How many patients do you really help?

[Yoyomama88]

I'm skeptical regarding psychiatry's medication of the "worried well"- those with depression, anxiety issues that are primarily a result of bad life experiences, poor coping mechanisms, poor lifestyle habits, and poor thought control. I am under the impression that many of these patients can get better with a good therapist, meditation, exercise and maybe some probiotics.



Now, I do believe that ADHD, MDD, Bipolar, Schizophrenia, OCD are real disorders and I am sure that these patients benefit from psychiatric medications and other modalities (ECT, TMS) etc. But is it reasonable to say that a majority of patients that a psychiatrist sees in private practice are not severely mentally ill and really fit under the category of the "worried well".... That many of these patients shouldn't be on a psych med long term. I am worried that I will feel that I am nothing more than a parasite when treating these patients by getting them hooked on meds they really don't need.


So I guess my question is, Do you feel your treatments for the worried well are 1) Justified 2) Efficacious 3) Rewarding ?

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[OldPsychDoc]

I'm skeptical regarding psychiatry's medication of the "worried well"- those with depression, anxiety issues that are primarily a result of bad life experiences, poor coping mechanisms, poor lifestyle habits, and poor thought control. I am under the impression that many of these patients can get better with a good therapist, meditation, exercise and maybe some probiotics.



Now, I do believe that ADHD, MDD, Bipolar, Schizophrenia, OCD are real disorders and I am sure that these patients benefit from psychiatric medications and other modalities (ECT, TMS) etc. But is it reasonable to say that a majority of patients that a psychiatrist sees in private practice are not severely mentally ill and really fit under the category of the "worried well".... That many of these patients shouldn't be on a psych med long term. I am worried that I will feel that I am nothing more than a parasite when treating these patients by getting them hooked on meds they really don't need.


So I guess my question is, Do you feel your treatments for the worried well are 1) Justified 2) Efficacious 3) Rewarding ?

No one's holding a gun to your head demanding that you prescribe something against your belief of what is clinically appropriate. I will say that when I was doing regular outpatient, less than 2% of my patients fit that "worried well" category, and if they did--well who better to give them some assurances, some problem-solving, some gentle nudges toward better lifestyle habits and choices? They might be more likely to listen to a doctor talk to them about sleep hygiene and exercise than to their mother....

The majority of outpatients a psychiatrist sees are the marginally stable with a serious mental illness, the partial remissions, the recovering at various stages of recovery...and yes, I am happy having a variety of justified and efficacious treatments to offer them.

 

[MLT2MT2DO]

I'm skeptical regarding psychiatry's medication of the "worried well"- those with depression, anxiety issues that are primarily a result of bad life experiences, poor coping mechanisms, poor lifestyle habits, and poor thought control. I am under the impression that many of these patients can get better with a good therapist, meditation, exercise and maybe some probiotics.



Now, I do believe that ADHD, MDD, Bipolar, Schizophrenia, OCD are real disorders and I am sure that these patients benefit from psychiatric medications and other modalities (ECT, TMS) etc. But is it reasonable to say that a majority of patients that a psychiatrist sees in private practice are not severely mentally ill and really fit under the category of the "worried well".... That many of these patients shouldn't be on a psych med long term. I am worried that I will feel that I am nothing more than a parasite when treating these patients by getting them hooked on meds they really don't need.


So I guess my question is, Do you feel your treatments for the worried well are 1) Justified 2) Efficacious 3) Rewarding ?

The only thing I'll comment on is that being on Psych Meds long term for MDD/Anx is never the initial plan.

Outside of that, I personally feel you should better educate yourself before forming such strong opinions.

 

[Yoyomama88]

Well given the fact that most psychiatrists do not perform psychotherapy...medication is the primary treatment option. Yes while in theory, the goal is not to have a patient on medication long term, we all know psychiatrists like to have those patients coming back for med checks to pay the bills....and you can only bill for seeing a patient if you're giving them medication...correct?

Also, I do not believe my opinions regarding the treatment of the worried well is inaccurate. I personally have had some very bad things happen to me in my life and psych meds did nothing to help me because they didn't change my thought patterns and they didn't change the very real problems that exist in my life. What Psychiatry offered me was not useful. However some good therapy books helped me turn things around.

I don't think I have any inaccurate opinions regarding psych, my main question really is what types of patients do you see in PP? It really is subjective whether or not you place these types of patients in the "worried well" category or not....it boils down to what is the primary cause of their depression or anxiety? Is it a genetic, primary neurobiological predisposition? Or is it really life experience, thought patterns, lifestyle? Could be a combo of both, but in my case, I believe it was the latter.

 

[OldPsychDoc]

Well given the fact that most psychiatrists do not perform psychotherapy...

Debatable fact. Perhaps do not have 50 minute hour analytic session with majority of their patients, but we still do a lot of therapeutic interventions, and a good portion of residency training is devoted to learning therapy methods and indications. And as I've said before, one does a lot of listening and supportive therapy type things, even in the context of providing medication management.

medication is the primary treatment option.

Not always.

Yes while in theory, the goal is not to have a patient on medication long term, we all know psychiatrists like to have those patients coming back for med checks to pay the bills....

Oh please... There are 12 more on the waiting list hoping to get in to see me before my first available appointment in 6 weeks. If I keep someone on a med it's because I'm actively treating something, or trying to prevent a recurrence of illness.

and you can only bill for seeing a patient if you're giving them medication...correct?

Absolutely incorrect.

 

[Firewood]

Pssst...lean closer and I'll tell you a secret: A few vitamins and some exercise is all our patients really need. But don't tell anyone, I've got student loans to pay.

 

[hamstergang]

Just 2 days ago I did an intake and referred the patient to a therapist without starting any meds. I'll probably see her once more in several months just to make sure that's still appropriate, but otherwise I don't want to start her on meds when therapy seems most appropriate for her.

 

[rkaz]

[Edit: I removed my post as I noticed you are a medical student yourself. I thought earlier you were a 'pre-health' student (according to your profile status) just here to make inflammatory statements against physicians.]

 

[birchswing]

I think it's worth pointing out the possibility that the psychiatrists who frequent this board may be more motivated to be good psychiatrists than the general population of psychiatrists. Do you really think you could even find consensus among currently active psychiatrists that long-term benzodiazepine therapy is not really a valid option for an anxiety disorder? Out of the many psychiatrists I know, I only know one who is inching toward that conclusion. The rest are either uninformed or in denial or don't care. Obviously I don't know all of the country's psychiatrists. But this board isn't really the best sampling, either.

 

[gibits]

Your "worried well" is what I call Adjustment disorder. And when that worried well become worried unwell they come to see me. No one comes to see me to tell me what good worriers they are. They come to me because they are not doing well. Can meds help them? Absolutely. Can therapy help them? Of course. Can we offer both? I certeinly do and I get great results.

Your post presents a bias; why do you say meds will not make your problems go away but never place such a stipulation on therapy? Meds will only take you so far. I use the analogy that my patients are trying to build a house and I just provide the tools. The patient is the one doing all the work I am just giving them hammer and nails. Therapy will help you reframe your problems, help you understand yourself and how you react to stressors. It will not make your problems disappear either.

So to answer your 3 questions: yes to all. But then again your question was invalid to begin with since there is no such thing as a "worried well" patient. At least not one that would seek my help in the first place. "What made you decide to come see me today?" or "What was it that made you want to seek help now?". The answer is almost always: "I'm not doing well, this illness is causing me problems at work/home/relationship". Does that sound like a "worried well" person?

 

[HoboCommander]

If you eat your veggies every week you will never develop psychiatric problems.

 

[dl2dp2]

If you eat your veggies every week you will never develop psychiatric problems.

There were a few sarcastic remarks up there. But just to re-iterate most of what OPD says up above. Most outpatient psychiatrists see are episodic MDD/Bipolar/personality disorders/substance abuse, some psychotic disorder, some OCD/trauma, etc.

Some "worried well" patients nevertheless benefit from psychotropic medications. It's a matter of risk vs. benefit analysis. Things are very complex, which is why you want someone fully trained to do an assessment because you rely on their judgement. If you are a patient, you don't have to get meds from a psychiatrist--you can ask your primarily care doctor or even get some drugs off the streets. But it's the expertise and clinical judgement that you are paying for.

And for those who thinks that it's all BS, I dare you to not get a good psychiatrist if your MOTHER or FATHER or WIFE or KIDS have a psychotic disorder or get severely depressed. I know I would.

 

[MacDonaldTriad]

This discussion and multiple supervision interactions this week make me want to suggest something.

Most of us have inherited patients that seem relatively well and have been on medications a very long time. When they seem intact, but have not functioned well enough to work and are supported by disability. We begin to wonder if we are not colluding in an abuse of benefits. Sometimes this suspicion is correct. We tapper them off and they get angry and go elsewhere. Sometimes we do this and they crash and burn and we do them a real disservice.

“Worried well” patients can surprise you. Don’t be so confident in your ability to tell the difference even with the most exhaustive chart search and reliable collateral information. I say this because it is July and a lot of residents are now meeting their new outpatients. Make haste slowly. You may be smarter than the last ten residents who have been treating your new patients, but even if that is true, your patients need some confidence in your understanding of them.

We make changes and patients will get better or worse. If they get better, you are a hero. If they get worse, you have made them worse and you barely know them. Not a great start to a long therapeutic relationship. You can be a hero in September.

 

[SeniorWrangler]

I'm skeptical regarding psychiatry's medication of the "worried well"- those with depression, anxiety issues that are primarily a result of bad life experiences, poor coping mechanisms, poor lifestyle habits, and poor thought control. I am under the impression that many of these patients can get better with a good therapist, meditation, exercise and maybe some probiotics.

I have to disagree with your assumptions here. There's absolutely no reason to assume that people with "bad life experiences, poor coping mechanisms, poor lifestyle habits, and poor thought control" don't suffer from actual psychiatric illness. There's actually plenty of evidence to suggest that these folks are at increased risk for psych disorders and are less likely to recover without treatment. If psychiatrists aren't supposed to treat people who have these issues, then should internists treat obese people for their diabetes, or smokers for their COPD?

I do agree with your suggestion that lifestyle changes and therapy can do a world of good in most patients, but I don't think they're a substitute for meds in all patients, and I don't think it's nearly as easy as you think it is to get depressed and anxious patients to exercise, meditate, eat right, etc. etc.

 

[Doctor Bagel]

“Worried well” patients can surprise you. Don’t be so confident in your ability to tell the difference even with the most exhaustive chart search and reliable collateral information. I say this because it is July and a lot of residents are now meeting their new outpatients. Make haste slowly. You may be smarter than the last ten residents who have been treating your new patients, but even if that is true, your patients need some confidence in your understanding of them.

We make changes and patients will get better or worse. If they get better, you are a hero. If they get worse, you have made them worse and you barely know them. Not a great start to a long therapeutic relationship. You can be a hero in September.

This times a thousand. I've had "worried well" patients get hospitalized on me, and I've had them turn out to be psychotic. You don't really know. Don't go in assuming all the other providers for your patient have been wrong.

 

[billypilgrim37]

It's amazing how that tylenol overdose fries the liver of your "worried well" patient as easily as it does your other non-cirrhotic patients.

When I came to residency, I had a lot of negative thoughts about the "worried well" too. Residency and fellowship changed those opinions dramatically. The fact that someone wants to see a psychiatrist can be a proxy for exactly how badly someone is doing. Not always, maybe not even most of the time, but the fact that they're coming to you instead of their preacher/PCP/hair stylist/therapist makes them a different risk pool in nonspecific but very real ways. They might be drug-seeking, but they might also be much more ill than they appear. And even very ill people can look very good in between episodes.

 

[shan564]

If you're really worried (no pun intended) about spending your life seeing the worried well, just go into inpatient psych or C/L or forensics or drug/alcohol. Problem solved.

 

[splik]

If you're really worried (no pun intended) about spending your life seeing the worried well, just go into inpatient psych or C/L or forensics or drug/alcohol. Problem solved.

not sure about C/L - consultation-liaison psychiatrists probably see more people without mental illness than psychiatrists in any other setting.

 

[shan564]

not sure about C/L - consultation-liaison psychiatrists probably see more people without mental illness than psychiatrists in any other setting.

Yeah, but in C/L, you can easily say "this person has no mental illness" and sign off on them. That still requires a real psych assessment and the practice of real medicine/psychiatry. I think the OP's concern was the potential patients who just keep hounding you to make them happier even though they have no clear psychopathology.

 

[vistaril]

To answer the question in the title, I think the answer is a good number. Certainly not everyone, maybe not most, but certainly more than a couple. But many of the patients I help aren't helped through a traditional 'medical' model. Helping a pt find ways to get her power cut back on, or budget more effectively, or the pt just knowing you are interested in them and their lives and care(for practitioners that really do) is often more advantageous than being able to tell someone their diagnosis and making pharm recs.

Then again I'm not as gungho about the efficacy of psychotropic medications in here as some, so that probably affects my answer.

 

[shan564]

To answer the question in the title, I think the answer is a good number. Certainly not everyone, maybe not most, but certainly more than a couple. But many of the patients I help aren't helped through a traditional 'medical' model. Helping a pt find ways to get her power cut back on, or budget more effectively, or the pt just knowing you are interested in them and their lives and care(for practitioners that really do) is often more advantageous than being able to tell someone their diagnosis and making pharm recs.

Then again I'm not as gungho about the efficacy of psychotropic medications in here as some, so that probably affects my answer.

Also just helping people manage a complex medical illness that might be difficult for them for cognitive reasons. In the past month, I've had at least 3 people who were admitted to inpatient psych with diagnoses like "catatonia" or "depression NOS" who were just feeling crappy because their blood sugar was out of control.