Cold Feet About Psychiatry After Applying for Residency

[twill2888]

Hi all. I'm a long time lurker, first time poster to the boards. Just a little background first: I am a MS-IV currently applying to psychiatry programs for residency, I was sort of a last minute convert to the field. I had my psych rotation early on in MS-III year and really enjoyed it. However, I went through the rest of my rotations and psych sort of got buried along the way. By the end of MS-III I was considering family medicine or pediatrics, but after doing a psych elective earlier this year, I remembered why I liked psychiatry so much: the varying presentation of the same pathology was fascinating and I liked spending more time with patients. So with that in mind, I applied to psychiatry.

Fast forward to now, and I'm feeling a little uneasy about my choice. In between all the talks about the actual effectiveness of antidepressants vs placebo, the dwindling number of new psych drugs in the pipeline, and the overall lack of practical understanding of the mind-body dynamic, among other things, I'm concerned. I've talked to one of my psych attendings about these concerns, and he's tried to allay my fears, but a lot of his advice mentioned the ever-nebulous "future of research is bright, etc." argument.

I don't know if it's cold feet (e.g., not knowing what's in store for the field down the road) or maybe I was too naive and "reality" is only now just settling in, but I guess I'm just sort of bummed out right now. Has anyone else had these feelings and how did you overcome them?

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[OldPsychDoc]

Hi all. I'm a long time lurker, first time poster to the boards. Just a little background first: I am a MS-IV currently applying to psychiatry programs for residency, I was sort of a last minute convert to the field. I had my psych rotation early on in MS-III year and really enjoyed it. However, I went through the rest of my rotations and psych sort of got buried along the way. By the end of MS-III I was considering family medicine or pediatrics, but after doing a psych elective earlier this year, I remembered why I liked psychiatry so much: the varying presentation of the same pathology was fascinating and I liked spending more time with patients. So with that in mind, I applied to psychiatry.

Fast forward to now, and I'm feeling a little uneasy about my choice. In between all the talks about the actual effectiveness of antidepressants vs placebo, the dwindling number of new psych drugs in the pipeline, and the overall lack of practical understanding of the mind-body dynamic, among other things, I'm concerned. I've talked to one of my psych attendings about these concerns, and he's tried to allay my fears, but a lot of his advice mentioned the ever-nebulous "future of research is bright, etc." argument.

I don't know if it's cold feet (e.g., not knowing what's in store for the field down the road) or maybe I was too naive and "reality" is only now just settling in, but I guess I'm just sort of bummed out right now. Has anyone else had these feelings and how did you overcome them?

It sounds like you're already thinking like we do.
But don't imagine that other fields are immune to this introspection and self-doubt.

It sounds (from this one post) that you made the decision for the right reasons.

 

[SmallBird]

Hi all. I'm a long time lurker, first time poster to the boards. Just a little background first: I am a MS-IV currently applying to psychiatry programs for residency, I was sort of a last minute convert to the field. I had my psych rotation early on in MS-III year and really enjoyed it. However, I went through the rest of my rotations and psych sort of got buried along the way. By the end of MS-III I was considering family medicine or pediatrics, but after doing a psych elective earlier this year, I remembered why I liked psychiatry so much: the varying presentation of the same pathology was fascinating and I liked spending more time with patients. So with that in mind, I applied to psychiatry.

Fast forward to now, and I'm feeling a little uneasy about my choice. In between all the talks about the actual effectiveness of antidepressants vs placebo, the dwindling number of new psych drugs in the pipeline, and the overall lack of practical understanding of the mind-body dynamic, among other things, I'm concerned. I've talked to one of my psych attendings about these concerns, and he's tried to allay my fears, but a lot of his advice mentioned the ever-nebulous "future of research is bright, etc." argument.

I don't know if it's cold feet (e.g., not knowing what's in store for the field down the road) or maybe I was too naive and "reality" is only now just settling in, but I guess I'm just sort of bummed out right now. Has anyone else had these feelings and how did you overcome them?

You make a good point - but I think what helps is that the practice of psychiatry such as it is today is already helpful, and (well, to me at least) an awful lot of fun to do. Thus, whilst it would be both unfortunate (and I think very unlikely) for psychiatry not to make significant progress in the future, you will likely always be able to enjoy treating "varying presentation(s) of the same pathology" with a fair degree of success and satisfaction.

Call me an optimist, but when I hear people like David Lewis speak about the work they are doing on the pathophysiology of schizophrenia, I cannot help but be excited about the future of the field.

 

[Jorje286]

I honestly think psych is one of the most active fields when it comes to treatment and doing something for your patients. You have pharm, you have psychotherapy, and neuromodulation (ECT and co). You have a rich choice of drugs for a relatively small amount of diseases, and they do work - probably not better or worse than most medical specialties. I'm not sure you can do much better in terms of treatment options in any other specialty.

I do agree though on the "gray area" in terms of understanding psychopathology and the etiology behind the disease and subsequently diagnosis. That is definitely psych's weakest point. But ultimately it really comes down to the unparalleled physician-patient relationship. Psych is more about empathy than any other specialty. It what sets it apart.

 

[Armadillos]

I think the uncertainty in psychiatry can be a positive, although it seems to always be presented as a negative.

All over medicine you hear people lamenting the loss of the "art of medicine", where else can the practice of medicine be more of an art than a field where many of the outcomes are inherently unique to each person and their subjective experience of life?

 

[digitlnoize]

I honestly think psych is one of the most active fields when it comes to treatment and doing something for your patients. You have pharm, you have psychotherapy, and neuromodulation (ECT and co). You have a rich choice of drugs for a relatively small amount of diseases, and they do work - probably not better or worse than most medical specialties. I'm not sure you can do much better in terms of treatment options in any other specialty.

I do agree though on the "gray area" in terms of understanding psychopathology and the etiology behind the disease and subsequently diagnosis. That is definitely psych's weakest point. But ultimately it really comes down to the unparalleled physician-patient relationship. Psych is more about empathy than any other specialty. It what sets it apart.

Yep. Agreed. And I think the argument that "psych meds aren't effective" is a load of crap. We all know they aren't as effective as we'd like, but for the average patient, antidepressants + therapy works pretty well. Certainly our anti-manics and antipsychotics work GREAT for acute mania and psychosis. They work well for long term stabilization too, if compliance was less of an issue. ECT is one of the safest and most effective treatments in all of medicine.

Do we have a long way to go? Totally. Are we making progress? YES! Is it more frustrating than we'd like? Yep. Have been burned 100 times with "the next big thing?" Yup. Does that mean there aren't great things around the corner? No!

Take a look at this. 150 years ago, people were being admitted to psychiatric hospitals for asthma (amongst other, sometimes hilarious, things). Asthma, even until the 1950's was considered by most physicians to be a purely psychosomatic disorder, along with Rheumatoid Arthritis, Peptic Ulcers, and Ulcerative Colitis. Those things are no longer our territory. Why not? Because research. We figured out the root causes and found other ways to treat them. Look how far we've come in 150 years!!!! Go psych advancement!!! And that's during a period in which we couldn't even really study the brain. Imagine what will come in the next 100 years. If our civilization doesn't collapse, I truly believe the future is very bright, despite the what all the Chicken Little's in medicine say.

 

[twill2888]

Thanks for the encouragement, all. I am currently rotating through wards right now, and I'm constantly looking at lab values and imaging so I guess some of my concerns come from the simple fact that, in comparison, we don't really have those types of objective tools (yet?) to really track psychiatric patient progress. And that concern sort of snowballed into caution about the field's future in general.

I mean, I was taught the "chemical imbalance" theory of psych disease throughout much of medical school, and though I didn't question it then, after doing some more reading recently, it just seems like that's an over-simplification at best, and a misunderstanding at worst. Learning stuff like that just kind of rattles me and makes me question where things are going and whether psychiatry can make substantial enough gains in diagnosis/treatment for my more concrete/logical side.

Anecdotally, my psych attendings have brought up the success they've had with certain patients as proof that certain medications work, and although I don't doubt it, it's sometimes hard to embrace it when, as a student, you're not privy to the long term course of management and gradual improvement.

Not to sandbag the field, but I just felt I needed to get those concerns off my chest now. And despite what I said earlier about lab values and such, the fluidity of psychiatry was one of the positives that attracted me initially. All that unbridled potential is alluring, but also daunting, because there doesnt seem to be a clear direction as of yet. But being able to air this out with others has been therapeutic, especially since there are so few people in my class going into the field to discuss this with.

 

[OldPsychDoc]

Actually--that's not so far off for my patient roster...

 

[digitlnoize]

Thanks for the encouragement, all. I am currently rotating through wards right now, and I'm constantly looking at lab values and imaging so I guess some of my concerns come from the simple fact that, in comparison, we don't really have those types of objective tools (yet?) to really track psychiatric patient progress. And that concern sort of snowballed into caution about the field's future in general.

To that I would say that, in general, there tends to be over-reliance on labs on medical wards these days. Your clinical exam should factor heavily into the equation too. Labs and Rads can be very wrong. The Mental Status Exam *seems* more subjective, but not really any more than an abdomen exam. Getting good at a MSE is quite a valuable test, and CAN be objective, at least for yourself.

I mean, I was taught the "chemical imbalance" theory of psych disease throughout much of medical school, and though I didn't question it then, after doing some more reading recently, it just seems like that's an over-simplification at best, and a misunderstanding at worst. Learning stuff like that just kind of rattles me and makes me question where things are going and whether psychiatry can make substantial enough gains in diagnosis/treatment for my more concrete/logical side.

Keep in mind who taught this to you. By and large, doctors outside psychiatry do NOT understand psychiatry well at all. (If it was a psychiatrist, there is no excuse except that they suck). There are a few exceptions, but in my experience most 3rd year medical students on their psych clerkship know WAY more about psych than 3rd year medicine residents. It's more variable in the real world, but in general, non-psych docs do not receive hardly any training in psych and thus, over-simplify the mechanisms and don't understand the diseases or drugs very well.

Real Conversation with Medicine PGY-3:
PGY-3: "What should I give my pt for anxiety? Nothing works but Xanax!!!"
Me (as intern): "What have you tried? Any SSRIs?"
PGY-3: "Oh yeah! I gave her Wellbutrin! It made her worse!"
Me: "Sigh. That's not an SSRI. How about an SSRI?"
PGY-3: "Oh. Umm...oh yeah! I gave her Effexor!"
Me: "Closer. Also not an SSRI. No Prozac, Celexa, Zoloft, Lexapro, etc?"
PGY-3: "No, haven't tried those."

Hadn't tried the first line treatment. Because they didn't even remotely understand the drugs. Like, at all. This person is now out in the real world. Hopefully I taught them one thing about psychiatry, but I don't think so.

Obviously, the mechanisms are much more complicated than even psychiatrists understand, but I think the over simplification for medical students is a combination of the VERY limited time spent on the material and the lack of understanding by 99% of non-psychiatrists.

 

[shan564]

Thanks for the encouragement, all. I am currently rotating through wards right now, and I'm constantly looking at lab values and imaging so I guess some of my concerns come from the simple fact that, in comparison, we don't really have those types of objective tools (yet?) to really track psychiatric patient progress. And that concern sort of snowballed into caution about the field's future in general.

I mean, I was taught the "chemical imbalance" theory of psych disease throughout much of medical school, and though I didn't question it then, after doing some more reading recently, it just seems like that's an over-simplification at best, and a misunderstanding at worst. Learning stuff like that just kind of rattles me and makes me question where things are going and whether psychiatry can make substantial enough gains in diagnosis/treatment for my more concrete/logical side.

Anecdotally, my psych attendings have brought up the success they've had with certain patients as proof that certain medications work, and although I don't doubt it, it's sometimes hard to embrace it when, as a student, you're not privy to the long term course of management and gradual improvement.

Not to sandbag the field, but I just felt I needed to get those concerns off my chest now. And despite what I said earlier about lab values and such, the fluidity of psychiatry was one of the positives that attracted me initially. All that unbridled potential is alluring, but also daunting, because there doesnt seem to be a clear direction as of yet. But being able to air this out with others has been therapeutic, especially since there are so few people in my class going into the field to discuss this with.

Based on the questions you're asking, I think you'll be a good psychiatrist.

The "chemical imbalance" theory is definitely an oversimplification/misunderstanding. I think that the "brain wiring malfunction leading to a chemical imbalance" theory is somewhat better. I like to tell patients that the brain is really good at rewiring itself (I sometimes even use the word "neuroplasticity" with my better-educated patients), but it's hard for it to rewire itself as long as the chemical imbalance is still there... so we fix the chemicals, and then let the brain heal.

As far as poor data about antidepressants vs. placebo... I think the studies that show no improvement over placebo are probably tainted by the fact that we tend to be too loose with diagnosing depression. If somebody doesn't really have major depression (a lot of people use the DSM criteria quite loosely), then the antidepressant won't work. I'm a big fan of evidence-based medicine, but we have to be careful to apply it in context of our own clinical experience-based judgement.

I had cold feet around this time last year too. But after doing several months of psychiatry residency along with some non-psych rotations, it's pretty clear that I made the right decision. I think you'll feel the same way. Sometimes it's hard to let go of the objective lab tests and the like, but remember that lab tests are only used in medicine if you are unable to make the diagnosis clinically. Med students like to fall back on labs because it proves what you thought you'd determined based on your clinical judgement, but medicine is a lot more fun when you practice it without those extra investigations. Some day, we'll have the same sort of stuff in psychiatry... and it'll make psychiatry more objective and more reproducible and better for patients, but it'll be less fun.

 

[shan564]

To that I would say that, in general, there tends to be over-reliance on labs on medical wards these days. Your clinical exam should factor heavily into the equation too. Labs and Rads can be very wrong. The Mental Status Exam *seems* more subjective, but not really any more than an abdomen exam. Getting good at a MSE is quite a valuable test, and CAN be objective, at least for yourself.

I love this post. I almost tried to explain the same thing about the MSE, but then I was too lazy, since I tend to type out ridiculous diatribes when all I need is a couple of sentences.

Keep in mind who taught this to you. By and large, doctors outside psychiatry do NOT understand psychiatry well at all. (If it was a psychiatrist, there is no excuse except that they suck). There are a few exceptions, but in my experience most 3rd year medical students on their psych clerkship know WAY more about psych than 3rd year medicine residents. It's more variable in the real world, but in general, non-psych docs do not receive hardly any training in psych and thus, over-simplify the mechanisms and don't understand the diseases or drugs very well.

Real Conversation with Medicine PGY-3:
PGY-3: "What should I give my pt for anxiety? Nothing works but Xanax!!!"
Me (as intern): "What have you tried? Any SSRIs?"
PGY-3: "Oh yeah! I gave her Wellbutrin! It made her worse!"
Me: "Sigh. That's not an SSRI. How about an SSRI?"
PGY-3: "Oh. Umm...oh yeah! I gave her Effexor!"
Me: "Closer. Also not an SSRI. No Prozac, Celexa, Zoloft, Lexapro, etc?"
PGY-3: "No, haven't tried those."

I've had so many of these experiences while I've been off-service. I try to explain how the team is grossly misusing a psych drug, and they generally ignore me because I'm an intern. Or respond with something nonsensical like "well, I understand that there's no data to support this, but it seems to work in my experience" (i.e. the patient isn't crazy anymore, so I must have treated their craziness, right? what? you're saying that I just sedated them? what's the difference?)

Hadn't tried the first line treatment. Because they didn't even remotely understand the drugs. Like, at all. This person is now out in the real world. Hopefully I taught them one thing about psychiatry, but I don't think so.

Obviously, the mechanisms are much more complicated than even psychiatrists understand, but I think the over simplification for medical students is a combination of the VERY limited time spent on the material and the lack of understanding by 99% of non-psychiatrists.

I had a patient transferred by a PCP who was trying to manage a complex regimen of psych meds (including benzos and opiates), and then decided to rapidly stop them all. When it made the patient crazy, they called it a "psychotic break" and gave her naloxone in the ED because she had opiates in her urine. That made her crazier, so they gave her lots of PRN Haldol. When I talked to him about what he thinks was going on, he said something about how they unmasked an underlying psychiatric illness that was previously being treated by the benzos, and that's why she had this "psychotic break." When I asked him to characterize this "psychosis," he described gross irritability, grandiosity, flight of ideas, decreased need for sleep, and pressured speech. The patient was admitted and all of the benzos were stopped. When she went into a DTs, they treated her with haldol and risperdal. Then her delirium became catatonic, so they did several EEGs, MRIs, LPs, and a smorgasbord of other tests. The benzos were held for 12 days before they finally sent her to us. Gave her some benzos, and she magically got better. Then tapered the benzos slowly over a few days, and she was fine.

 

[digitlnoize]

I love this post. I almost tried to explain the same thing about the MSE, but then I was too lazy, since I tend to type out ridiculous diatribes when all I need is a couple of sentences.

Thanks!

I had a patient transferred by a PCP who was trying to manage a complex regimen of psych meds (including benzos and opiates), and then decided to rapidly stop them all. When it made the patient crazy, they called it a "psychotic break" and gave her naloxone in the ED because she had opiates in her urine. That made her crazier, so they gave her lots of PRN Haldol. When I talked to him about what he thinks was going on, he said something about how they unmasked an underlying psychiatric illness that was previously being treated by the benzos, and that's why she had this "psychotic break." When I asked him to characterize this "psychosis," he described gross irritability, grandiosity, flight of ideas, decreased need for sleep, and pressured speech. The patient was admitted and all of the benzos were stopped. When she went into a DTs, they treated her with haldol and risperdal. Then her delirium became catatonic, so they did several EEGs, MRIs, LPs, and a smorgasbord of other tests. The benzos were held for 12 days before they finally sent her to us. Gave her some benzos, and she magically got better. Then tapered the benzos slowly over a few days, and she was fine.

All the time. Seriously. I see this crap all the time. It makes me sad and is the primary reason I can't do C-L despite the fact that I find it really cool.

 

[splik]

if you are hoping that there is going to be a flurry of effective drugs released for psychiatric disorders, or that the genome will finally shed some light on psychopathology, or that neuroimaging will yield the causes of schizophrenia and bipolar disorder you will be sorely disappointed. the 1990s was the 'decade of the brain', it was supposed to be an exciting time for psychiatry, and an extremely biological discourse for mental distress was promulgated as fact, with baseless claimsmaking regarding schizophrenia and depression being 'diseases' just like physical disease. Unfortunately, this approach was just as ridiculous as the psychodynamic approach that came before it, which claimed that psychiatrists as moral entrepreneurs could use the 'science' (ha!) of psychodynamics to solve the problems of crime, war, racism, divided societies. There is a tendency to oversell things, and psychiatry has a bad history of doing it, whether from the psychoanalytic or biomedical perspective. Some of that unabashed optimism has been tempered as numerous drug companies have closed their neuroscience or psychopharm research wings, the latest 'blockbuster' drugs are received with skepticism, those neuroimaging studies remain no more than pretty blobs of bright color, and those genetic study fails to be replicated. Medical students voted with their feet and avoided psychiatry at the beginning of this century forcing programs to close. I think the end of the age of optimism in American Psychiatry is something to be optimistic about.

This is a really exciting time to be in psychiatry. If you don't believe me, look at the numbers, since 2008 there has been a small, but sure, upswing in applicants for psychiatry residency. The recent release of DSM-5 (and upcoming release of ICD-11) has held the process of psychiatric diagnosis and classification up to ridicule and that's a good thing. It's a good thing we don't believe uncritically in data peddled by drug companies and are more critical about the results. And it's a good thing we're owning up to the potentially devastating effects of being on long-term psychotropic medications. It's great that psychiatrists in training are learning about evidence based approaches to psychological treatment including CBT, motivational interviewing, DBT, interpersonal therapy, and the short-term dynamic therapies. It's brilliant, that the cultural assumptions about mental disorders being universal are being deconstructed, and we aim to work more collaboratively with LAMICs to develop better mental healthcare systems. It's particularly great that we are just about starting to take a long hard look at the social matrix in which people become mentally ill, seek help, get well, or don't get well, and the experience of stigma, prejudice and discrimination they experience. For the first time we are actually considering the psychiatric consequences of having bad things happen to you (which has been ignored for most of the history of American Psychiatry).

Psychiatry is making great strides, but it's not to be found in the biomedical side of things, which continues to make the same fallacies it always did.

And despite pronouncements for many years about the death of psychiatry as a medical specialty - it's not going anywhere anytime soon. And d'you know why? It's because no one else wants to deal with the mentally ill.

So if you're passionate about working with some of the most vulnerable, and disenfranchised members of our society, and treating them with the respect, care, humanity, and dare I say love, that they may have never experienced elsewhere then psychiatry is right for you!

 

[OldPsychDoc]

So if you're passionate about working with some of the most vulnerable, and disenfranchised members of our society, and treating them with the respect, care, humanity, and dare I say love, that they may have never experienced elsewhere then psychiatry is right for you!

This.

 

[Jorje286]

the 1990s was the 'decade of the brain'

But most serious scholars weren't under the delusion that the brain will be figured out in over a decade. The 1990s was the decade of the brain and now we're in the century of the brain. I don't agree at all with your skepticism around neuroscience and its relation to psychiatric disease. We're only starting to peek through the keyhole and psychiatric disease represent the most intricate function of one of the most complex systems in the whole universe. It's also undeniable that there have been astonishign breakthrough in our biological formulation of brain function and psychiatric disorder over the last 30 years. Personally I believe the future is in neurophysiology, computational techniques and computer-simulations of the brain. Not fMRI as its far too simplistic in providing a comprehensive layout of how the brain functions. What's exciting in psych is marrying this challenge with the challenge of interpersonal communication and psychodynamics.

 

[splik]

a good scientist should be skeptical about the limits of advancement of knowledge and the cultural frame that sets the agenda for what is privileged as meaningful. The rhetoric surrounding the neuroscience and the new genetics to revolutionize the treatment of mental illness has remained such, and every time it is challenged, the goalposts are simply shifted. In 2005, Tom Insel published a key paper 'Psychiatry as a Clinical Neuroscience Discipline' laying out a roadmap for the discipline. By 2015, he said, we would have evolved to a psychiatry reframed around 'biodiagnostics' and 'treatment of core pathology'. Well, 2015 is very close and we seem no closer to this elusive aim. It is embarrassing how much time people have wasted on researching the biological correlates of DSM diagnoses like 'schizophrenia' and 'depression' as if they were 'things' with an existence in external reality, rather than cultural constructs that reflected a particular way of seeing. The major limitation of DSM what that it conflated disease with disorder, disorder with syndrome, and syndrome with disability. By adding in the rider of needing 'functional impairment' to have a psychiatric 'disorder', the project of biological psychiatry was doomed from the start. Functional impairment is almost entirely socially determined. Whilst the RDoC avoids this, it too reflects a particular construct for viewing human behavior very mechanistically. This may be very useful for understanding drug addiction, for example, but it is very limited when it comes to understanding 'depression' or 'psychosis'.

I am not opposed to neuroscience research in psychiatry at all. What I do oppose is the seeming neuro-hegemony in psychiatric research that has occurred in recent years. Not only have patients not benefited from this approach, they have suffered, as this approach has come at the expense of funding of services and policies that really had the power to transform the lives of those with mental illness. The NIMH was not initially established as a research only center, and certainly not one that almost entirely privileged a biological discourse for understanding morbid mental life, but was founded with aims of research, treatment and prevention of mental illness, through policy and service development and not just research. Today, it almost exclusively focuses its remit on "the sciences of brain and behavior" [sic]. Much of the research monies spent on the new phrenology of neuroimaging would have been much better spent elsewhere.

We must also consider that the dominance of the biobehavioral paradigm occurs within a particular context. The rise of this particular approach in American Psychiatry coincides entirely with the rise of neoliberalism, in the same way that psychodynamic psychiatry coincided with late capitalism. As such individuals have recoded their problems in terms of broken brains, defective genes, and twisted molecules. In doing so, the wider social context in which people experience distress, and the growing inequality in society has been obfuscated.

A final consideration which older researchers concerned themselves with are the moral and ethical implications of a neuroscientific psychiatry. Whilst a psychiatry that was seen to blame individuals and parents for mental illness was neither desirable or helpful, the biological approach to psychiatry has undermined and eroded individual and social responsibility for mental health and behavior. More corrosively, there is evidence suggesting practitioners who have a more biological slant seeing the mentally ill as 'diseased' as less likely to work collaboratively with them. Quite at odds with neoliberal triumphalism, the project for a neuroscientific psychiatry has encouraged people to see their behavior and experiences as beyond their control, for individuals to see themselves as sick, encouraged a dependency on the state, and allowed individual and moral exculpation from responsibility, not only for one's own behavior, but our moral obligation to help others.

 

[happygilmore]

In other words, it's a bit of both.

 

[Fenster]

All I can say is, I'm so glad SDN now has a like button!

 

[twill2888]

Props for your post

but I think most psych programs are moving toward this school of thought anyway (social psychiatry, community psych, geriatric). Others are tied to old initiatives or the money that can be made pursuing these "more biological" approaches.

Less focus on categorizing of pathology and dissecting the patient to death. Things made by man liks your phone, chair, math, tools lend themselves to language and then human thought. But the rest of living world, like our bodies,is less discrete and this leads to imprecise disease treatment

Most of my attendings subscribe to the more biological approach of psychiatry, so I've been taught and exposed more towards that. But now I'm curious, practically speaking, how would more socially/community-focused psychiatry apply to training and patient diagnosis and treatment? Is there more psychotherapy/counselling involved? Less medication? Is there more involved social work? Is it similar in process to something like AA (I have participated in a number of addiction-focused group therapy sessions and I don't think they're for me)?

I'll admit, I do believe in (or at least I'm more used to) a more neuroscience-driven psychiatry, so this is a little bit of a shock. That being said, I have never discounted the major role that social/environmental factors play in contributing to psychiatric disease. And even though I was always concerned about the actual likelihood of substantial biological advances, a little part of me still held some optimism for the current neuroimaging research (if for no other reason than my attendings constantly supported it).

I guess what I'm saying is that I am still concerned about the future of the field. I really enjoy learning the material/theory, but the application seems very unstable at the moment, and I need to be comfortable in knowing that there is some more unified direction moving forward in terms of clinical practice. I have my first interviews coming up, and you had better believe I'll be asking everybody questions like these, but if I don't get enough substantial feedback, I don't know if I can feel comfortable committing to the field.

 

[notdeadyet]

In other words, it's a bit of both.

Nicely said. This debate will go 'round and 'round with the false dichotomies between the two camps.

One camp cries that the Next Big Thing is up and coming. Just you wait. In x years, the field will be revolutionized by inflammation/imaging/circuitry/biologics/etc. And (as splik mentions) as we get closer to that magic date, we start losing interest and focus on the next bright and shiny modality. The Next Big Thing is just around the corner... and always will be.

The other camp cries that the meds don't work, ECT doesn't work, nothing invented since psychotherapy is worth a damn (though we're comfortable with all things psychotherapy and cite its effectiveness with studies that typically aren't measured against sham and therefore don't mean much). We need to just rest our elbows comfortably on the faux leather patches of our tweed jackets while we hash it out verbally since we know this works. Of course we don't know if this is more effective when patients do it with a $200/hour psychiatrist vs. a $50/hour social worker, but let's not worry about that.

Like most things in medicine (or life for that matter), neither of the extreme camps holds much water and is just a distraction from serious discussion. The truth is going to be a boring shade of grey, and time is better spent there than chest beating in the nether regions.

 

[Jorje286]

There's absolutely no contradiction between emphasizing a biologically rooted approach to psychiatry and recognizing the importance of interpersonal dynamics, interpersonal history, social values and psychotherapy in the etiology and treatment of psychiatric diseases. The people who do see an issue in the synthesis of this perspective are the dualists who refuse to acknowledge that the brain is the seat of all behavior, a very spurious unscienfitic position imo. The monists do recognize the extreme importance of things generally considered in the domain of psychology and sociology on behavior but they argue that they are important because they leave their imprint on the brain. There's also a current in psychiatry/psychology that looks at biological psychiatry as somehow a trivialization of psychiatric disease, as if "it's just another illness" - which is actually merely a spin on the core arguments used to drive the stigmatization of mental illness in society. To mention an example, our psychiatry department started an educational campaign against stigmatization, arguing that psychiatric diseases are medical diseases, and the people who took offense and had a big issue with this were the psychologists...