off was Xanax (the use of which was supposed to be far preferable to the risk that I might slip and use Heroin whilst on the Methadone program - kinda like putting out a fire with gasoline )

edited to add: I should just clarify this was a GP (FMD in the US) with Methadone prescribing privileges, and not a Psychiatrist.

 

[Ceke2002]

is it considered indirect eugenics to crank the dose of prozac to the point the libido is non-existent, then add risperdal to boost the pro

I don't know about indirect eugenics, but one of my mates managed to end up on seven different antidepressants at one point, all prescribed by the same the Psychiatrist. To this day I have no idea what his Psychiatrist was actually thinking, and why you wouldn't stop one AD before throwing another (and another, and another) on top of it. I mean I get augmenting one AD with another AD, but 7 ADs at once?


Now granted my mate does have a severe form of depression, the type of which will more than likely lead him to slip into a state of near catatonia without some form of medication to control his symptoms, but I still don't see how the severity of his depression would warrant 7 different ADs. As for killing off libido, well a combined total of seven Antidepressants will certainly do that, seeing as my mate once described an attempt to masturbate (he had no actual sex drive left, he just wanted to see if the antidepressants had left him anorgasmic as well) in terms of practically chaffing the skin of his penis before he finally realised it wasn't going to be happening and gave up. Thankfully since then, at the concern and behest of his friends and family, he did find another Psychiatrist to treat him. His new Psychiatrist promptly withdrew him from all medications bar one, encouraged him into rehab for alcohol addiction, which didn't work out but at least he's managed to significantly reduce the amount he drinks, and overall he's now doing a heck of a lot better than I've seen him do in the past.

 

[smalltownpsych]

So is the prescribing pressure coming just from us, or do you see it a lot from other non-prescribing mental health professionals? I feel like I do. I get referrals for someone with "anxiety and depression" with a ton of other psychosocial and addiction factors going on with a feeling of an expectation that I'm supposed to come up with some psychiatric treatment (separate from a psychosocial type of treatment, btw, because again the referral is from this person's psychologist or social worker) that will alleviate their symptoms. I'm often left with the feeling that I'm doing it wrong if I don't prescribe or if I even take away medications. Of course maybe they believe we have this magic because we've been trying to sell them on this all along.

If I am making the referral, I would greatly appreciate your reducing the medications for my patient. The truth is that I don't make very many referrals for medication for my outpatient practice patients who are not already on medication. Some psychologists do it almost routinely. I think it tends to be more for CYA reasons than I believe pills will fix this. There are, of course, the therapists who have never seen serious mental illness and tend to over-react when a patient is in the moderate to severe range of any of the categories of mental illness. It is really ludicrous when they are referring their NSSI Borderline patient for medication in the false hope that they would stop cutting because "I told them all the reasons they should not cut and even told them they could do this instead and they still did it" is the extent of their treatment plan. Fortunately, in my town, I get most of these patients sent to me since we don't have a psychiatrist. Before I came to this town, there were probably no psychotherapists who had competency in treating Borderline PD so what does a psychiatrist do in that case? Makes it tough. I have about the same experience with OCD. I have nowhere near the level of competence necessary to treat this disorder effectively and I don't think anyone in the community really does either. I know ERP principles, but since it is not a big area of interest, I have not developed the skills sufficient to treat this. I supervised a post-doc who was good at OCD treatment and lo and behold, her patients with OCD improved rapidly. Sort of like my patients with Borderline PD. They can go to therapists and psychiatrists for years with no improvement and actually tend to get worse, then I start seeing them and "voila" rapid improvement. I think that in an attempt to reduce what we do to meds and techniques, we are missing the boat on the actual science of treatment which is quite a few orders of magnitude more complex than most people in or out of the field realize.

 

[Ceke2002]

It is really ludicrous when they are referring their NSSI Borderline patient for medication in the false hope that they would stop cutting because "I told them all the reasons they should not cut and even told them they could do this instead and they still did it" is the extent of their treatment plan.

That's the thing with cutting that I think a lot of therapists neglect to understand or take into consideration, and that is the fact that despite being an obviously unhealthy coping mechanism it does actually work. You're not going to get a cutter to stop cutting just by telling them why they shouldn't be doing it (trust us, we already know, we're not that stupid ) and listing off a bunch of things we could be doing instead, unless said list of things contains something that is actually going to work anywhere near the extent that cutting does. Just from personal experience so far I've found the only alternative to cutting, that was actually a comparable alternative, is mindfulness based meditation techniques.

edited to add: By the way, if you want to ask me any questions on self harm that you couldn't otherwise ask your patients, please feel free (bearing in mind of course that I can only answer from my own experience).

 

[Shikima]

Risperdal typically works better for those urges.

Titrate until milk expression?

 

[whopper]

Responding to the posts where we talked about inappropriate medication over BS reasons...

Consider diagnosing with adjustment disorder, or a personality disorder (or at least traits of it) and simply refer them to psychotherapy if you don't do the psychotherapy yourself.

I kid you not, I had a nurse about 2 years ago brought to the hospital because he caught his wife in bed with a guy having sex and he punched the wall. The wife called 9-1-1 and kept freaking out that the husband needed to be in the hospital. There was nothing wrong with the guy other than the stress of catching his wife in bed with another man. I discharged him the next day. The only reason why I kept him for one night was because the wife kept freaking out about the case leading me to suspect maybe something was going on worthy of admission.

Adjustment Disorder.

Wife: "Since he punched the wall he's a psycho so he's psychotic right?
Me: No, most men if in his situation would be very angry and I don't see punching a wall as something outside a cultural norm.

 

[VMSmith]

The pressure to get a diagnosis and the medication for that diagnosis has increased gradually and has led to current situation.

What do you all use as a diagnosis when you see someone for an eval for 60 minutes and find them not to meet criteria for any mental disorder? Let's say they've undergone a stressor, are actually coping admirably with it, but have an open mind about mental health treatment and just wanted to make sure they took care of something early in case it needed to be taken care of.

Let's assume you do want to get paid by the insurance company for the 60 minutes you spent with them. I find using adjustment disorder to be kind of a cop-out if someone is actually adjusting well, but don't really see what alternatives there are. I've never tried it myself but have been told by others that if they put "No diagnosis" the insurance company refuses to pay them.

 

[touchpause13]

How about some QID xanax to help you with the anxiety of starting a heroin treatment program?

/saw this one from a BC addiction psychiatrist last year.

Are you ****ing kidding me

 

[WingedOx]

21. the obsession with "objectivity" and finding biomarkers
- Yes, identifying VGKC-Ab, NMDAr-Ab, Anti-GAD Ab, etc were all such a waste.

umm, I don't think you ans Splik are talking about the same thing here.

 

[Salpingo]

8. people using the term "med management" - makes them sound like pharmacists

Its better than psychopharmacologist...

27. outpatient commitment/"assisted outpatient treatment"

Okay, I'll bite. I've only heard good things, particularly in North Carolina and New York, specifically with reduction in hospitalization, violence and imprisonment. I agree its only as good as the outpatient services provided, but I'm curious about the argument against it.

Otherwise, agree with most of whats been said. I've been pleased so far that psychiatry is fairly balanced, and for the most part have worked with people who don't blindly put all their eggs in the biological or psychodynamic basket. I think psychiatrists and psychologists are so desperate for a concrete foundation to base their practice on, there's a tendency to get swept away and over-subscribe. Just because some result was published in a journal or was studied in an RCT or creates spot on a PET scan doesn't make it "evidence-based" or substantiated.

 

[Salpingo]

But in reply to splik, I just wanted to say that I have been under the impression that the reason NIMH has chosen to focus on the biological model and the recent trends in that direction are due to the previous slow pace of progress in finding treatments using the alternative models. To practice hour long psychotherapy over multiple sessions, or attempt to fix social/environmental factors to treat schizophrenia for example, is so daunting and impractical that without advances in biological treatments, new genetic treatments, and I hesitate to say, more advanced forms of pharmacotherapy, how can we ever hope to find treatments or even cures to some of the severe mental illnesses that we currently have no answer for?

I think its been the opposite. I might be wrong, but the most substantial NIMH-based initiatives the past several years has been RAISE, focusing on early assessment and intervention in psychosis, and creating a support network for patients with schizophrenia in Maryland & New York, and has shown more tangible and actionable results than anything else I've seen. That being said, it receives probably <10% of the total budget.

While the connectome project sounds great and sexy, we've already been down that road. We were told >15 years ago that sequencing the genome would revolutionize science and medicine, cure cancer, end poverty and settle upset stomachs. And while it has definitely advanced science (with the secondary benefit of forcing egotistical academic isolationists to work together in order to avoid being embarrassed by private industry), it really hasn't delivered MEANINGFUL change.

 

[heyjack70]

What do you all use as a diagnosis when you see someone for an eval for 60 minutes and find them not to meet criteria for any mental disorder? Let's say they've undergone a stressor, are actually coping admirably with it, but have an open mind about mental health treatment and just wanted to make sure they took care of something early in case it needed to be taken care of.

Let's assume you do want to get paid by the insurance company for the 60 minutes you spent with them. I find using adjustment disorder to be kind of a cop-out if someone is actually adjusting well, but don't really see what alternatives there are. I've never tried it myself but have been told by others that if they put "No diagnosis" the insurance company refuses to pay them.

Unspecified depresssive disorder is even more vague than adjustment disorder. I would use that.

 

[splik]

Okay, I'll bite. I've only heard good things, particularly in North Carolina and New York, specifically with reduction in hospitalization, violence and imprisonment. I agree its only as good as the outpatient services provided, but I'm curious about the argument against it.

So this is the thing, the US studies show the findings you mention specifically because of the high intensity services provided. The Australian and UK studies (the OCTET trial in particular) where the services are no better than they would be without coercion (but they actually have community psychiatry in those countries unlike the paltry excuse for such thing in the US) have not found any benefit. It has not been adequately studied in the US whether providing that level of services without coercion would have the same effect but there is compelling reason to think so. Also AOT doesn't allow outpatient forced medication as par course. I am not saying forced medication/drugging is a good thing but it essentially makes the coervice part a little toothless and typically means putting the patient back in the hospital. The argument has been made by people like Tom Burns at Oxford that the coercion doesn't work - what has made the difference is the actual clinical services provided.

Outpatient commitment is degrading, disproportionately targets African Americans, may scare people way from treatment, has not been shown to be effective on outcomes definitively compared to providing high quality intensive services, and does not do what it was designed to do and which psychiatrists should have no part in (which is effectively reduce random acts of violence that are ultimately unpredictable). AOT actually does NOT appear to have a significant effect on the violence risk. But it may reduce victimization.

I also agree with people like Paul Appelbaum who have argued that we shouldn't use the term "assisted outpatient" as it sounds Orwellian and essentially obfuscates what it is: outpatient commitment. It is a jonathan stanley term based on the premise that the individuals targeted have "anosagnosia" and that if they had insight they would make the choice to engage in treatment, and so the program simply "assists" them with decisions they would have made otherwise. This is extremely pernicious. There are lots of very good reasons why people may make a perfectly rational decision to not take neuroleptics.

see Alternatives to Outpatient Commitment for a nice overview

 

[Shikima]

What do you all use as a diagnosis when you see someone for an eval for 60 minutes and find them not to meet criteria for any mental disorder? Let's say they've undergone a stressor, are actually coping admirably with it, but have an open mind about mental health treatment and just wanted to make sure they took care of something early in case it needed to be taken care of.

Let's assume you do want to get paid by the insurance company for the 60 minutes you spent with them. I find using adjustment disorder to be kind of a cop-out if someone is actually adjusting well, but don't really see what alternatives there are. I've never tried it myself but have been told by others that if they put "No diagnosis" the insurance company refuses to pay them.

v71.09 - try it once and follow-up on the billing for it. I was told ICD NOS wasn't a good billable code but it is.

Update: I did inquire about this code, and it's NFG. Best to use 309.00 for Adjustment d/o NOS.

 

[Salpingo]

Outpatient commitment is degrading, disproportionately targets African Americans, may scare people way from treatment, has not been shown to be effective on outcomes definitively compared to providing high quality intensive services, and does not do what it was designed to do and which psychiatrists should have no part in (which is effectively reduce random acts of violence that are ultimately unpredictable). AOT actually does NOT appear to have a significant effect on the violence risk. But it may reduce victimization.

Thanks for the article. I've seen conflicting outcome reports. For example, one NYC study did show a reduction in violent acts when comparing AOT patients to a control group of recently hospitalized patients going to similar clinics and receiving near similar services (although to your point, AOT patients were more likely to received assisted living/housing and vocational training). The authors do point out that the violent acts are thankfully rare, so to interpret with caution, but given the selection bias towards the AOT patients (presumably, likely to be more violent), I see that as encouraging. Also, interestingly, they report less sense of stigmatization and better satisfaction with care. Whats also interesting is the degree to which AOT patient's continue with treatment after the mandate lapses.

Like you mentioned, AOT has little teeth in terms of forcing medications on people; all you can do is make it easier to get the person hospitalized. In that sense, the coercion is mostly on the outpatient team to follow-up with the patient. It forces the mental health system to take these patients seriously (which is unfortunate, since you would hope you wouldn't need a judge mandate to do so, but that's the reality we live in). And yes, it is a totally euphemistic and patronizing term, but as far as I can tell most people don't even know what it stands for (thank goodness to TLAs).

To get back to the original point of the thread, its actually something that gives me more hope and faith in the future of psychiatric services.

 

[whopper]

? Let's say they've undergone a stressor, are actually coping admirably with it, but have an open mind about mental health treatment and just wanted to make sure they took care of something early in case it needed to be taken care of.

Adjustment Disorder. A medication could help in some of these cases. E.g. the person is showing some signs of depression because they just got fired from the job. I could offer, say an SSRI, but if it's just adjustment disorder I tell them that the science doesn't strongly push for a medication in this case, and they could tackle the problem by doing several other things such as diet, exercise, looking for a new job, talking about the problem with friends or a professional.

Cases like this I usually refer to someone else because there is a shortage of psychiatrist in most (but not all) places. There is not a shortage of psychotherapists in most places, so in terms of a community model, IMHO, I need to free myself up for the people that have more severe problems.

In all places I've worked, even private practice, there were other mental health providers there that could handle the issue. The patient responses I've seen have been generally positive with these issues. E.g. many of them would say something to the effect of -oh geez I'm not that bad? That makes me feel better." The fact that the other provider was in-house didn't make them feel abandoned. I also told them if they ever wanted to come back to me they could do so.

A little self-disclosure, I just saw a marriage counselor for the first time yesterday. The person's not a psychiatrist (she has an Ed.D in counseling) and IMHO almost every psychiatrist I know wouldn't be able to handle marriage counseling well. My marriage isn't on the rocks. Wife and I love each other a lot but a combination of stress from raising a 2 and 4 year old mixed with a recent move mixed with both of us having new jobs I think put stress on the marriage so we're seeing the counselor to help us out.

This is the exact type of thing where talking it out, using a counselor, and sorting through it would be a very good thing, and it's not something medication or a physiological model of mental illness is going to play a part.

Psychotherapy just doesn't have to be used to treat illness. It could also be used to just make you better. I know people who are doing fine that have a psychotherapist because by having one they prevent themselves from getting worse or it helps them to be better than what they would've been without it.

IMHO the above is not where psychiatry should go from a community model because most communities need us for the more hard-core stuff, and I also opine that training programs don't emphasize enough that a lot of problems people have don't need medications. Schizophrenia, bipolar disorder, etc, of course they need medication but adjustment disorder, mild depression or anxiety, cluster B issues, no they don't need meds. Meds may offer some benefit but they are not needed and in some cases might make things worse.

 

[heyjack70]

Adjustment Disorder. A medication could help in some of these cases. E.g. the person is showing some signs of depression because they just got fired from the job. I could offer, say an SSRI, but if it's just adjustment disorder I tell them that the science doesn't strongly push for a medication in this case, and they could tackle the problem by doing several other things such as diet, exercise, looking for a new job, talking about the problem with friends or a professional.

Cases like this I usually refer to someone else because there is a shortage of psychiatrist in most (but not all) places. There is not a shortage of psychotherapists in most places, so in terms of a community model, IMHO, I need to free myself up for the people that have more severe problems.

In all places I've worked, even private practice, there were other mental health providers there that could handle the issue. The patient responses I've seen have been generally positive with these issues. E.g. many of them would say something to the effect of -oh geez I'm not that bad? That makes me feel better." The fact that the other provider was in-house didn't make them feel abandoned. I also told them if they ever wanted to come back to me they could do so.

A little self-disclosure, I just saw a marriage counselor for the first time yesterday. The person's not a psychiatrist (she has an Ed.D in counseling) and IMHO almost every psychiatrist I know wouldn't be able to handle marriage counseling well. My marriage isn't on the rocks. Wife and I love each other a lot but a combination of stress from raising a 2 and 4 year old mixed with a recent move mixed with both of us having new jobs I think put stress on the marriage so we're seeing the counselor to help us out.

This is the exact type of thing where talking it out, using a counselor, and sorting through it would be a very good thing, and it's not something medication or a physiological model of mental illness is going to play a part.

Psychotherapy just doesn't have to be used to treat illness. It could also be used to just make you better. I know people who are doing fine that have a psychotherapist because by having one they prevent themselves from getting worse or it helps them to be better than what they would've been without it.

IMHO the above is not where psychiatry should go from a community model because most communities need us for the more hard-core stuff, and I also opine that training programs don't emphasize enough that a lot of problems people have don't need medications. Schizophrenia, bipolar disorder, etc, of course they need medication but adjustment disorder, mild depression or anxiety, cluster B issues, no they don't need meds. Meds may offer some benefit but they are not needed and in some cases might make things worse.

A little self disclosure? Are you sure you want to post that on the internet as a forensic psychiatrist? Do you worry this could serve to impeach your expertise in any way?

 

[doctorpilgrim]

I have seen a number of clear borderline personality disorder patients with chronic suicidal thoughts get multiple ect treatment series without benefit. I have had patients who do equally well with and without medication.IMHO antidepressants are over prescribed for dysthymia , adjustment disorder and personality disorders.

 

[whopper]

re you sure you want to post that on the internet as a forensic psychiatrist? Do you worry this could serve to impeach your expertise in any way?

I'll take the risk on this one. It's not like I'm admitting to being a serial killer in my spare time. Oh, sorry, oops.

 

[Psychobabbling]

things i don't like about psychiatry:

1. this ridiculous quest people have to make psychiatry sound more 'scientific' and technical than it is or ever should be
---> Reminds me of a PET scan I read at a dementia clinic once. "Depression is ruled out."

2. academic posturing from idiots like jeffrey lieberman who are an embarrassment to the field
-> don't know enough to comment

3. the generally poor standard of alot of mental health care in the community
-> True. A rather crappy systems issue that runs deep. Not necessarily the fault of a clinic in and of itself, but certainly doesn't mean there is no fault. I could never work at the clinic I'm at in residency (or similar). Too much "well they are here, so they're MUST be something we can diagnose and give a med for" vs. just the basic ability to refer people out for things like anger management, etc.

4. the fact that so many psychiatrists have abandoned the mentally ill
-> Again, don't know enough. If you mean some docs not seeing "suicidal" people, discharging people after an attempt to "decrease risk," etc I would agree

5. dismissing genuine criticisms of the field as "anti-psychiatry"
-> From what I've read on the subject, I would agree. Some claims are bonkers. But there are some valid points

6. psychiatrists who claim that those that aren't psychiatrists can't criticize the field
-> I think this happens in every field

7. the excessive use of coercion in the field
-> In what sense? I think most would agree that Psych is more paternalizing than other fields. I've never been a big fan of "they just don't know any better. Try and talk to them and see if you can make them agree to take X....."

8. people using the term "med management" - makes them sound like pharmacists
-> Eh. If you're in a "split treatment" model, this is the expectation of the system. With a high functioning group of people, this can reasonably be done. Otherwise, it is nearly impossible to do just med management with the severely ill/person's with various personality styles

9. the artificial divide between psychiatry and medicine
-> not really artificial. We can't have it both ways. "That's a medical problem, talk to your PCP" and balking at the push for the medicalization of psychiatry

10. the challenges of providing basic medical care to patients as a psychiatrist
-> Not sure what you mean.

11. lack of intellectual curiosity in clinical practice
-> ?

12. the reification of psychiatric diagnoses that have no validity and little reliability
-> Well, if it interferes with the functioning of social, occupational........our magic phrase to make anything a disorder. Hell, I say lets add a few more things. Video game use disorder. Cell phone use disorder. Laptop Use Disorder. Basketball use disorder. Sky diving use disorder. Twerking use disorder. "I just don't know what to dooooooo, I just want to play basketball all the time but my family won't let me. I even leave work to play sometimes. Doc, you gotta help me. Can I get some Xanax, Prozac, Abilify and Depakote to treat me please!"

13. disparaging of evidence-based practice/14. the overselling of evidence-based practice
-> nothing's perfect?

15. the obsession in some quarters for measurement-based practice with silly things like the PHQ-9
-> Not the silliest thing in the world. Doesn't hurt to have some objective evidence.

16. psychiatrists referring to themselves as "eclectic"
-> Electic usually as a means to describe someone who uses different modalities of therapy? Never heard a psychiatrist described as such. Besides, studies reflect therapists with enough years of training actually look more similar than their counterparts who are earlier on in their respective field of training. In the end, they all really get at the same thing anyways

17. dogmatism in psychiatry from those who think they have the only claim to "truth"
-> Narcissism runs rampant in all of medicine and most professions

18. pervasiveness of pseudoscience in the field
-> well that's why we need biomarkers silly

19. the promotion of the myth that mental illnesses are "brain disorders" - which has been shown to increase the stigma of mental illness
-> Stigma more so originates as it means there is something inherently wrong with YOU. Saying "I have hypertension" is an external thing in most people's eyes. You 'caught' pneumonia, you are not pneumonia. You 'had' a stroke, you are not a stroke. You do "have" depression, and therefore you ARE depressed. And if you ARE depressed, well, that's weird and different. So, there is something wrong with YOU, in turn, there is "something wrong with me." The stigma exists because of societies view as a whole. WE as psychiatrists actually do little to disparage this, even when we think we are. It's embedded in our culture. Change occurs slowly.

20. institutional racism and the marginalization of african american psychiatrists
-> don't know enough

21. the obsession with "objectivity" and finding biomarkers
-> see above

22. the almost complete irrelevance of the NIMH to clinical practice
-> don't know enough

23. the relative neglect of psychiatry to address the question of how to expand access to mental health care for those most in need
-> not just the fault of psychiatry. have to address who is going to fund this research, hiring of practitioners, etc

24. the proneness of the field to fadishness - both diagnoses and treatments
-> Narcissism runs rampant in our field. Some of us become obsessed with almost making something true. Being homosexual was a disorder. We thought autism could be cured by family therapy. Every child who isn't a G**D*** angel is bipolar. Oh you have a family history of bipolar disorder? you have "bipolar 4" (or whatever the hell they call it). The DSM has criteria, which are used sometimes, or not. The criteria are also sometimes valid and reliable, and other times, not so much. Doesn't help that you need to bill and get insurance to approve something. So, if you work in a community mental health clinic and want to help some with a borderline personality by prescribing lamictal to potentially help with their ability to manage/regulate their emotions somewhat better....you can do nothing and make the person pay out of pocket and/or enter therapy (which isn't as bad as it actually sounds). However, that route seems more threatening, we're supposed to "care, be empathic, want to heal, to help, to cure all of man's woes" - so, you're bipolar now, enjoy you're depakote....

25. the almost total neglect of social aspects of mental health and illness in the US
-> I think social workers/case workers/etc do their best a lot of the time. Again, it's the system we're within. Unlike a buddhist monk, it's going to take more than change coming from within to fix it (i.e., social workers/psychiatrists don't have a magic wand to make everyone bend to their will)

26. psychiatrists capitalizing on mass shootings and other tragedies to campaign for increased funding for mental health care despite our inability to predict or prevent these occurrences
-> ?

27. outpatient commitment/"assisted outpatient treatment"
-> Couldn't one just argue this point by saying "inpatient commitment/involuntary admission"?

28. rampant polypharmacy and off-label use of too many drugs, and too high doses, for too long
-> True. But off-label doesn't mean it doesn't work. Trileptal is "off label" for bipolar disorder. That's more of a function of a pharm company not wanting to throw money into a study because psychiatrists already use it for its intended purpose.....

29. how the pharmaceutical company has undermined the credibility of the profession despite things being much better than a few years ago
-> This is why using your brain helps sometimes I hate hearing "oh well, like, Latuda is new. And they did a study where like, patients depression scores on a scale went down. Therefore, use this over lithium for bipolar depression...." SMFH

30. lack of honesty about what psychiatry can and cannot do (cannot cure social ills, prevent suicide in majority of cases, predict violence, reform non-mentally ill criminals and sex pests)
-> I think we perpetuate a lot of this. The ones who actually work to be more transparent and honest about what can and can't be accomplished...usually don't go to well. (Either in the few attendings I've seen this happen to, or myself. For example: I had an outpatient come in and ask me to tell him how to make Partner #1 (to which he had kids with) okay with the fact that he has a Partner #2 (with the same amount of kids with this person). Partner #2 was okay with it. The patient couldn't fathom why Partner #1 could be so mad/upset because Partner #1's Dad did the same thing to her mother, so she should be used to it. Knowing this before the evaluation, I posed "this person, by no means, sounds appropriate for this clinic. He should be discharged." I was told "oh come on, he could be a really nice guy" - and it wasn't with a smirk. It was "but what if he's a nice guy and he really genuinely wants help." I saw the patient, but that's a whole other story lol (he did not last if anyone was wondering)

 

[whopper]

Maybe you know something I don't, but everything I've seen of Lieberman has been impressive.

The guy did the CATIE trial, rightly pointed out celebrity psychiatrists like Keith Ablow violating the ethics in our field, and was an APA president.

Now you might know something I don't so I'm not saying you're wrong, just that I'd like to know why he is an embarrassment.

 

[whopper]

Hmm okay. I did read the article in the link provided and while I did not read Luhrman's article ( I did, however, read Of Two Minds and I think that book is incredible), I don't disagree with Dr. Lieberman's article. But I'm not disagreeing with you either.

I do agree with Lieberman that psychiatry has advanced to the degree where several aspects are as scientific as say neurology or oncology. While he didn't bring it up, I also must emphasize that psychiatry isn't exactly a cut and dry practice either. As we've whined on this forum there are so many people misdiagnosed and wrongly-medicated by substandard physicians that do happen to be licensed practicing physicians.

Lieberman may be in the ivory tower so to speak. The guy's on the cutting edge and likely surrounded in an cushioned academia environment where he doesn't regularly see and deal with clinicians that give out Xanax like it's candy, dx bipolar disorder on a whim, and see people made significantly worse by a bad psychiatrist.

I on the other hand see it happen quite a bit and you all see me whine about it here.

 

[Jorje286]

I did read the article in the link provided and while I did not read Luhrman's article ( I did, however, read Of Two Minds and I think that book is incredible), I don't disagree with Dr. Lieberman's article.

TBH, there was hardly anything controversial about Luhrmann's article (http://www.nytimes.com/2015/01/18/opinion/sunday/t-m-luhrmann-redefining-mental-illness.html?_r=0 ) that necessitated the type of response from Liberman. She was simply stating something that most psychiatrists would agree with: that the current diagnostic classification does not do a very good job in telling us something real and concrete about psychiatric disease, and that we need to start from a "fresh plate" based on our current scientific understanding of how brains work. She essentially restated the position of the NIMH and put it along the British position. Both perceive problems with the current classification but for different reasons. I could be missing something.

 

[doctorpilgrim]

We as a field should admit that the current classification and diagnostic criteria have major shortcomings. Our treatment plans have significant rate of failure. Just disregarding criticisms and saying that most of our peers are substandard and out to make money at the expense of human misery is an inaccurate picture of our field Imho.

 

[hamstergang]

28. rampant polypharmacy and off-label use of too many drugs, and too high doses, for too long
-> True. But off-label doesn't mean it doesn't work. Trileptal is "off label" for bipolar disorder. That's more of a function of a pharm company not wanting to throw money into a study because psychiatrists already use it for its intended purpose.....

Am I recalling incorrectly, or does the admittedly nearly nonexistent evidence not support Trileptal as an effective bipolar medication?

I agree that many things can be used off-label based on available evidence, but I don't think this is a good example.

 

[Leo Aquarius]

We as a field should admit that the current classification and diagnostic criteria have major shortcomings. Our treatment plans have significant rate of failure. Just disregarding criticisms and saying that most of our peers are substandard and out to make money at the expense of human misery is an inaccurate picture of our field Imho.

Agreed. In addition, we should always strive to be good physicians first. This means staying current on the literature and studies, going the extra mile to do what is best for patients, abiding by high ethical standards. Pretend you make no money on this job, would you treat patients any differently?

 

[Psychobabbling]

Am I recalling incorrectly, or does the admittedly nearly nonexistent evidence not support Trileptal as an effective bipolar medication?

I agree that many things can be used off-label based on available evidence, but I don't think this is a good example.

There have been several, small studies (N ~ 6-60 I want to say) with the use of trileptal in acute mania. A couple monitored long term use I believe, can't remember if they were controlled or not. Doses equate to about Tegretol + 1/3. Studies have been done in us/europe, etc. Point being it is used often enough the financial expense of going for FDA approval is not worth the investment for minimal, if any, return.

 

[OldPsychDoc]

Read--> http://real-psychiatry.blogspot.com/2015/06/the-myth-of-monolithic-psychiatry.html?spref=fb

 

[NontradCA]

Some mental illness appears to be due to dysfunctional processes in the brain although we don't really know enough to say that very definitively. Many mental illnesses are not due to neurological dysfunction. About 20% of inpatient and 10% outpatient are BPD. Not much evidence that is a brain disorder. PTSD can be thought of as a typical response to trauma with people having differing amounts of resiliency. How often is MDD purely biological in nature and isn't depressed mood a normal response to many life events. Same for anxiety or obsessive thoughts or compulsive behaviors. For most mental illnesses it is more of a matter of degree and where we draw the line than it is with a typical physical illness.

I'm sure that Splik is referring to too many psychiatrists working with the worried well as opposed to the truly sick.

A response where?

 

[hamstergang]

There have been several, small studies (N ~ 6-60 I want to say) with the use of trileptal in acute mania. A couple monitored long term use I believe, can't remember if they were controlled or not. Doses equate to about Tegretol + 1/3. Studies have been done in us/europe, etc. Point being it is used often enough the financial expense of going for FDA approval is not worth the investment for minimal, if any, return.

I get that no one would pay for a good enough study, but that's besides my point. Does the available evidence support that Trileptal works or not?

 

[smalltownpsych]

A response where?

A response by a complex neurobiological system. My point was not that the biology is not involved. My point is that the disorder is not caused by a "malfunctioning" central nervous system. Of course some people are more sensitive to trauma than others and some of that is likely due to biological factors in addition to the developmental environment. The problem is when someone starts with the false premise that mental disorders are the result of neurological dysfunction. It also gets in the way of treatment. I get tired of telling all of my patients that they are not crazy, especially those who have a history of severe trauma or loss or neglect. I also see time after time these people being prescribed a medication with the expectation that it will treat their disorder. It happens with colds and flus and antibiotics so I get that it is not the docs fault, but we don't want contribute to it.

 

[Ceke2002]

Some mental illness appears to be due to dysfunctional processes in the brain although we don't really know enough to say that very definitively. Many mental illnesses are not due to neurological dysfunction. About 20% of inpatient and 10% outpatient are BPD. Not much evidence that is a brain disorder. PTSD can be thought of as a typical response to trauma with people having differing amounts of resiliency. How often is MDD purely biological in nature and isn't depressed mood a normal response to many life events. Same for anxiety or obsessive thoughts or compulsive behaviors. For most mental illnesses it is more of a matter of degree and where we draw the line than it is with a typical physical illness.

I have to agree with this, it's far too simplistic to condense something as multi-faceted as mental illness down to just one nice, neat, identifiable reason for it's existence. Even with something like psychosis I don't believe its that cut and dried that it is something going on in the brain with no other factors to consider. In my case, for example, yes there is most likely a brain element to the psychotic features part of being diagnosed with MDD with Psychotic fx, considering I have a family history of Schizophrenia and other Psychosis type spectrum disorders, but then you also have to factor in other elements such as repeated exposure to trauma as a child, underlying psychological make up, and so on. Just personally I've found myself doing far better in terms of symptom control during an episode after receiving ongoing psychotherapy with medication as an adjunct only when truly needed, rather than just being told 'well you have psychotic symptoms, that means there's something wrong with the way your brain works, take these meds and you'll be fine'.