Knee-jerk Psychiatry

April 7th, 2013 by gelenberg Leave a reply »

She was a young woman who’d grown up in an abusive family. Like so many others, she re-created her familiar home environment with a series of abusive partners—bearing children from a number of them. She easily grew frustrated and irritable. Feeling desperate one day, she made a life-threatening suicide attempt and was hospitalized.

 He was a middle-aged man who had built and run a successful business for decades. The business came on hard times, he went into bankruptcy, and his wife left him. He too felt desperate, made a very serious attempt on his life, and also was hospitalized.

In both cases, the serious suicide attempts resulted in a general-hospital stay, followed by transfer to a psychiatric facility. Each patient was diagnosed with a mood disorder, then treated with psychiatric medications—lots of medications. Each was discharged on multiple antipsychotics and antidepressants, a couple of benzodiazepines, gabapentin, and an antihistamine (presumably for additional sedation and anxiety relief).

Within weeks of hospital discharge, each patient showed the adverse effects of these medications: akathisia, parkinsonian signs, substantial weight gain, decreased libido, lipid and glucose abnormalities, and more. The mood-disorder diagnoses seemed questionable to me. More, the cognitive and affective side effects of these complex pharmaceutical regimens made it hard to disentangle preexisting symptoms. The out-patient doctors were challenged in their attempts to establish a therapeutic rapport and help these troubled human beings find new coping strategies in difficult circumstances.

So often what I see around the country is superficial, knee-jerk psychiatry. Harried doctors assume a serious suicide attempt must mean a mood disorder—which is often, but not always true. And a mood-disorder diagnosis (even Depression NOS) and psychiatric admission “demand” medications—often many.

How did we get to this state? Everyone loves to hate insurance companies—except their shareholders and senior executives. Most of us complain about DSM-3 and -4 (and in about a month -5). And medical educators know that Psychiatry often fails to attract the best and brightest medical-school graduates: we don’t get enough respect, our patients are stigmatized, managed care forces us to do short visits, our compensation is low among specialties, etc.

It’s all true. But somehow people in crisis deserve a little time with a knowledgeable, thoughtful professional, who can blend neuroscience with social and psychological dynamics, who brings compassion and wisdom to the clinical encounter. Psychiatry in 2013 has powerful tools. Let’s find a way to employ them with care.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

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