The Reluctant Psychiatrist

The Reluctant Psychiatrist

3 years ago

When I was a resident physician in training, I remember my excitement in mastering the principles of psychopharmacology. I was so eager to diagnose patients" problems and apply the right treatment.  The treatment plan consisted of addressing biologically correctable facets of the illness presentation and supportive psycho social therapies. This model neatly fit my medical training and the prevailing medical model. Over the years of my practice, I have given many presentations on new medications and disease states to physician groups.

As I age and hopefully become a wiser clinician, I find myself questioning the pure medical model for many psychiatric and chronic medical conditions. I am also more averse to the risks of various therapies for my patients. I am much more aware of temperamental differences among individuals. Many people are leading hard lives and have real existential challenges to their safety and existence. Some have been badly scarred at an early phase of their lives. I am happy that I can still maintain the medical model but apply it in a much more nuanced way that takes into account the patient's experience, individual variability, and possible alternative and holistic therapies.

Since the dawn of psychiatric medicine as a separate discipline, the goal has been to come up with and identify simplistic causes to complex human experiences.  Regrettably, it has fallen short of this goal, and its false promises only aggravate the experience of the person seeking that help and their families.  Thie initial error of wanting to reduce human psychopathology to a particular psychological experience only leads to frustrations and anecdotal success results.  The modern promise of understanding brain functions and neuroscience made strange claims of neurochemistry and "chemical in balance" models explaining experiences such as anxiety and depression. 

In this chaos, the partially helpful interventions available are either based on theoretical loyalty or downright malevolent pharmaceutical interests of their camps of supporters.  The best approach for a benevolent psychiatric physician is to adopt a collaborative approach with the patient, and realistically present risks and benefits of various interventions.  Hence, when an atypical anti-psychotic medication is presented as an augment to antidepressants to manage depression, the possible long-term side effects of tardive dyskinesia cannot be discounted. 

The field itself also needs to retire some of the old voices with strong links to pharmaceutical companies and fund fresh research without theoretical or financial ties to address human suffering.  This does not mean to adopt a defeatist attitude towards mental suffering, but more of a realist and collaborative approach that includes the complexity of human experience, including its existential spiritual dimensions.

 

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