Where Is Guilt?

Why Leave Childhood?

Integrated Care: I Don’t Think So

Training primary care physicians to manage mental health problems is now termed “integrated care,” a phrase I have come to associate with those fingers on a chalk board. In my old, pre-Prozac life, integrated care was a wonderful way of encouraging collaboration between mental health providers and bodily health providers. Communication facilitated a deeper understanding of the patient and that excitement brought me to the field of  psychiatry. Psychiatrists could share with primary care (we did not call them that then, they were internists or family practitioners), the issues the patient was struggling with, in broad confidential terms, while at the same time, primary care physicians could shed light on how their physical problems might be impacting their activities of daily living. This was, dare I say, the “good ole’ days.” Now, however, integrated care means that the psychiatrist does “chart review” and based on the electronic medical record (which tends to have a minimal narrative) offers suggestion for treatment. Oh my, the history taking skills of a psychiatrist are once again, no longer valued, or needed. In fact, the psychiatrist is seen as the physician who offers the “magic potion” which will elevate the patient away from his suffering, all without ever making eye contact with the patient. The primary care physician makes the eye contact, but not really, since he/she is buried in making sure the electronic record is filed and hence his eyes are often on the computer, and maybe for a few minutes on the patient. Yes, the upside of this paradigm is that more people will have mental health services, but that brings us back to the question of whether bad care is better than no care? However, for the moment, I am not focused on the patient care aspect of this paradigm, but rather I am focused on the job satisfaction of the psychiatrist. How do you feel pleasure from suggesting a medication, when in fact, there are no “magic bullets,” but rather a journey, or as Yalom says, a “fellow traveler” aspect to healing. Psychopharmacological intervention needs to be woven into that journey, rather than extracted as a separate avenue. In my mind, integrated care means integrating medication into psychotherapy, rather than integrating medication into a seven minute primary care visit. So, I am all for a comprehensive approach to mental health care, one that integrates body and mind, but doing this with limited time, simply makes no sense.

Teaching Depression

 

Fall is here and I return to teaching psychoanalytic candidates about mood disorders. As per my style I open the class as a confession. “I do not understand depression,” I say, “after 25 years of practice, psychoanalytic training, psychiatry training, and life experience, I remain clueless as to what that word means.” The dye is cast. The students perceive my style immediately, mostly positively, with a visible sign of relief associated with validation. The discussion ensues. Nature vs. nurture. The role of trauma versus the role of mental constructs associated with the trauma. Does a person “make himself depressed” or is a victim of “depression.” Psychoanalysis, the study of the unconscious, argues that negativistic thinking is related to unconscious conflict, and when this becomes conscious, the person can resolve the conflict and take charge of their mental state. The is counter to the argument that depression comes on like a kidney stone attack, with mysterious forces, resulting in agony. The issue of agency, as to whether the person controls is mental state is key to the conception of depression, as on the one hand, this is the “blame the patient” approach, but on the other hand, if the patient is responsible for his mood, then he can fix it. The helplessness associated with depressed feelings could be a defense against dealing with even more difficult or agonizing issues, such that when the patient understands that although he feels helpless, he is not helpless, he can begin to consider how helplessness aids him in his avoidance of deeper conflicting feelings. Ada, thirty-seven, comes to mind. She has continual thoughts of wishing she were dead and she feels this is “just part of my life, I have always felt that way.” “That sounds how your mom feels as well,” I say, highlighting that those feelings may reflect a very strong identification with her mother’s state of mind. “You mean other people do not feel that way?” Ada says with genuine wonder. “It is interesting that you do not see wishing you were dead as a problem of your mental state,” I say, helping her to see that passive suicidal ideation is a sign of mental distress. Understanding how people think and feel about their lives is the key to understanding how they frame their world, and in so doing, how they have moods which change with both external and internal circumstances. At the end of the class I suspect that my students and I will share our confusion together, and in true psychoanalytic style, we will feel richer for it. Like studying philosophy, the more we learn the more confused we get. It is a fun class.

Why Therapy?

Anxiety

“Help, I can’t swim! No immediate danger, but it does worry me.”

Anxiety….

 

 

 

 

“Help! I can’t swim! No immediate danger, but it does worry me.”

Opiates, Race, and Public Health

 

http://www.theatlantic.com/politics/archive/2015/08/crack-heroin-and-race/401015/

 

“Heroin use has changed from an inner-city, minority-centered problem to one that has a more widespread geographical distribution, involving primarily white men and women in their late 20s living outside of large urban areas.”

What role should psychiatrists play in this changing epidemic? Is Opiate Use Disorder, (the new ICD 10 language), a psychiatric diagnosis? The issue of psychiatry and addiction has always been murky. Substance abuse as a disease is the common conception, and yet, little is known about what is diseased. What is the difference between substance abuse and criminal behavior? Is every armed robber in need of psychiatric treatment? Is there a difference between bad behavior and “sick” behavior. This Atlantic article highlights the issue that when the problem is predominantly in minorities, we tend to criminalize the behavior, but when the problem hits the middle class white folks then we see the need for rehabilitation.

Certainly the field is exploding, both because of the epidemic of opiate use disorders and the expanding health care coverage for drug problems. Yet, our understanding is very primitive. How do we help these people? Is it “tough love” or should we put them in a cocoon, feed them three square meals and tell them how to spend their time? Should we pamper them so they learn to love themselves or should we turn off the spigot of support so that they can “hit bottom”? Or, do we start with the loving, warm approach to treatment and slowly, as they “get better” diminish the support? Do they need group therapy, individual therapy and/or family therapy? How long does therapy take to prevent a relapse? On the other hand, if relapsing is part of the problem, then how do we hold providers accountable for their treatment?

Accidental overdoses are an all too common happening in this world. Who is responsible? Heroin use has grown in popularity in large measure because of prescription opioids. When the patient cannot get their “pills,” in order to prevent withdrawal, they have to switch to heroin. So, do we hold the prescribing doctor responsible for the addiction, or is this physician just trying to provide relief to needed suffering? What about the drug companies? Are they to be praised for creating a pill which diminishes pain, or are they the evil corporations which knowingly gets massive amounts of people addicted to drugs which  could lead to death?

Psychiatrists usually do not treat chronic pain, and yet we do have medications which diminish the cravings associated with substance abuse. Again, are we part of the problem or are we part of the solution? Diminishing cravings is helpful, but does it make sense to substitute one drug for another? Certainly if we can prevent the rise in accidental overdoses we are helping the world, but on an individual basis, the answer is less clear. In a simplistic sense, psychiatrists can be most helpful by trying to help the patient understand the escape. What is the patient trying to numb out about? Is it trauma? Usually, in my experience, the answer is yes. Metabolizing this trauma, helping to put it in perspective with a caring listener is, by my way of thinking, the best way for psychiatrists to help these patients. When the patient faces the childhood trauma with an adult, mature mind, the patient has less of a need to escape themselves. Can I prove that what I propose is true? Nope, but neither can anyone else. Given the lack of evidence in this field, intuition has to play a role, until otherwise notified.