Do you feel people get drastically better with psychiatry

[DO_or_Die]

Please hear me out on this. I'm 100% not a troll. I'm choosing between peds and psych (child psych) very soon. I think both are incredibly interesting for different reasons and am currently on an inpatient CAP elective to gain more experience. I'll be doing several more CAP electives but this will be after I've already had to decide.

The reason that I'm presently drawn away from psych is that I have only been around the sickest patients in both this rotation and my adult inpatient rotation and I, myself, haven't seen a marked improvement in them from a psychiatry perspective. I do think they benefit from group, social work and therapy.

I feel that I might not have seen the drastic clinical improvement because of the limited time frame I have to work with the patients vs the psychiatrist would in an outpatient setting over a period of months to years. My lack of experience in the field leads me to a confirmation bias that psych patients don't get drastically better and that I should choose peds because giving medicine = better automatically. Not necessarily because I want to practice traditional medicine but that I want to know that my work leads to direct improvements. I know that this narrow sighted mindset might have me ultimately end up choosing the wrong field. Please, please set me straight. I wish I had a lot more time to explore the field, but I don't. That's why I'm here.

Do you feel that psychiatry makes a marked improvement in the lives of patients and do you feel that your work is meaningful?

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[Celexa]

Do you feel that psychiatry makes a marked improvement in the lives of patients and do you feel that your work is meaningful?

Yes. Unambiguously yes. Psychiatry practiced well (that is, using meds skillfully within an understanding of therapeutic context, and therapy alone when appropriate) can be transformative.

Inpatient psychiatry is not at all representative of the majority of our field.

If you choose CAP instead of peds you will earn more and have a better job market, and if you do peds you'll still have to do a lot of psych but without the compensation or the training.

 

[Doctorows]

From the perspective of an inpatient psychiatrist, seeing a patient who is brought in acutely manic bouncing off the walls, masturbating in front of others, unable to sustain their line of thought for longer than two seconds, transform into a fully functioning person who gets to return back to work and fix the messes they don't even remember creating in their life after a week or two of mood-stabilizing psychopharm treatment feels like a marked improvement to me. Same can be said about the patient withering away in bed with severe depression who cracks jokes during your rounds after a couple weeks of ECT. For more immediate and drastic, ever seen a catatonic person respond to lorazepam? I think the improvement in the quality of life of patients is more "marked" (with the right treatment) in psychiatry than many other fields.

 

[Chrish]

Person I work with sees a shrink. They used to be a gaslighter and pretty unpleasant person to be around. But after seeking a treatment for so many months, I definitely see a drastic improvement in their behavior.

While I don’t know the exact nature of their condition or treatment, to answer the OP, yes people do get better.

 

[brazilianpsych]

I am going in the opposite way and say I don't actually see a marked improvement in patients, specially in child psych. A big chunk of the patients who needs meds the most won't use them. Homeless patients, with severe mental illness and poly substance abuse are very unlikely to keep their treatments and therefore no improvement.

Depressed patients? Some of them improve, but also very related to the rest of their life. They have a work, supporting family and social network? Lexapro will likely do the work. Patient has been in prison a few times, abandoned by family, homeless, and depressed? I do not feel Lexapro does much in this case.

Child psych has its own problems and it will depend on the setting you practice, I assume. But marked improvement in most cases? That is not what I have seen. A lot of children with psych problems have dysfunctional parents and most of the times you cannot fix them. ADHD sure gets better, but borderline IQ with impulsivity? Severe autism? Not so much.

Unpopular opinion, but for me the patients that mostly needed help are the ones we don't help that much. It's like you are a cardiologist that only see people after they have MI. Maybe in the future that will change when we can treat people before they have their first episode psychosis.

Although I don't think this should stop you from doing the specialty. Between pets and child psych, would still recommend child psych, but would recommend adult psych over both of them.

 

[Liquid8]

I think OP’s experiences reflect a lot of the problems with medical school psychiatry training. I remember as a student we were exposed to predominantly inpatient psychiatry, only seeing the worst of the worst who met the strict hurdles of the public system. That remained the same even during my junior doctor years and first year of formal training. And while patients did improve, we often never really saw it as they would be discharged early, relapse and were readmitted.

What I did find is that later on the bias works the other way - private outpatient psychiatric practice ends up selecting for better off, more motivated patients who will appreciate what you do and tend to have better outcomes and better overall satisfaction.

 

[forchinet121]

It depends on the patient population.

 

[annoyedpsychiatrist]

1. Woman in her 30s developed severe anxiety after her mother in law passed. Stopped going to work, couldnt get herself out of bed, felt like a failure, etc. Previously she was working in the hospital setting, leading a team, but struggling to engage in her job. Ive been seeing her biweekly for a few months. Through some med changes, adjunct therapy, insight oriented therapy etc she has minimal depression/anxiety, down roughly 80%. She is going to her job everyday, feels hopeful, etc.

2. Very polite middle aged guy with terrible social anxiety and low self confidence was on valium 30mg a day and remeron. I helped him understand and challenge how he felt about himself, and helped him realize that he had a lot of reasons to be confident. He repeatedly turned away promotions, would never step up in meetings, etc. He now works as a supervisor at his job, and going for district supervisor, and leads every team meeting. I have him down to valium 5mg daily.

3. Older male in his 60s, was seeing someone else, failed 5 differnet medications. Severe depression. I had suspicion of parkinsons based on his clinical presentation, referred to neurology for further workup and started wellbutrin which can do quite well in parkinsons. Drastic response. Depression completely gone, and neuro confirmed parkinsons.

4. Young male in his 20s with schizophrenia, hospitalized for paranoia the government was coming for him. Barricaded himself in his house. I have been working with him, he now goes to college and works 20-30 hours a week. Wants to try out for college basketball.

5. Another young male with schizoaffective, has had significant manic episodes in the past. He had kicked out the car windows twice while riding in the car with his mom, and drove off to another state randomly when he got home. Months later, hes now finishing his AA degree, and working two jobs. He is excelling in science courses.

6. Woman in her 50s came to me on doxepin 200mg and lexapro 20mg. Was feeling tired all of the time, exhausted. Felt like she couldnt remember anything. Tapered her off doxepin, and her memory is better, fatigue is gone, and has thanked me repeatedly for actually stepping up and taking her off a medication people just mindlessly continued.

7. Multiple people with bipolar diagnosis on heavy meds that were endlessly continued with no improvement that ive taken off because it was a completely inaccurate diagnosis. But many people didnt have the guts to mess with it, because continuing a stupid medication regimen is easier.

I have had many people go into complete remission in regards to depression/anxiety and positive sx of psychosis. The cases above are just some of the ones I remembered from recent experiences. Can people get drastically better? Well yeah.

You need to understand, the job of a psychiatrist isnt to "fix" people. Its to help people understand what part of them is broken, so they can start to work on fixing themselves. Will people with polysubstance use and severe personality disorders struggle more to get better? Well yeah probably. But maybe you dont stop them from abusing 5 different drugs. However maybe you do stop them from overdosing and dying on the streets.

Your job isnt to solve the life stressors of people like homelessness, its to help people adapt to their situations, and if you can, offer resources.

I think what is important is to understand what psychiatry is meant for, which is something that many of my physician colleagues in other specialities still havent figured out.

 

[TexasPhysician]

First giving medicine does not equal automatically better in peds. There are plenty of viruses in which no meds help and parents are upset that you don’t have a cure. Infections can be resistant then you need cultures or more invasive tests. Kids still get cancer and terrible illnesses that never improve. Acne and other rashes can require multiple trials of other meds.

Psych can see drastic improvement to complete resolution of symptoms.

Neither field is all green grass. You will have difficult cases in either field. You will see patients struggle to improve. You will see death.

 

[docksan]

Oh my gosh yes. Absolutely yes.

 

[tr]

A lot of children with psych problems have dysfunctional parents and most of the times you cannot fix them.

This. This is what made me decide against CAP. I found it extremely frustrating when the source of the problem is somebody who is not your patient and over whom you have extremely limited influence. I think you would have to make your peace with this aspect of things to go forward with a CAP career.

Adults are also often products of their dysfunctional childhood environments, but by that point there may be awareness and agency, and if they are interested in fixing themselves there is actually a lot that you can do to help them *provided their current environment is reasonably safe and predictable*.

To speak to the OP, I echo most posters above and would say that I actually feel that psychiatry is probably *more* effective as far as direct and meaningful improvements to people's lives than many other areas of medicine. But it definitely depends on your practice setting, and I don't work with kids.

 

[thelastpsych]

You'll see patients make remarkable progress, some even in dire situations. But you have to adapt yourself to what progress means: if you can afford seeing a chronically depressed 50y.o. female patient leave their house to go for a walk on the park for the first time in years and call it a victory, then yes, there is a lot of improvement.

If you imagine doctors as people that CURE ailments through miraculous science and high-end medical procedures that are life or death, than maybe psych isn't for you, but then again, neither would peds be (except the rare neonatologist maybe?).

As you practice more, you'll realize that it is not so obvious how you are helping people; one thing you can be sure is that medications and all their fancy neurotransmitters are only part of the healing process, and patients recover much more when they have a solid doctor-patient relationship. In psychiatry, because you don't have as many time constraints as other medical specialties like peds, and the nature of the problems is much more subjective, there is space for a more profound therapeutic alliance - you can be a powerful ally to the people that are being helped, sometimes for years. If that attracts you, then psych might be a good fit. If you would prefer a more objective and linear, although not entirely technical, specialty, then maybe peds is a better fit?

 

[Mad Jack]

Please hear me out on this. I'm 100% not a troll. I'm choosing between peds and psych (child psych) very soon. I think both are incredibly interesting for different reasons and am currently on an inpatient CAP elective to gain more experience. I'll be doing several more CAP electives but this will be after I've already had to decide.

The reason that I'm presently drawn away from psych is that I have only been around the sickest patients in both this rotation and my adult inpatient rotation and I, myself, haven't seen a marked improvement in them from a psychiatry perspective. I do think they benefit from group, social work and therapy.

I feel that I might not have seen the drastic clinical improvement because of the limited time frame I have to work with the patients vs the psychiatrist would in an outpatient setting over a period of months to years. My lack of experience in the field leads me to a confirmation bias that psych patients don't get drastically better and that I should choose peds because giving medicine = better automatically. Not necessarily because I want to practice traditional medicine but that I want to know that my work leads to direct improvements. I know that this narrow sighted mindset might have me ultimately end up choosing the wrong field. Please, please set me straight. I wish I had a lot more time to explore the field, but I don't. That's why I'm here.

Do you feel that psychiatry makes a marked improvement in the lives of patients and do you feel that your work is meaningful?

I specifically chose psychiatry because it was one of the only fields where patients can and do often get better. This often takes far longer than you'll see on a typical rotation, but even in the inpatient setting, my patients typically make great improvements in a month. Outpatient, some of the sicker patients take months to stabilize, but once they do it is very satisfying. Some patients will never get better, but the proportion of our patients that completely overcome their illnesses when compared to other fields is actually quite high. If you've got COPD, CHF, CKD, inflammatory bowel disease, or any other number of conditions, they are basically lifelong. You can improve the base state, and people continue to rack up lifelong conditions as they age. You play a game of managing the speed drain circling, but they never fully escape. In psychiatry I have a lot of patients that end up in full remission of various conditions, with or without medication, depending on the underlying condition.

I will say though, I am trained in child and adolescent psychiatry and moved away from it because children, generally, lack the agency for major change. The ones I could help were incredibly rewarding, but the ones that languished by nature of their environment were enough to really grate on me.

 

[smalltownpsych]

Sometimes we make a huge difference fairly quickly, sometimes a gradual difference over time, and much of the time we are battling individual, family, cultural, and systemic issues that seem overwhelming. I enjoy working with the tough cases though because any improvement is so much better than the downward spiral that was happening before. I’ll second the post that said peds will be more psych than you think just without the training and focus on it.

 

[splik]

People with psychiatric illness can get dramatically better, but it is not the norm. It is also very much depends on the patient population, setting, resources available, and work you are doing. The kinds of patients treated during residency patient tend not to be reflective of "real world" practice in terms of being more psychosocially complex, and refractory to treatment etc. You have to be content with small wins and more gradual progress, and relapses for the most part. Most psychiatrists work in outpatient settings where the work can be quite slow at times (again depending on the patients you are working with) There are certain conditions where recovery is the rule:
-the NNT for ADHD with stimulants is between 1.1-2.5, which rivals antibiotics for bacterial infections.
-50% of patients with MDD never have another episode of depression
- panic disorder is curable (or as close to "cure") with CBT
- single incident PTSD is curable (or as close to "cure") with CPT/PE
- 1 in 3 patients with schizophrenia fully recover, and 70% of patients experience symptom remission at some point
- 75% of patients with substance use disorders recover
- 80% of patients with borderline personality disorder no longer meet criteria after 5 years
- recovery rates for psychotic depression and catatonia with ECT are over 80%

There are also many, many people who never recover or need lifelong treatment. And the patients that do recover are not the ones reflected in many psychiatric settings. Most psychiatric disorders are chronic (which is similar to most other medical specialties). Many patients have experienced or continue to experience unimaginable trauma/abuse, or deal with poverty, social exclusion, stigma, racism, dysfunctional families and relationships, toxic and dangerous work environments, live in uninhabitable conditions or experience homelessness, serious medical illness, or otherwise tormented by shïtty lives that we cannot even begin to address. You have to be okay with that and recognize you can still helpful in small ways.

Psychiatrists get way less thank you cards and gifts than pediatricians, but our patients (and their parents) are often quietly grateful. I do find my work meaningful but I know a lot is psychiatrists work in settings where it is difficult to do meaningful work.

 

[HemeOncHopeful19]

Do you feel that psychiatry makes a marked improvement in the lives of patients and do you feel that your work is meaningful?

I'm not sure if we're supposed to talk about personal experiences on this site but my diagnosis of ADHD as a child was probably the single most important/impactful thing that has ever happened in my life (short of maybe meeting my spouse? I guess) and there is no way I would have otherwise made it into my current successful career nor my happy marriage. I will admit I probably would have made it through college assuming I didn't perish in an at-fault car accident somewhere along the way...

That being said I have a close friend who is CAP and you absolutely cannot save them all but this will be true no matter what specialty you ultimately choose. That is no different than my Oncology clinic or a Pediatric inpatient ward for that matter. There is no specialty in medicine IMO that is "pointless"/"meaningless" otherwise it would not need to exist!

 

[Mad Jack]

I'm not sure if we're supposed to talk about personal experiences on this site but my diagnosis of ADHD as a child was probably the single most important/impactful thing that has ever happened in my life (short of maybe meeting my spouse? I guess) and there is no way I would have otherwise made it into my current successful career nor my happy marriage. I will admit I probably would have made it through college assuming I didn't perish in an at-fault car accident somewhere along the way...

That being said I have a close friend who is CAP and you absolutely cannot save them all but this will be true no matter what specialty you ultimately choose. That is no different than my Oncology clinic or a Pediatric inpatient ward for that matter. There is no specialty in medicine IMO that is "pointless"/"meaningless" otherwise it would not need to exist!

Yeah, I will say that was a satisfying aspect of C&A psych. That and helping kids with autism. Helping parents understand and set reasonable expectations for their kids in the setting of their underlying conditions and doing my best to emphasize that people's brains are different and that is okay were probably the most important aspects of the job aside from treatment itself.

 

[calvnandhobbs68]

So about child, I think you just have to be realistic about your expectations. You also need to like pediatrics to do child. If someone doesn’t like their peds rotation, I feel it’s pretty unlikely they’ll like child psych as many of the same issues come into play (family dynamics impacting presentation, treatment, perception of illness, demands from family).

There are lots of positive in my eyes though. One has always been for me a difference between adult medicine and pediatrics in general. Medical staff just seem to CARE more about pediatrics. Go onto a pediatric inpatient psych unit and an adult inpatient unit and this is probably most drastic there. People tend to go into anything pediatric because they like working with kids despite all the other negatives. There are absolutely crappy pediatric inpatient/PHP/IOP/outpatient therapists, etc but overall less so seemingly. This is true on the medicine side too.

You can also make a big difference just by lending your support and expertise. Sometimes teenagers are relieved to hear that you think the major problem is just that they don’t get along with their family and that they aren’t “messed up” in some way or are “bipolar” or whatever their family tells them. Sometimes you’re the only person kids can talk to about their crappy life or whatever is bothering them

I’ve had kids with autism have drastic improvements in agression and ability to participate in therapy supports with appropriate medication. Are you going to fix the core autism/DD symptoms? No but you need to just be realistic. As noted above ADHD improvements can be drastic, I’ve had kids go to having the best grades of their lives in a semester once we figured things out. Anxiety disorders can see drastic improvements in kids at times with CBT and SSRIs. OCD as well, I can think of one case off the top of my head where a kid was essentially nonfunctional from OCD rituals and is basically in remission now.

 

[PsyDr]

If you cure someone, they'll quit coming to see you. If someone isn't getting better, or their treatment is complicated, they will see you regularly.

That's not unique to psych. Go ask any specialty.

*And that is survivorship bias.

 

[Merovinge]

I am going in the opposite way and say I don't actually see a marked improvement in patients, specially in child psych. A big chunk of the patients who needs meds the most won't use them. Homeless patients, with severe mental illness and poly substance abuse are very unlikely to keep their treatments and therefore no improvement.

Depressed patients? Some of them improve, but also very related to the rest of their life. They have a work, supporting family and social network? Lexapro will likely do the work. Patient has been in prison a few times, abandoned by family, homeless, and depressed? I do not feel Lexapro does much in this case.

Child psych has its own problems and it will depend on the setting you practice, I assume. But marked improvement in most cases? That is not what I have seen. A lot of children with psych problems have dysfunctional parents and most of the times you cannot fix them. ADHD sure gets better, but borderline IQ with impulsivity? Severe autism? Not so much.

Unpopular opinion, but for me the patients that mostly needed help are the ones we don't help that much. It's like you are a cardiologist that only see people after they have MI. Maybe in the future that will change when we can treat people before they have their first episode psychosis.

Although I don't think this should stop you from doing the specialty. Between pets and child psych, would still recommend child psych, but would recommend adult psych over both of them.

I think that's a really bizarre standard to have. Are you going to "fix" the severe autism? Of course you aren't going to cure it (any more than 90% of medicine which does not cure patients), but the interventions for ASD make a big difference in quality of life. You can just see the difference on caregiver's faces when the Abilify actually stems the severe aggression or SIB and they can keep the kid at home and not have to consider giving them up to the state just for comprehensive services. You might find the low dose SSRI or alpha 2-agonist that really makes a difference, find a sleep aid that helps them get through the night, or connect them with behavioral therapists that can make all the difference.

We also don't see what happens to the patient who comes in and gets help as a kid then never goes on to develop the crippling SUD, or social anxiety that makes them drop out of school, or OCD that gets treated before taking over someone's life because we get them the help before the disease progresses. These cases happen all the time. Counterfactuals are tough for the human brain to wrap itself around but absolutely worth exploring when plausible.

I am sure there are cases where you work with the lowest SES, lowest functioning populations where improvement is rare, but those individuals will have plenty of treatment refractory other medical problems as well.

 

[comp1]

I definitely second the above posters bringing up academic inpatient psychiatry not exactly being representative of the entire field and recovery rates. I can see why some med students might think no one gets better if they only see straight up county inpatient psych. These are extremely sick people who are often refractory to treatment. In a more humane world, many would be living in long term institutions and not rotating in and out of acute care units. As patients, however, they are very helpful for education because they tend to meet many classical disorder definitions and thus help to refine a student and eventual resident's diagnostic prowess for assessing much more subtle presentations. It's a trade off. You have to be aware going into it that you're not seeing a representation of the whole.

 

[vanfanal]

I'll echo what's been said. Psychiatry can be very rewarding based on the practice setting and the people one works with. I can tell you that there are many memories I carry of the people I have helped get better that live rent free in my brain. Post-partum catatonia that responds to ECT, severe depression that responds to ECT, very brittle bipolar illness with rapid cycling that eventually resolve with a very cautions and unorthodox medication regimen (I melted when he hugged me on discharge), and the countless addiction patients I see who achieve stability and are able to rebuild their lives and are unrecognizable one year later. If you can establish a practice setting to maximizing these kinds of encounters, the better! I'm not cut out for working with PDs which can make a lot of settings a grind, you can't avoid them at the end of the day. These memories give me lots of solace on hard days or when I feel lost in my career, or when i start entertaining thoughts that I should have done radiology- sure the $$ is great, but I don't if they carry the rewarding memories of the images they read like I do. lol.

 

[whopper]

Yes-but this amount isn't close to 100%. It's a slight majority that I'd guestimate to be about 60%. Then there's about another 30-35% where they are better but only partially so and still in a zone of not doing great, but at least feel the treatment was worth it.

While it's rare to see some patients not benefit at all from several treatments, this is not unfortunately a less than 1% phenomenon. I've had severely treatment resistant patients in all areas.

 

[Ceke2002]

Please hear me out on this. I'm 100% not a troll. I'm choosing between peds and psych (child psych) very soon. I think both are incredibly interesting for different reasons and am currently on an inpatient CAP elective to gain more experience. I'll be doing several more CAP electives but this will be after I've already had to decide.

The reason that I'm presently drawn away from psych is that I have only been around the sickest patients in both this rotation and my adult inpatient rotation and I, myself, haven't seen a marked improvement in them from a psychiatry perspective. I do think they benefit from group, social work and therapy.

I feel that I might not have seen the drastic clinical improvement because of the limited time frame I have to work with the patients vs the psychiatrist would in an outpatient setting over a period of months to years. My lack of experience in the field leads me to a confirmation bias that psych patients don't get drastically better and that I should choose peds because giving medicine = better automatically. Not necessarily because I want to practice traditional medicine but that I want to know that my work leads to direct improvements. I know that this narrow sighted mindset might have me ultimately end up choosing the wrong field. Please, please set me straight. I wish I had a lot more time to explore the field, but I don't. That's why I'm here.

Do you feel that psychiatry makes a marked improvement in the lives of patients and do you feel that your work is meaningful?

I can only speak as a former patient, but yes I did get marked improvement from Psychiatry. Prior to starting long term outpatient therapy/treatment I had been dealing with multiple mental health issues, some for more than decades, including a prior diagnosis of BPD, fairly severe generalised anxiety and panic disorder, periods of both clinical depression and depression with psychotic features, anorexia nervosa and other psychological issues related to abuse in childhood - 5 years after 'graduating' outpatient treatment I've only had one true panic attack (understandable, I'd just been diagnosed with cancer and when the realisation fully hit I had a bit of a melt down), I very rarely experience anxiety and when I do it's easily manageable for me, I've only needed to pull the trigger once in regards to needing medication for a depressive episode (and still ended up not needing it in the end), I've not had any psychotic like episodes at all (they may still occur in future, but I'm far more equipped to deal with them now), I haven't self harmed or had any urges/desire to do so for almost 7 years, and I consider myself 95% recovered from chronic AN (I was actively eating disordered for almost 25 years, I've accepted I will never be 100% recovered). I turn 51 this year and I am more stable, more confident, and genuinely happier than I have been throughout the majority of my life.

I also have a number of friends from various mental health support groups I connected with over time, and a lot of them are also now either fully recovered, or have their symptoms well managed so as to no longer need regular treatment (some of them have gone on to become healthcare professionals themselves). When performed well Psychiatry can be both a life saver, and a life changer for patients.

 

[SeniorWrangler]

Remember that specialties aren't well represented by what med students get to see: most pediatricians work with mostly healthy kids and caring, sometimes clingy parents, not kids with nightmarish congenital disease or tragic injuries. Most psychiatrists work with ambulatory patients who need some expert help and are sometimes the "worried well", not homeless people with schizophrenia or chronically suicidal patients with mood disorders and SUD. Go with what is interesting for you and don't worry about saving the world, that was never on the table.