Upside Down Medicine

Do I need a Psychiatrist?

You Do Need a Shrink After All

Or didn’t you know it?

Consider the following: It is estimated that up to half of the population suffer symptoms consistent with one the recognized psychiatric diagnoses described in the official Diagnostic and Statistical Manual. Of those diagnosed, fewer than half ever have their symptoms treated by a physician. Of the half that receives treatment for psychiatric symptoms, a full 70% are treated by their primary care physicians, while only 30% ever get before a therapist or a psychiatrist.

Now, primary care physicians are generalists. They are not expected to go into great depth in regard to their patients’ behavioral symptoms, nor do they have the time(7 minutes per patient?) nor the expertise to do so. Having seen many patients who have experienced either partial or full treatment failures with their PCPs, I can relate the following highly common scenarios that routinely present to me: 1-The patient is treated by the PCP for depression, but the dose of the antidepressant prescribed is far too low.  It is as if many PCPs feel comfortable only with prescribing what for most people are subtherapeutic doses of antidepressant medications. As a result, the symptoms often do not improve at all, but if they improve some,  the patient is maintained on the inadequate dose and suffers significant symptoms over long stretches of time. This is not, by any means, a “partial success.” Persistent depressive symptoms lead to full relapses of depression, and significantly increase the risk for suicidal behaviors. In addition, the longer depressive symptoms are allowed to fester, the deeper the “rut” they create in the brain, the longer the depression will last, and the more difficult it will be to treat later.

2- The PCP has accurately diagnosed depression, but has failed to detect that the depressive episode is but one feature of a broader Bipolar Disorder with both manic and depressive episodes. He or she has placed the patient on an antidepressant, again for a considerable length of time, but the patient never improves. Indeed, a significant number of such patients suffer a worsening of their manic or hypomanic symptoms such as irritability, aggressive behaviors, hyperactivity, and excessive spending. Not only do Bipolar depressed patients often fail to respond to antidepressants used alone; the antidepressant actually worsens the hypomanic symptoms and can generate a full-blown manic episode. I do not fault the PCP for improper diagnosis in this situation. Often, hypomanic(less than fully manic) symptoms are subtle and quite difficult to detect; many psychiatrists miss them as well. Too, patients will more likely volunteer their depressive but not their hypomanic symptoms. Moreover, it is well-nigh impossible to elicit these symptoms in the brief amount of time a PCP is able to spend with his or her patient. The result? As with depression, failure to timely diagnose Bipolar Disorder and treat it early is not a neutral act. This too leads to deeper, more-treatment-refractory  manic episodes and potential psychiatric hospitalization. Alas, statistics currently indicate that the average time between the onset of Bipolar symptoms and the beginning of its treatment is 8 years! This is far too long a stretch of time for optimal treatment outcomes.

3. The PCP has either under- or over-prescribed benzodiazepines for the patient’s anxiety. “Benzos” are the class of medications which include Xanax, Ativan, and Klonopin, as well as many sleeping medications. Underprescribing is common because many PCPs fear inducing an addiction in their patients, while overprescribing and yielding to the patient’s inappropriate demands for more pills and higher doses often leads to that very result.

4. Whatever the diagnosis , primary care physicians do not often detect dangerous behaviors in their patients, not their suicidal behavior nor homicidal behaviors. These severe behavioral problems are not the strong suit of primary care, and nonpsychiatric physicians generally feel uncomfortable dealing with these extreme symptoms. Moreover, were the PCP to detect such behaviors, he or she would likely both not know what to do with them nor have the time to follow through appropriately. As a result ,the physician prefers and chooses not to ferret out  these behaviors last they render him or her helpless to intervene. This leaves the patient, the physician, at the community in a serious and potentially dangerous situation, whereas the patient should be immediately transferred to  a far more intensive level of behavioral treatment.

None of this is meant to diss or disparage primary care physicians. Quite to the contrary, theirs is a demanding role which is under recognized, under funded, and significantly overtaxed for time. I have immense respect for their work and their burdens. Still, patients are underselling and undertreating themselves when they fail to seek out a psychiatric specialist.  Unfortunately though understandably, people feel they can avoid stigmatization, either their own or others’, as “mental cases” if they seek treatment preferentially from primary care rather than psychiatry. So, in addition to the already-noted diagnostic and treatment issues, it is important too to put behavioral, cognitive, and emotional problems in their proper biological perspective in order to help get beyond the fear of consulting primarily with psychiatry.

As a product of our innate human tendencies toward grandiosity, we would like to believe we have control over our minds. Not so. In fact, hardly so at all. The brain is an organ, not unlike our liver or spleen. Do you control these organs? Do you will your stomach to secrete acids, your pancreas to produce insulin? Do you instruct your gall bladder to release its bile? I certainly cannot. The brain, lovely and complex and elegant though its operationsbe, is similarly an organ, at base, which “does its own thing” for the most part. Need proof? Let’s examine the evidence. Did you consciously author the wonderful, colorful dreams you had last night?  I was quite entertained by my own, like watching fascinating movies one after another, but I have no idea whence the script; certainly not from my conscious mind. Oh, you might argue, "Well of course I do not control my mind at night--I am asleep!” Consider the following : Of the 100 billion to 1 trillion nerve cells in the brain, it is estimated that 1% represent sensory input from the periphery of the body to the brain, and 1% represents output to the muscles and glands. The remaining 98% of neurons represent the brain "talking to itself." Not only do these neurons talk to themselves, they do so most of the time. Specifically, Stage IV sleep(not dream sleep) is considered that part of the sleep cycle in which the brain is most silent. Nonetheless, even in stage IV sleep approximately 65% of those central brain neurons are actively conversing. When we are awake, perhaps 98% of our neurons are chattering away. Neither you nor I are in on the conversation consciously. The brain is mostly talking to itself, silently. The brain, in other words, much like the liver, is "doing its own thing.”

Among the many products of this jabbering are emotional, cognitive, and behavioral symptoms which unfortunately impair our ability to function properly. The symptoms are little more in our control than are our intestinal juices or the beating of our hearts. It is important to get beyond the silly notion that we are somehow to blame for an organic brain which is often designed to produce depression, anxiety, panic attacks,  social self-consciousness , compulsions , mania, schizophrenia, attentional problems and autism from birth. We need to be disabused the phobia of seeing a psychiatrist, and treat this specialist as the one in charge of working with us to remove those symptoms, mostly not of our creation , much as we would look to the cardiologist or gastroenterologist to undo the symptoms in the organs they are trained and mandated to treat .

Don’t sell yourself short.  You do need the shrink after all.