Psychiatry Rant

[thepoopologist]

Collection of thoughts

1. I don't know if we've advanced far enough to explain why out of two people who see and taste chocolate cake, with resulting similar releases in neurotransmitters (dopamine, serotonin, blah blah blah) one perseon could intensely hate the cake and the other could love it.

2. No there is no biomarker distinguishing the difference between hate and love, the difference between anxiety and mania, the difference between psychosis and a history of trauma. It would be great if these complex emotions could result in your brain crapping out a single peptide that could distinguish one from another on routine lab work.

2. The DSM is not the greatest tool however there was a time before the DSM and before medications where there was literally no consistency in diagnosis or treatment and people were doing things willy nilly. NIMH research now is going beyond the DSM and using their rdoc instead of DSM diagnoses, maybe that will result in the breakthrough we're looking for (eventually). We actually do have scales to assess things like depression, anxiety, psychosis.

3. The medications are more a guessing game with the treatment refractory cases. Things like antidepressants and antipsychotics were discovered serendipitously, appeared to have a good effect on asylum patients and lots of our current pharm is based on these earlier meds. Still people become depressed and kill themselves. Still people hear voices that tell them to kill their mother and then kill them, but at least some of them recover enough to return to society instead of needing to be housed somewhere. If you would like to not refer these patients to psychiatry based on the premise that psychiatry doesn't do anything, be my guest.

4. Psychiatrists vary in quality. The well trained psychiatrist is well versed in what guidelines we have, knows their pharm, and is adequately practiced in therapy. If you observe a psychiatrist who is lacking in any or all of these qualities, why blame the paint for what the painter does. Therapy uses fancy terms to describe common human interaction, so what. Yes the mental status exam is not an exact science.

5. Other specialties crap on psychiatry all the time, and then when they need a patient in the inpatient unit, they come knocking on our door using the terms "manic", "psychotic", "depressed" because they didn't want to deal with this population of patients. They didn't want to assess how suicidal or homicidal someone was before releasing them from the hospital for their next followup appointment in 10 days. They didn't know how to deal with the anorexic or the behaviorally disturbed demented patient or the substance abuser.

6. Ultimately if you don't think psychiatry is a valid field, then choose a different specialty and be done with it.

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[Crayola227]

I literally said that it was necessary and often helpful. I've never argued that it isn't. It's still dehumanizing and depressing. It can be both. You can be grateful for the outcome without losing sight of the fact that the process sucked.
I don't personally find either of your examples particularly dehumanizing from the perspective of the patient, not in the way that institutionalization is; they don't even involve interactions with other people, which I find pivotal to the entire concept of not being treated like a person or considered one.

I don't actually feel that we disagree on the utility or validity of psychiatry, even inpatient treatment, so there's not much debate to be had here.

I do find it interesting that you can choose not to have medical intervention, should it ever become necessary to preserve your life/function. You can choose to risk future death from something that would otherwise be treatable/manageable, simply because you find the treatment too distasteful to be worth the outcome...but you cannot choose the same thing about institutionalization, should it ever become necessary to preserve your own life/function. I don't necessarily disagree with it, but I do find it an interesting philosophical point.

more ignorance

plenty of times I've forced any number of treatments on hospitalized patients, because they weren't competent

it doesn't just come up in psychiatry

people can kill themselves, but we attempt to treat medical conditions that may be the driving force behind that

Basically, my goal is to get someone competent enough to make the sort of choices that will kill themselves. That's true whether or not it's mental health or some other cause.

 

[Crayola227]

There's a difference between holds and institutionalization. The standard for both is quite high - some think too high.

There's plenty of chronic conditions where people have to be institutionalized. Later stage dementia, for example. A lot of those folks aren't safe to live on their own, although they would express wanting to continue living in general, and on their own. That said, many of those folks express a wish to live, and can even meet the test of competency when it comes to choosing treatment to continue living.

So not sure how the example of "bodies that we just make continue to live" is all that relevant to the complex considerations regarding institutionalizing people.

 

[Crayola227]

I don't give a frak if people just don't like psychiatry from a personal practice standpoint.

I don't like surgery - from a practice standpoint.
I don't like pediatrics - I find it too sad and frustrating to deal with that population and their parents.

Wanna talk some ethics of forcing things on patients???

But you don't see me maligning the good that either field does. Not sure why psychiatry seems the field to pick on. Every field of medicine attempts to alleviate suffering in its own way with its own set of tools and set of shortcomings. It's not all the same but it all addresses something about the human condition that needs addressing.

I have enormous respect for the good psychiatry does. I think it is fascinating. As a doc outside psych, I try to do my best as someone outside it to apply to my practice to improve it. However, I couldn't practice psychiatry. Just don't have it in me. I don't think that's a fault of the field or myself.

 

[mehc012]

more ignorance

plenty of times I've forced any number of treatments on hospitalized patients, because they weren't competent

it doesn't just come up in psychiatry

people can kill themselves, but we attempt to treat medical conditions that may be the driving force behind that

Basically, my goal is to get someone competent enough to make the sort of choices that will kill themselves. That's true whether or not it's mental health or some other cause.

I'm speaking more about advanced directives - at a time when someone is competent, they can choose to not let you force those treatments on them in the future, even when they are incompetent.
I know that otherwise we force treatments on people all the time, and I honestly think that's the right path, especially when there's no indication from the pt what they would want...because as you said, that preserves the patient's ability to make future decisions.

I'm not sure why you have to jump straight to calling me ignorant. I've not actually disagreed with you on any point yet, I'm just picking at some of the boundaries of where what's allowed in psych differs from what's allowed in other areas of medicine and pointing them out. Psychiatry is intriguing because the thing being treated is the person's behavior, perspective, etc...which definitely affects everyone's comfort levels when it comes to various interventions (or lack thereof). I'd personally rather talk about that - an area that frustrates many about psych, but is necessary and causes some real differences (and sometimes less than you'd think) compared with medicine - than I would continue the thread as it started, with baseless rants about how it's actually invalid as a field and complete misunderstandings of its successes and processes.

I don't give a frak if people just don't like psychiatry from a personal practice standpoint.

I don't like surgery - from a practice standpoint.
I don't like pediatrics - I find it too sad and frustrating to deal with that population and their parents.

Wanna talk some ethics of forcing things on patients???

But you don't see me maligning the good that either field does. Not sure why psychiatry seems the field to pick on. Every field of medicine attempts to alleviate suffering in its own way with its own set of tools and set of shortcomings. It's not all the same but it all addresses something about the human condition that needs addressing.

I have enormous respect for the good psychiatry does. I think it is fascinating. As a doc outside psych, I try to do my best as someone outside it to apply to my practice to improve it. However, I couldn't practice psychiatry. Just don't have it in me. I don't think that's a fault of the field or myself.

I'm not maligning the good that the field does. I have repeated that in every post I've made in this thread since the beginning. I'm specifically saying "it does good, but I find inpatient depressing and dehumanizing and would not want to do it." I only ever brought it up because, as much as I could not stand to practice psych and have had negative experiences with it both in my own life (when close friends/family have had to deal with the field) and in med school...even so, I can't say that it's not a valid and useful and crucial field. I've actually attempted to move on from the negatives because those just reflect my personal opinion on the field, which has no rational basis and will be different for everyone...as I explicitly stated in my last post. I found the ethics aspect more interesting than reiterating what more educated minds have already said in here addressing the horrible misconceptions in the OP and a few subsequent posts. I didn't start the thread and focus it on psych. If you'd like to start one that tangents into ethics in surgery or peds, I'd be more than happy to discuss, for example, the incredibly convoluted world of ethics when you throw in an interested third party with final say (parents).

 

[hamstergang]

I'm speaking more about advanced directives - at a time when someone is competent, they can choose to not let you force those treatments on them in the future, even when they are incompetent.

At least in NJ, you can make a psychiatric advanced directive. I've never seen anyone actually do it, though, so I don't know all the rules surrounding it. I imagine if you are acting dangerously towards others they'd still involuntarily commit you for public safety reasons.

 

[mehc012]

At least in NJ, you can make a psychiatric advanced directive. I've never seen anyone actually do it, though, so I don't know all the rules surrounding it. I imagine if you are acting dangerously towards others they'd still involuntarily commit you for public safety reasons.

That's really cool! And yeah, autonomy is great and all when it affects your own well-being, but you've gotta draw the line when you endanger others.

 

[Mass Effect]

Not that I don't think psychiatry is not important, but as it is right not, its inefficient and even harmful in some cases.
We still do not understand the brain, we still don't know the mechanisms for almost all cognitive functions, nor the areas involved. And while psychiatrists and are attempting to help with the knowledge we have, their efforts seem like a hit or miss.
I mean something as simple as chronic sleep deprivation can result in serious cognitive impairments and mood instability, which would lead a psychiatrist to falsely diagnose them with depression/anxiety based of arbitrary metrics that are subjective and relative to each individual. Then the patient is prescribed a medication which is not likely to work and can even cause bad side effects, only to come back to the psychiatrist again and get prescription for a different medication and so on. See what I mean?

I just feel like its a broken field, and the patients are suffering because if it.

Uh, just because you've worked with incompetent psychiatrists doesn't mean you should paint the whole field. Any psychiatrist who doesn't consider sleep when evaluating mood is incompetent and shouldn't even be an MS 3, let alone a practicing doc. And OP, I worry about you because if you're being taught by people that incompetent, it makes me wonder what kind of doc you'll be since you're paying your med school to learn from their incompetence. Makes me question your med school too.

It's obvious the OP has had very, very little exposure to either psych or neuro or he/she wouldn't say such absurd things like "we still don't know the mechanisms for almost all cognitive functions, nor the areas involved."

It's also obvious the OP has had zero exposure to legit mental illness or neurocognitive dysfunction, especially outside the hospital, and the difference made by psychiatric medications.

I worry less about psychiatrists and more about the IM or FM doc who can't recognize the difference between mania and anxiety.

 

[AsianPersuasion]

As someone who benefited from psych meds, scr*w you Thanks.

 

[WingedOx]

I worry less about psychiatrists and more about the IM or FM doc who can't recognize the difference between mania and anxiety.

What's fun is when your inpatient psychiatric nurses can't either. I had a great time on one of my last calls as a resident when the nurse called me to tell me the patient who'd been admitted shortly before my shift had a CIWA of ~17. She gave 14 of those points due to "anxiety/agitation" and when I went to see him he was manic as a bouncy ball.

 

[Stagg737]

I literally said that it was necessary and often helpful. I've never argued that it isn't. It's still dehumanizing and depressing. It can be both. You can be grateful for the outcome without losing sight of the fact that the process sucked.
I don't personally find either of your examples particularly dehumanizing from the perspective of the patient, not in the way that institutionalization is; they don't even involve interactions with other people, which I find pivotal to the entire concept of not being treated like a person or considered one.

I don't actually feel that we disagree on the utility or validity of psychiatry, even inpatient treatment, so there's not much debate to be had here.

I do find it interesting that you can choose not to have medical intervention, should it ever become necessary to preserve your life/function. You can choose to risk future death from something that would otherwise be treatable/manageable, simply because you find the treatment too distasteful to be worth the outcome...but you cannot choose the same thing about institutionalization, should it ever become necessary to preserve your own life/function. I don't necessarily disagree with it, but I do find it an interesting philosophical point.

You and I clearly have different definitions of what "dehumanizing" means, so I'll leave that alone.

To your last paragraph, I don't think it's as interesting as you're making it out to be and it's actually pretty clear cut in a lot of cases. The difference is just competency and the possibility of AMS. If a patient isn't of a sound mind, they shouldn't be making their own decisions as they may be directly in conflict with what the patient would want if they were competent. It's the reason the patients I referred to earlier were grateful they were held involuntarily. That doesn't just have to be AMS or psychosis either, it can be with mania or depression, which is why most people who survive a suicide attempt (something like over 99%) are grateful they failed a year later.

What I do find more interesting is how competency is actually determined. Maybe it'll be less interesting to me with more experience, but I haven't had a lot of forensic exposure, so that will be a tbc topic for me. However, I have seen patients who felt treatment was "too distasteful to be worth the outcome" be forced to receive the treatment and deemed incompetent by their physician (not psychiatrist) because the doc didn't like their decision. I've also seen patients be forced to receive chemo because they were deemed "to depressed" to make competent decisions. Not saying whether either situation was right, but I find that far more interesting than someone who is truly mentally incompetent being forced to go to an inpatient unit.

I worry less about psychiatrists and more about the IM or FM doc who can't recognize the difference between mania and anxiety.

The amount of PCPs I've met or worked with who regularly attempt to treat their patient's psych needs but have no clue what they're doing legitimately upsets me. The next time I hear a PCP say that a patient who has multiple mood swings in a day has "rapid cycling bipolar" I may actually scream...

 

[Mass Effect]

You and I clearly have different definitions of what "dehumanizing" means, so I'll leave that alone.

To your last paragraph, I don't think it's as interesting as you're making it out to be and it's actually pretty clear cut in a lot of cases. The difference is just competency and the possibility of AMS. If a patient isn't of a sound mind, they shouldn't be making their own decisions as they may be directly in conflict with what the patient would want if they were competent. It's the reason the patients I referred to earlier were grateful they were held involuntarily. That doesn't just have to be AMS or psychosis either, it can be with mania or depression, which is why most people who survive a suicide attempt (something like over 99%) are grateful they failed a year later.

What I do find more interesting is how competency is actually determined. Maybe it'll be less interesting to me with more experience, but I haven't had a lot of forensic exposure, so that will be a tbc topic for me. However, I have seen patients who felt treatment was "too distasteful to be worth the outcome" be forced to receive the treatment and deemed incompetent by their physician (not psychiatrist) because the doc didn't like their decision. I've also seen patients be forced to receive chemo because they were deemed "to depressed" to make competent decisions. Not saying whether either situation was right, but I find that far more interesting than someone who is truly mentally incompetent being forced to go to an inpatient unit

Agreed, but just as a point of clarification, forensics is where you will deal with competence (competency to stand trial), which is determined by a judge with input from the forensic psychiatrist/psychologist. In the hospital and within the scope of making healthcare decisions, what we actually do is assess for capacity, not competency. They're actually assessed in different ways with different criteria. It's the lack of capacity that causes us to hold people involuntarily. And you're absolutely right, that capacity is assessed in ALL specialties for treatment purposes, not just psychiatry.

 

[mehc012]

You and I clearly have different definitions of what "dehumanizing" means, so I'll leave that alone.

To your last paragraph, I don't think it's as interesting as you're making it out to be and it's actually pretty clear cut in a lot of cases. The difference is just competency and the possibility of AMS. If a patient isn't of a sound mind, they shouldn't be making their own decisions as they may be directly in conflict with what the patient would want if they were competent. It's the reason the patients I referred to earlier were grateful they were held involuntarily. That doesn't just have to be AMS or psychosis either, it can be with mania or depression, which is why most people who survive a suicide attempt (something like over 99%) are grateful they failed a year later.

What I do find more interesting is how competency is actually determined. Maybe it'll be less interesting to me with more experience, but I haven't had a lot of forensic exposure, so that will be a tbc topic for me. However, I have seen patients who felt treatment was "too distasteful to be worth the outcome" be forced to receive the treatment and deemed incompetent by their physician (not psychiatrist) because the doc didn't like their decision. I've also seen patients be forced to receive chemo because they were deemed "to depressed" to make competent decisions. Not saying whether either situation was right, but I find that far more interesting than someone who is truly mentally incompetent being forced to go to an inpatient unit.



The amount of PCPs I've met or worked with who regularly attempt to treat their patient's psych needs but have no clue what they're doing legitimately upsets me. The next time I hear a PCP say that a patient who has multiple mood swings in a day has "rapid cycling bipolar" I may actually scream...

Again, I am not talking about a mentally incompetent person refusing hospitalization for a current condition, either medical or psychiatric. I mean that people can create a list of acceptable/unacceptable medical interventions while they are still healthy and of right mind, that will still apply when they are no longer capable. If I wanted to, right now, I could explicitly document that I reject intubation, transfusion, or any form of resuscitation, should I ever need it in the future. The entire point of such a document is to allow me to make my decisions clear now, in case I am ever incapacitated or incompetent at a future date.
However, if I right now, in full sound mind and mental status, write up a document and have it signed and witnessed that states that I would rather risk serious self harm or even death rather than ever be admitted on a psychiatric hold, nobody is going to listen to that in the future when I am no longer deemed fit. They're going to place me on the hold. Despite that I, while in a fully clear-minded state, made my decisions and preferences clear.

Basically, I am allowed to preemptively accept the risk of possibly fatal complications of future medical conditions I may one day suffer from, but I am not allowed to preemptively accept the risk of possibly fatal complications of any future psychiatric conditions I may one day suffer from. I find that distinction interesting.

 

[Stagg737]

Agreed, but just as a point of clarification, forensics is where you will deal with competence (competency to stand trial), which is determined by a judge with input from the forensic psychiatrist/psychologist. In the hospital and within the scope of making healthcare decisions, what we actually do is assess for capacity, not competency. They're actually assessed in different ways with different criteria. It's the lack of capacity that causes us to hold people involuntarily. And you're absolutely right, that capacity is assessed in ALL specialties for treatment purposes, not just psychiatry.

Idk why but I always get those two terms mixed up. I actually know the differences fairly well, I just always say competence when I mean capacity, which I is a habit I really need to start breaking

Again, I am not talking about a mentally incompetent person refusing hospitalization for a current condition, either medical or psychiatric. I mean that people can create a list of acceptable/unacceptable medical interventions while they are still healthy and of right mind, that will still apply when they are no longer capable. If I wanted to, right now, I could explicitly document that I reject intubation, transfusion, or any form of resuscitation, should I ever need it in the future. The entire point of such a document is to allow me to make my decisions clear now, in case I am ever incapacitated or incompetent at a future date.
However, if I right now, in full sound mind and mental status, write up a document and have it signed and witnessed that states that I would rather risk serious self harm or even death rather than ever be admitted on a psychiatric hold, nobody is going to listen to that in the future when I am no longer deemed fit. They're going to place me on the hold. Despite that I, while in a fully clear-minded state, made my decisions and preferences clear.

Basically, I am allowed to preemptively accept the risk of possibly fatal complications of future medical conditions I may one day suffer from, but I am not allowed to preemptively accept the risk of possibly fatal complications of any future psychiatric conditions I may one day suffer from. I find that distinction interesting.

I see where you're coming from now. I think there's a significant difference though. If a person's mental state is just them being mildly demented/delusional that's one thing, but when it gets to the point that they are a potential risk for harming themselves or others it changes things. The same is true on the medical floor. If a patient doesn't want treatment and expresses that when of sound mind, it's acceptable. However if that person starts ripping out their IVs or directly harming themselves, they are restrained, either physically or chemically, which isn't all that different from the psych standards.

The one point I do find very interesting is that in most places it's unacceptable for someone of sound mind to want to end their life, even in situations where they are terminal and keeping them alive would cause more suffering.

 

[psych md jd]

The entire point of such a document is to allow me to make my decisions clear now, in case I am ever incapacitated or incompetent at a future date.

Correct. Generally, you have the legal right to determine what happens to your body.

However, if I right now, in full sound mind and mental status, write up a document and have it signed and witnessed that states that I would rather risk serious self harm or even death rather than ever be admitted on a psychiatric hold, nobody is going to listen to that in the future when I am no longer deemed fit. They're going to place me on the hold. Despite that I, while in a fully clear-minded state, made my decisions and preferences clear.

Basically, I am allowed to preemptively accept the risk of possibly fatal complications of future medical conditions I may one day suffer from, but I am not allowed to preemptively accept the risk of possibly fatal complications of any future psychiatric conditions I may one day suffer from. I find that distinction interesting.

Correct again. But in the case of a psychiatric hold, it is not your wishes or document which is controlling. Rather, it is a societal [legal] decision that because of your actions/behavior, you need to be on a hold.

 

[Mass Effect]

Basically, I am allowed to preemptively accept the risk of possibly fatal complications of future medical conditions I may one day suffer from, but I am not allowed to preemptively accept the risk of possibly fatal complications of any future psychiatric conditions I may one day suffer from. I find that distinction interesting.

MDHHS - Psychiatric Advance Directive

 

[mehc012]

MDHHS - Psychiatric Advance Directive

Somebody mentioned something similar in NJ higher up...I think that's a really cool concept, and thank you so much for finding a concrete version thereof! It's useful so far as seeing which sorts of things are within the purview of the advance directive (meds, ECT, choice of facility, etc.), as well as what's not (i.e. 'would prefer risk of self harm over institutionalization').

Correct. Generally, you have the legal right to determine what happens to your body.

Correct again. But in the case of a psychiatric hold, it is not your wishes or document which is controlling. Rather, it is a societal [legal] decision that because of your actions/behavior, you need to be on a hold.

And I totally understand that when you pose a risk to others, or when your own wishes (given when of sound mind) are not known as to your own care, because the default is always 'best standard' unless there is POA or advance directive in place. I think it's interesting that it extends so far as to not permit a risk to yourself.

If you subscribe to the medical model of psychiatric illness, then self injurious behaviors become, essentially, the equivalent of a serious adverse event from any other disease...which we are allowed to reject prevention or acute treatment for.

I'm not sure I actually disagree with the distinction (except in the case of physician assisted suicide in right-to-die states, ofc), I just find it somewhat inconsistent.

 

[Mass Effect]

If you subscribe to the medical model of psychiatric illness, then self injurious behaviors become, essentially, the equivalent of a serious adverse event from any other disease...which we are allowed to reject prevention or acute treatment for

Only if you have capacity to do so. Nothing inconsistent about that.

 

[mehc012]

Only if you have capacity to do so. Nothing inconsistent about that.

So if a patient came in, actively suicidal, but with a signed, witnessed, notarized Advance Directive made while in sound state of mind that said he would prefer the risk of being sent home in that state to being placed on a hold...would you send them home?

 

[Mass Effect]

So if a patient came in, actively suicidal, but with a signed, witnessed, notarized Advance Directive made while in sound state of mind that said he would prefer the risk of being sent home in that state to being placed on a hold...would you send them home?

If I worked in a state that allowed for advance directives for psychiatric illness, yes.

 

[mehc012]

If I worked in a state that allowed for advance directives for psychiatric illness, yes.

Cool. But my point is that most places don't seem to allow for that...so I'm not sure how that fits your 'Nothing inconsistent' statement above.

I'm also curious as to WHY these illnesses are treated so differently. I love that you have a consistent attitude on this, but the fact that we have to wonder whether such types of advance directives exist highlights the fact that that is not necessarily common.

 

[Mass Effect]

Cool. But my point is that most places don't seem to allow for that...so I'm not sure how that fits your 'Nothing inconsistent' statement above.

I'm also curious as to WHY these illnesses are treated so differently. I love that you have a consistent attitude on this, but the fact that we have to wonder whether such types of advance directives exist highlights the fact that that is not necessarily common.

No, they aren't common and that's something to change in the law. My guess is that one reason why many states don't have psychiatric advance directives, aside from the fact that no one has likely lobbied the legislature, is because the nature of many psychiatric illnesses don't allow for the person to have capacity unless they're being actively treated. A schizophrenic is likely going to be on antipsychotics when he/she has the capacity to say "in the future, if I decompensate, no antispychotics." That, in and of itself, is inconsistent.

 

[nicola.kirwan]

Antipsychotics even--they may improve the daily functioning of people with schizophrenia, but until there's a treatment that is more directed towards the underlying disease (perhaps not realistic), they will always seem to me like a much gentler version of the lobotomy.

Antipsychotics are perhaps a somewhat blunt instrument; but maybe a blunt instrument is better than none. In fact, isn't chemotherapy a rather blunt instrument as well? The most common criticism many laypersons wield against it is that it attacks healthy cells just as much as malignant ones. Research has made strides toward increasingly targeted therapies, but it has taken time. Maybe psychiatry is behind other fields, but you have to keep at it to ultimately get anywhere. I think progress will largely depend on developments in neuroscience.

And treatment of psychosis is probably the number one factor in favor of psychiatry because its presence and resolution can be easily observed. Now, I have wondered though if enough research has been done on allowing episodes of acute psychosis to naturally resolve or resolve through other therapies vs. treating it with drugs because the assumption has become that it is medically necessary to treat with drugs.

Unfortunately I think that psychiatry got caught up in America's quick-fix, consumerist culture. If a pill is marketed to the public as being able to take away your internal struggles, many people will go to their psychiatrist asking for exactly that. I also suspect that the overmedication of kids for ADD, ADHD, etc. has just as much to do with parental attitudes and expectations as it does with psychiatrists.

 

[Mass Effect]

And treatment of psychosis is probably the number one factor in favor of psychiatry because its presence and resolution can be easily observed. Now, I have wondered though if enough research has been done on allowing episodes of acute psychosis to naturally resolve or resolve through other therapies vs. treating it with drugs because the assumption has become that it is medically necessary to treat with drugs.

It's treated because people with acute psychosis are usually unable to function. That isn't the case with things like hyperlipidemia or diabetes.

Unfortunately I think that psychiatry got caught up in America's quick-fix, consumerist culture. If a pill is marketed to the public as being able to take away your internal struggles, many people will go to their psychiatrist asking for exactly that. I also suspect that the overmedication of kids for ADD, ADHD, etc. has just as much to do with parental attitudes and expectations as it does with psychiatrists.

Until you've suffered from mental illness, please don't call a psychiatric medication a "quick fix." It's no more a quick fix than a statin or beta blocker is a quick fix and it's insulting to those with mental illness to suggest such. As for your last sentence about ADHD, I could say the same about antibiotics for the common cold, which are still routinely prescribed by many in the medical profession.

 

[theSupremeHobgoblin]

Bottom line: there is good EMPIRICAL evidence that psychiatric medicines alleviate symptoms, prevent and stem episodes and recurrences, and change patients' lives, statistically significantly more so than placebos. What more do you need?

What's the alternative? What suggestions are you really making?

Someone else posted this at the top of page 1, so search for Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses

 

[psych md jd]

So if a patient came in, actively suicidal, but with a signed, witnessed, notarized Advance Directive made while in sound state of mind that said he would prefer the risk of being sent home in that state to being placed on a hold...would you send them home?

No.

An Advanced Directive is different than a psychiatric hold.

An Advanced Directive, like the MDHHS, allows for the patients wishes and choices be known regarding advocates, choice of hospital, choice of provider, medications, and procedures. That form deals with voluntary patients: "My admission as a formal voluntary patient...," "I still have the right to give three days notice of my intent to leave a hospital if I am a formal voluntary patient."

A psychiatric hold, on the other hand, is involuntary. If a patient presented as described, and meets the legal criteria for involuntary hospitalization, the procedure is initiated allowing for confinement, observation, evaluation, and treatment. If the patient does not meet criteria, he/she cannot be held involuntarily, but may consent to voluntary hospitalization. Despite being on a hold, a patient can refuse medications and treatment, unless it is an emergency.

Now, I have wondered though if enough research has been done on allowing episodes of acute psychosis to naturally resolve or resolve through other therapies vs. treating it with drugs because the assumption has become that it is medically necessary to treat with drugs.

Sometimes an acute drug induced psychosis will clear in a few days without the need for meds.

Studies have shown that prolonged psychosis is a toxic state. Not treating it is like deciding not to put out a fire, resulting in more injury and disability.

 

[Candidate2017]

So if a patient came in, actively suicidal, but with a signed, witnessed, notarized Advance Directive made while in sound state of mind that said he would prefer the risk of being sent home in that state to being placed on a hold...would you send them home?

A depressed patient with active SI is incapacitated, incompetent and a threat to society. I'm morally, medically and legally bound to hold them. Irrational people make irrational choices. You've probably never met a depressed, suicidal patient who's driven into oncoming traffic and will do so again if given the opportunity, have you?

Terminally ill patients who are suicidal can be fully competent with capacity. I have no problems with someone of sound mind wanting to kill themselves. However verbalizing it to me means they are ambivalent on some level. A patient who wants to commit suicide can just lie to me, say they don't feel suicidal, get discharged and kill themselves. But they don't because they want help.​

 

[Candidate2017]

Antipsychotics are perhaps a somewhat blunt instrument; but maybe a blunt instrument is better than none. In fact, isn't chemotherapy a rather blunt instrument as well? The most common criticism many laypersons wield against it is that it attacks healthy cells just as much as malignant ones. Research has made strides toward increasingly targeted therapies, but it has taken time. Maybe psychiatry is behind other fields, but you have to keep at it to ultimately get anywhere. I think progress will largely depend on developments in neuroscience.

And treatment of psychosis is probably the number one factor in favor of psychiatry because its presence and resolution can be easily observed. Now, I have wondered though if enough research has been done on allowing episodes of acute psychosis to naturally resolve or resolve through other therapies vs. treating it with drugs because the assumption has become that it is medically necessary to treat with drugs.

Unfortunately I think that psychiatry got caught up in America's quick-fix, consumerist culture. If a pill is marketed to the public as being able to take away your internal struggles, many people will go to their psychiatrist asking for exactly that. I also suspect that the overmedication of kids for ADD, ADHD, etc. has just as much to do with parental attitudes and expectations as it does with psychiatrists.

How many of these anti-psych people are actually med students or physicians? If you are, I would love for you to encounter in the ED or on the med floors a patient with increasing CPK and lactate being restrained by 5 security officers, kicking, spitting and screaming about killing the devil. I would love for you to tell your attending and RNs, "Eh, let it self-resolve." Active psychosis is a medical emergency.

Get outta here with the quick fix nonsense and ADHD rant. That's a PCP issue.

 

[michaelrack]

agree with psych MD JD.

Let me just add that psychiatric holds usually have nothing to do with incompetence/incapacity - They are typically based on danger to self/others - and I often place them on patients who have capacity. Occasionally I will place them on patients who lack capacity (for example, Disorganized schizophrenic incapable of meeting his own physical needs), but typically the patients I put on a 72 hour hold have capacity- for example, female college student who overdosed after an arguement with her boyfriend, who is no longer suicidal, but I would like to observe on the psych unit for a day or 2 before discharging.

 

[Mass Effect]

agree with psych MD JD.

Let me just add that psychiatric holds usually have nothing to do with incompetence/incapacity - They are typically based on danger to self/others - and I often place them on patients who have capacity. Occasionally I will place them on patients who lack capacity (for example, Disorganized schizophrenic incapable of meeting his own physical needs), but typically the patients I put on a 72 hour hold have capacity- for example, female college student who overdosed after an arguement with her boyfriend, who is no longer suicidal, but I would like to observe on the psych unit for a day or 2 before discharging.

Depends on state law and clinician's judgment, I guess. I've discharged people like that before. Unless I feel they are at imminent risk of self-harm or if the suicide attempt was pretty serious or if the patient is pretty nonchalant about it/minimizes it, I will discharge. I will also put people on 72-hour hold when they don't have capacity to voluntarily consent to inpatient admission. For instance, I had an older patient several months ago who had an extensive history of schizophrenia and was willing to come in voluntarily. When she got to the unit, she was confused about where she was, wasn't even oriented at all, and didn't quite understand what was happening, though she would have signed anything I gave her. I put her on an involuntary hold because she just didn't have the capacity to voluntarily sign herself in.

 

[Crayola227]

not really up to thinking about terminology, I think my point was that there are plenty of opportunities in fields outside psychiatry to "force" treatment on patients "for their own good" who are otherwise not able to consent, or even refuse/resist intervention

this happens for reasons ranging anywhere from delirium to dementia, other causes of AMS, and all sorts of other complexities

often it's a totally ethical course of action (not always), and I wouldn't say is dehumanizing or lacking dignity when done appropriately, or is any more lacking comparing psych to other fields where this happens

in fact, it can be so so much worse in other fields

when you hold the acutely suicidal depressed patient as an example, most are able to do a song and dance and get discharged within a short time frame, and are free to just try again, possibly using what they have learned to succeed in a further attempt. So you've only "taken away" their choice for a short time, hopefully long enough that should they regret their earlier attempt, they now have the chance to course correct. Many are grateful for the intervention. Those that aren't, can just bide their time. Infringing on the proportion of those in this category I think is justified by the lives that might be saved with intervention. That's medicine; balancing risk of harm with benefit, NNT, beneficience and patient autonomy and other ethical considerations, while also considering the effects of treatment not just on one patient but a population.

This same example can apply to other that are acutely psychotic, etc.

OTOH, in other fields, a lot of frak ups where you intervene and later find out the patient didn't want the intervention, can't be undone as easily. I can think of a couple of very sad cases of resuscitation. In some cases the consequences of intervention can't be undone with a discharge or an extubation or other removals of care.

So I would argue that ultimately psych patients, even on the inpt side, have a lot of choice left to them, or at the very least, the goal is to get them well enough to to not be an immediate danger to themselves and others, and to discharge and return to them freedom of choice.

 

[Crayola227]

I think I just take issue with characterizing those with mental illness and the best interventions we have, including those that need long term hospitalization, as being dehumanized or lacking dignity.

I would say the same for those suffering with ALS, late stage dementia, etc: any situation where patients can't care for themselves or have drastically reduced QOL due to their conditions. I prefer to think that we need to take care to do as much as we can to treat these patients with dignity and humanity. Sounds like semantics but I think it carries a much different connotation and possibly has an effect on care.

 

[Crayola227]

How many of these anti-psych people are actually med students or physicians? If you are, I would love for you to encounter in the ED or on the med floors a patient with increasing CPK and lactate being restrained by 5 security officers, kicking, spitting and screaming about killing the devil. I would love for you to tell your attending and RNs, "Eh, let it self-resolve." Active psychosis is a medical emergency.

Get outta here with the quick fix nonsense and ADHD rant. That's a PCP issue.

This sounds so exactly like a case I saw in med school that I wonder if we are from the same place....

Or maybe this presentation isn't that uncommon.

 

[Crayola227]

Again, I am not talking about a mentally incompetent person refusing hospitalization for a current condition, either medical or psychiatric. I mean that people can create a list of acceptable/unacceptable medical interventions while they are still healthy and of right mind, that will still apply when they are no longer capable. If I wanted to, right now, I could explicitly document that I reject intubation, transfusion, or any form of resuscitation, should I ever need it in the future. The entire point of such a document is to allow me to make my decisions clear now, in case I am ever incapacitated or incompetent at a future date.
However, if I right now, in full sound mind and mental status, write up a document and have it signed and witnessed that states that I would rather risk serious self harm or even death rather than ever be admitted on a psychiatric hold, nobody is going to listen to that in the future when I am no longer deemed fit. They're going to place me on the hold. Despite that I, while in a fully clear-minded state, made my decisions and preferences clear.

Basically, I am allowed to preemptively accept the risk of possibly fatal complications of future medical conditions I may one day suffer from, but I am not allowed to preemptively accept the risk of possibly fatal complications of any future psychiatric conditions I may one day suffer from. I find that distinction interesting.

I think an issue in the case where you want to hurt yourself AND you don't have capacity or competency or whatever, you're not in your right mind, if you've lost some touch with reality as you are psychotic, or are not able to articulate understanding of what might be the reasonable outcomes of refusing treatment (quick and dirty definition of capacity for making decisions), is to what extent are you a danger to others.

If you're totally with it to the point that you can get yourself d/c'd and kill yourself, great, I think you might manage that and not injure others. OTOH, perhaps you decide to go out "suicide by cop", jumping off a bridge into traffic, gun kill spree, murder suicide, even swallowing your gun a bullet could pass through. That's all suicide choices that hurt others that even "with it" people can make.

So I would argue that it's one thing for you to want to commit suicide when you're with it enough to arrange your own discharge. To some extent people who are going to practice self-murder, I would argue might be more of a concern about possibly hurting others compared to those who are mentally well, or stable, or don't need inpt tx, and don't express any SI/HI.

OTOH, while the proportion of mentally ill people who become violent is less than the gen pop, a psychiatrist is always considering to what extent are you a danger to others. If you're being held against your will because of the danger you are to yourself, often you're also a danger to others.

I think it's one thing to refuse a transfusion, and another to think that you should be able to ask that you not be institutionalized if you become psychotic to the point of being a danger to yourself or others. Which I would argue many are just by virtue of being a danger to oneself in many (not all) cases. No man is an island.

 

[Mass Effect]

This sounds so exactly like a case I saw in med school that I wonder if we are from the same place....

Or maybe this presentation isn't that uncommon.

It's not uncommon.

 

[Crayola227]

The one point I do find very interesting is that in most places it's unacceptable for someone of sound mind to want to end their life, even in situations where they are terminal and keeping them alive would cause more suffering.

I dunno. I see a lot of providers essentially pushing some people with one foot in the grave all the way into it.

Also, as long as you are of sound mind and can express your wishes, you can refuse treatment. There is a movement to hospice and palliative care that I see a lot of docs making. Granted a lot of people might not qualify for hospice.

Many times what drives the sort of suffering you describe are families, IMHO. Even advance directives can get thrown out by family pressure and docs, I've seen it so many times.

I think the greatest barrier is, as I always say, doctors getting all Latin about acting as teachers of patients and families. The current grind of medicine is so much a limiter. I find that if you have a good palliative care team you can consult that's a godsend.

 

[Crayola227]

Antipsychotics are perhaps a somewhat blunt instrument; but maybe a blunt instrument is better than none. In fact, isn't chemotherapy a rather blunt instrument as well? The most common criticism many laypersons wield against it is that it attacks healthy cells just as much as malignant ones. Research has made strides toward increasingly targeted therapies, but it has taken time. Maybe psychiatry is behind other fields, but you have to keep at it to ultimately get anywhere. I think progress will largely depend on developments in neuroscience.

And treatment of psychosis is probably the number one factor in favor of psychiatry because its presence and resolution can be easily observed. Now, I have wondered though if enough research has been done on allowing episodes of acute psychosis to naturally resolve or resolve through other therapies vs. treating it with drugs because the assumption has become that it is medically necessary to treat with drugs.

Unfortunately I think that psychiatry got caught up in America's quick-fix, consumerist culture. If a pill is marketed to the public as being able to take away your internal struggles, many people will go to their psychiatrist asking for exactly that. I also suspect that the overmedication of kids for ADD, ADHD, etc. has just as much to do with parental attitudes and expectations as it does with psychiatrists.

Um, I do think that all of human history and well-documented cases of psychosis by providers in the past (Osler and Freud and such, may have had a lot of mistaken ideas about etiology of many illnesses, however the past is full of docs who were able to make excellent and accurate observations) as well as in this very century, I think can give us a pretty clear idea of the natural course of a lot of illnesses with psychosis.

Keep in mind I'm only talking about very severe mental illness, not the sort that I think can be ambiguously ascribed to societal factors.

I recently reviewed the history of figures like Van Gogh, Mozart, Beethoven, Churchill, Lincoln. Their struggles are pretty clearly documented. Many had periods of relative wellness, so I hesitate to think a lot of their extreme and well-documented symptoms were a result of a consumerist society gone wrong.

I do see what you mean, there is a cohort of people that I think need medication, and a cohort that need life transplants and other therapies.

 

[WingedOx]

Depends on state law and clinician's judgment, I guess. I've discharged people like that before. Unless I feel they are at imminent risk of self-harm or if the suicide attempt was pretty serious or if the patient is pretty nonchalant about it/minimizes it, I will discharge. I will also put people on 72-hour hold when they don't have capacity to voluntarily consent to inpatient admission. For instance, I had an older patient several months ago who had an extensive history of schizophrenia and was willing to come in voluntarily. When she got to the unit, she was confused about where she was, wasn't even oriented at all, and didn't quite understand what was happening, though she would have signed anything I gave her. I put her on an involuntary hold because she just didn't have the capacity to voluntarily sign herself in.

I'd get worried that she belongs on the medical floor in that situation.

 

[Mass Effect]

I'd get worried that she belongs on the medical floor in that situation.

Nah, she was medically cleared in the ED (and I agreed with that assessment). It wasn't a new presentation for her. Full workup on previous admissions and baseline presentation, but definitely didn't have capacity to sign in.

 

[hamstergang]

OTOH, while the proportion of mentally ill people who become violent is less than the gen pop, a psychiatrist is always considering to what extent are you a danger to others. If you're being held against your will because of the danger you are to yourself, often you're also a danger to others.

I don't know that this is really true. Thinking back to the involuntary commitment forms I've signed, I can't say it was "often" that I considered someone dangerous to others based on their potential method of suicide. If someone seems imminently at risk for suicide, that ends the conversation right there (more or less) without a need to think if there is also risk to others involved.

 

[Crayola227]

I don't know that this is really true. Thinking back to the involuntary commitment forms I've signed, I can't say it was "often" that I considered someone dangerous to others based on their potential method of suicide. If someone seems imminently at risk for suicide, that ends the conversation right there (more or less) without a need to think if there is also risk to others involved.

maybe we should start considering that more

even today I talked to someone who is considering jumping in front of a truck - nevermind that it's not a given that the truck just plows through you and keeps on trucking

when you consider the harm that even just someone finding your body can do... there's not a lot of methods that don't put others at risk of psychological harm if not outright physical harm

I don't pretend that it's a consideration for actually committing someone, but the the poster who said that they think people should just be free to be mentally ill and attempt suicide when criteria for commitment is met... there's a difference in implications to others when you refuse intubation vs some sort of advance directive where someone wants to decline hospitalization for psychosis or acute suicidality with intent to go forward

you can't have an advanced directive for your dementia where you can just live at home, leave the burners on your stove, and burn the apartment building down, or just wander the streets where you might wander into traffic (obviously this happens, but it's not like we can respect someone's wishes to be released into the wild to potentially do these things)

so ultimately the idea that society is always going to do what you want done with yourself under all health conditions is just ridiculous no matter how you slice it

this gets into positive vs negative rights... you might argue I have the right to kill myself or be extubated, but I don't have the right to jump into traffic etc

 

[Crayola227]

Putting aside suicide in the context of terminal illness (although many times removal of care and allowing the natural progression of many illnesses will lead to death), the state has decided no one has the right to knowingly take action for the express goal of killing oneself.

Individual rights aside, it makes total sense for many societies to prohibit this practice, I'm talking sociologically speaking.

Mother Nature, societies, families have a vested interest in the continuation of most members' lives, and, interestingly enough, there is much to be gained even by someone's miserable existence than by suicide as far as others might be concerned.

As I always say, Mother Nature just wants us to contribute efforts towards reproduction (this I believe can be efforts towards the society), and it doesn't give a damn about how happy we are doing it. Happiness has some evolutionary benefit, clearly, but it's not the end-all be-all in my view of how this all works.

Seems silly to me to bemoan many of the limitations imposed on us by society, like that we're called on to continue to live and break our backs under the weight of it all.

Moaning about society intervening to prevent suicide over the good of the whole - just seems like some sort of millennial bullshyte.

Not all suicides are by depressed people. But, depressed people absolutely have distortions in thinking. Most just want their pain to end, and can't imagine there is a better way to accomplish this. Many will look back on their lives thinking that they've never been much better, and so can't imagine ever being better in the future. Often the depression is distorting a realistic appraisal of both the present and the past. There is also frequently a tunnel vision on their pain, and less realistic assessment of how damaging their suicide will be on others. We know all of this to be true based on what people frequently report when they recover from depression. (also psychosis as well).

The fact that frequently suicide is driven by these very real distortions that can be treated, putting someone in a much better place to make reasoned and informed decisions, is just one reason to justify intervention.

The conditions under which a society comes to thinking the suicide by otherwise fairly well or young individuals.... has historically been pretty narrow. I don't see that going away anytime soon, going by history so far.

 

[Crayola227]

I have some experience with assisted suicide. So I've seen suicide chosen in circumstances where I think it was well-reasoned, informed, and not driven by changeable or self limited reasons, distorted thinking, mental illness, or impulsivity.

I've read about people choosing suicide based on philosophical beliefs and not health. I mean.... OK. Like, I don't know what we should stop this Darwin Award process, but I hardly expect most societies to turn around and go for this. Maybe Sweden.

I mean, under what conditions do you think your mom should support your choice for suicide?

This concept of expecting societies to stop imposing involuntary interventions regarding this, is just ridiculous to me. Not realistic. Maybe if the pop density gets high enough. But then you're likely to have wars and such. So many ways for people to die. Society wants to direct who and why.

 

[NickNaylor]

Collection of thoughts

1. I don't know if we've advanced far enough to explain why out of two people who see and taste chocolate cake, with resulting similar releases in neurotransmitters (dopamine, serotonin, blah blah blah) one perseon could intensely hate the cake and the other could love it.

2. No there is no biomarker distinguishing the difference between hate and love, the difference between anxiety and mania, the difference between psychosis and a history of trauma. It would be great if these complex emotions could result in your brain crapping out a single peptide that could distinguish one from another on routine lab work.

2. The DSM is not the greatest tool however there was a time before the DSM and before medications where there was literally no consistency in diagnosis or treatment and people were doing things willy nilly. NIMH research now is going beyond the DSM and using their rdoc instead of DSM diagnoses, maybe that will result in the breakthrough we're looking for (eventually). We actually do have scales to assess things like depression, anxiety, psychosis.

3. The medications are more a guessing game with the treatment refractory cases. Things like antidepressants and antipsychotics were discovered serendipitously, appeared to have a good effect on asylum patients and lots of our current pharm is based on these earlier meds. Still people become depressed and kill themselves. Still people hear voices that tell them to kill their mother and then kill them, but at least some of them recover enough to return to society instead of needing to be housed somewhere. If you would like to not refer these patients to psychiatry based on the premise that psychiatry doesn't do anything, be my guest.

4. Psychiatrists vary in quality. The well trained psychiatrist is well versed in what guidelines we have, knows their pharm, and is adequately practiced in therapy. If you observe a psychiatrist who is lacking in any or all of these qualities, why blame the paint for what the painter does. Therapy uses fancy terms to describe common human interaction, so what. Yes the mental status exam is not an exact science.

5. Other specialties crap on psychiatry all the time, and then when they need a patient in the inpatient unit, they come knocking on our door using the terms "manic", "psychotic", "depressed" because they didn't want to deal with this population of patients. They didn't want to assess how suicidal or homicidal someone was before releasing them from the hospital for their next followup appointment in 10 days. They didn't know how to deal with the anorexic or the behaviorally disturbed demented patient or the substance abuser.

6. Ultimately if you don't think psychiatry is a valid field, then choose a different specialty and be done with it.

Completely agree with all of this.

OP, if you're interested in some actual somewhat thought-out critiques of psychiatry, at least plagiarize Thomas Szasz or some other known critic of psychiatry. Psychiatry is far from perfect, there is no doubt about it, but what would you have us do instead? You claim that psychiatry is pseudoscience, that there is no objective way to validate our diagnoses, and that response rates to medications are poor. To that I say... what then? What would you propose we do with folks who currently benefit from psychiatric intervention?

Psychiatry has a long way to go compared to other medical fields, but I'm not sure what exactly it is you'd propose we do if your argument is, essentially, that psychiatry is bull****.

 

[Crayola227]

I don't know that this is really true. Thinking back to the involuntary commitment forms I've signed, I can't say it was "often" that I considered someone dangerous to others based on their potential method of suicide. If someone seems imminently at risk for suicide, that ends the conversation right there (more or less) without a need to think if there is also risk to others involved.

more on this idea, it seemed to me whenever I was interviewing someone, I would ask about SI/HI, and it just made sense to me that when someone is getting so desperate and mentally ill that they are thinking about violence as a solution (towards themself), to consider if they are also thinking about hurting others.....

I'm not sure why you wouldn't think about this. Especially since it seems like a lot of crises involve some degree of issues with interpersonal relating.... like, are they suicidal because their SO broke up with them? wouldn't you consider if they are thinking about murder-suicide? I've frequently been surprised how much that comes up

 

[hamstergang]

I'm not sure why you wouldn't think about this.

Because as I said, it doesn't change anything. You are keeping in the hospital the person who seems to be an imminent risk of suicide regardless of how many other people would get hurt with their chosen method. I'm sure we could construct a scenario where this does change our clinical decision, but such a scenario doesn't seem to occur in real life very often.

 

[fivelikes]

This is so ignorant... psychiatric medications have saved and improved so many lives. There are people who literally could not function without them. Granted, there are problems with the field as there are with any area of medicine, but to call the entire profession of psychiatry a sham when it has done so much good is just ignorant.

 

[apoptosisosis]

Fair enough, what are your thoughts on this paper publish in NEJM:

Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy




Sent from my iPhone using SDN mobile

 

[Crayola227]

Because as I said, it doesn't change anything. You are keeping in the hospital the person who seems to be an imminent risk of suicide regardless of how many other people would get hurt with their chosen method. I'm sure we could construct a scenario where this does change our clinical decision, but such a scenario doesn't seem to occur in real life very often.

Fair enough. We're talking clinical decision-making vs. the theoretical issues surrounding involuntary holds/institutionalizing patients for the greater good. Since we were talking abstract notions about the "dehumanization" and "dignity" of patients it seemed fitting to point out protecting the safety of a patient often is also protecting the safety of others, one reason that justifies doing so.

 

[psych md jd]

Psychiatric treatment may not be "great" today, but it is better than it was in the past considering that a few hundred years ago if you saw things or heard voices you were probably labeled a witch and burned at the stake.

A few other therapies from the past:

Edit: link to Medscape won't work. Try searching for Medscape Odd and Outlandish Psychiatric Treatments Throughout History

[Does mesmerism sound like TMS?]

And, treatments today are better than being chained to a tree or heavy farm equipment.

Given Medicine, the Patients Got Better. They Remained in Shackles Anyway.