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A Psychiatrist Airs His Professional Doubts

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Did you ever stop to wonder or ask yourself 'what am I doing?' I did and in many ways I wish I had not. As a Psychiatrist, I still do not know what our profession is trying to do. It seems we have a series of solutions and now we are trying to find the problems that they can solve. My observations are either anecdotal or part of research that I have done as a Psychiatric Auditor and are based on my 38 years experience in the field of Psychiatry.

Psychiatrists are treating two major populations: Adults and Juveniles. These populations are further subdivided into severe and mild disturbances.

I am not a Juvenile Psychiatrist, but I speak from impressions and my readings in the field. There is nothing more heart breaking than the severely mentally ill juvenile. We have increased our arsenal of medications, but in results and understanding, compared to other medical professions, our success rate is poor. Prevention is a distant dream.

The mildly mentally ill juveniles are a cause of concern to me. Psychiatry has waltzed into learning disorders with the crusading gusto that only psychiatrists seem to have. We are witnessing the 'medicinization' of a former outlawed drug. The criteria for using Ritalin far too often go unmet. There is no doubt in my mind that children that would not be given Ritalin by experts in the field are receiving it. No one can say with honesty and certainty what the effect of Ritalin use in juveniles will have on their brains as they age. Yet the Ritalin pushers have an almost messianic fervor for their 'solution'.

In the adult population, generally speaking, the influence of the Drug Companies is terrifying. Very few research projects disprove the efficacy of a drug when the trial is sponsored by the drug's manufacturer. Harmful facts that may be discovered are not disclosed. When they are, their importance and significance are downplayed. For example, one of the major, popular, new anti psychotic drugs actively and substantially increases the risk factors for heart attacks or CVAs. In all the adult population the major medical goal is to reduce these risk factors. Only severely mentally ill psychiatric patients are the exception.

It has been shown that after 10 years of illness a psychotic not taking medications is four times more likely to be symptom free than one that is taking medications. Read that again. You would expect the complete opposite. In spite of the hype, the quality of life in patients using the older medications are better than the new. So we are paying more, endangering more and getting less. Not very impressive is it? The mantra of today's Psychiatric Services are something like this:

  • A patient gets ill.
  • He goes to the emergency room where he is admitted or referred to community service organizations.
  • On admission he is diagnosed, medicated and sent home to continue care in the community.
  • He continues his therapy in the community.
  • He is only re-referred if the community cannot cope.

What happens in reality?

  • There are no hard and fast rules or consistency as to who is received and why. A large proportion of first time hospitalized patients will never re-appear in the Mental-Health system. Why were they hospitalized in the first place?
  • Referrals to community care from the ER are done badly, if at all.
  • The vast majority of hospitalized patients remain unknown to community care after discharge.
  • A large proportion of the patients are no longer taking medications in a meaningful way three months after discharge from hospital.
  • Most of the patients seen in community care were not hospitalized.

Grim reading indeed.

Over 30% of the adult population will visit their Family Doctor in any year. 30% of them, 10% of the population, are considered to have emotional problems.

For some reason these emotional disturbances are treated as if they are mild forms of  mental illness. They are not. Very often we are seeing stress caused by poor coping styles or skills. They are treated as if they have, or about to have depression, anxiety, or panic. The vast majority are offered medication. They should be offered alternative drug-free modalities such as Cognitive Behavioral Therapy or Psychotherapy.

Of those referred to psychotherapy much less than half will get past three visits. The major explanation of 'file closure' in these cases is drop-out. 'Completion of therapy' ranks as one of the least given reasons.

Are there any bright points? Yes there are:

CBT: Cognitive Behavioral Therapy is causing a rethink of treatment. It asks a patient to think about their feelings and behavior and thus influence subsequent behavior. This is a good answer for the patients with emotional problems in primary care. It enhances coping skills. This is a different approach from the attempt to cure an illness that does not exist. We can now offer Online CBT in a Self-Help format over the Internet.

Compliance and adherence: This is not a problem inherent only to Psychiatry. Doctors are not trained to explain and ensure compliance. They do not have the time to do simple weekly follow ups. This is easily done using the Internet web sites.

Medical Management: Uniform systematic treatment is essential. It is possible to ascertain accurately patient needs and utilization. It is possible to follow the two parameters in real time. Thus ensuring efficient performance of the Mental-Health system as a unit. Alongside this, the individual patient is never unknowingly lost. This can be done in real time and online.

Yes there is a lot of criticism here. Is it justified?  It certainly is honest and based on my  clinical experience. I have hopefully done my part by initiating a discussion and providing solutions, as I see them to the problems as I saw them.

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  • Matthew Holford

    Dear Dr Benjamin,

    I found this piece quite interesting. I’m currently engaged in a toe-to-toe exchange with the MHRA in the UK over its assessment procedure (it appears to amount to rubber-stamping the opinion of the company applying for a marketing authorization). I’m posting the correspondence on the Uncommon Knowledge depression forum (UKDF), in the hope that the MHRA’s evasive replies will be more influential than anything that I could say.

    Which brings me to the point, I suppose. There are those members of UKDF who have appear to have serious issues, but for the most part, people just want to have somebody to talk to about their “stuff”. People don’t appear to “want” or “need” drugs – they appear to need solutions, and just learning how other people have dealt with similar issues to their own is often valuable. The more serious cases are those who are at the point where they absolutely refuse to try anything new, and won’t even discuss their issues in depth, even though they’ve taken the effort to visit a support forum.

    Anyway, I’m not sure if that adds anything to your experience, but, as you suggest, at one point, above, life skills are what most people are lacking. No drug provides those.

    Best regards

    Matthew Holford

  • Most people involved in the Mental Health System did not learn proper skills in life because they were sexually abused or physically abused as children.

    The lies and manipulations, and living in lies, that results, as well as the lack of felt ownership of their bodies means these people do noyt feel – and are not – in cotrol of their lives.

    There is no strict divide between “orgnanic illness” and psychological problems rooted in childhood. There is as great or greater a correlation between surviving an abusive childhood and getting a diagnosis of Schoizophrenia or Psychosis as an adult.

    On average survivors or Childhood Sexual Abuse spend years in the system before getting appropriate diagnosis if at all. Most never do.

    Psychiatry is forced into a mad world by the division of mind and body medicine into such false camps. We are seeing this with the increasing realisation that the strict barriers erected between mind and matter by Descartes do not exist and the thinking that has lead to in medicine and elsewhere is faulted.

  • It is quite interesting to know your years of experience and your realizations and insights about your field. Well, for me taking up my masters degree, I feel quite a novice compared to you.

    In my little experience as an public health educator, it is indeed true that it is difficult to convince people about the success in psychiatric treatments. Others think that going to a psychiatrist will make you the craziest and the most misunderstood person on Earth. Stereotyping is one of the hindrance why there is a little success in that field.

    Well, as for you Sir, good luck to all your endeavors.

  • Gordon Nielson

    While I concur with the majority of Dr. Benjamin’s basic conclusions, I think the heavy-handed use of generalizations undermines the credibility of his comments.

    I realize that my experience comes from working in mental health in the US, but the scenario presented of typical patient care is NOT typical in that experience.

    I have used CBT as my treatment modality of choice for many years, but I also believe that appropriate use of psychopharmacological agents has a legitimate place in mental health care. I do not have prescriptive authority and do not receive any form of compensation from any pharmaceutical manufacturer, but I have been grateful many times in my work, that certain of those products exist and are available for use.

    Can we agree that stereotypical attacks of any sort diminish our standing and credibility as health care professionals? I would hope as a body of caring individuals we could someday learn to refrain from employing such tactics as we champion our personal causes.

    Thank you.