Psychiatrists should talk with patients, not just give pills

My psychiatrist friend Danny Carlat has an important and deeply moving article in today's New York Times Magazine.

Danny describes the pendulum swing for psychiatry - going from a "brainless" phase, in which psychological factors were seen as the cause of all psychiatric troubles, to its current "mindless" phase in which "chemical imbalance" is looked to as the explanatory factor. Danny referred to my cohort of psychiatrists - who were trained with a strong psychological grounding in the 1950s - 1970s but were able to incorporate the advances in psychopharmacology that have emerged in the last 20 years as a "golden" generation, able to offer "the full package of effective psychiatric treatments to patients."

Danny started his residency training in 1992, which means that he emerged into a world that made "split treatment" the expectation. Psychiatrists made diagnoses and prescribed medications. Psychologists, social workers, and psychiatric nurses provided psychotherapy.

Happily, my career did not involve that model. I had a large panel of patients in my practice. I did psychotherapy and, when medication was called for, prescribed it. When patients began to ask if I was a "psychopharmacologist" I was puzzled. We wouldn't ask a primary care doctor if he was a prescriber. Talking with patients, getting to know them as full human beings, and conducting whatever form of psychotherapy was called for, and, at the same time, assessing their symptoms, thinking through the diagnosis, and prescribing any medication that was called for - that's what it meant to be a psychiatrist.

Danny's superb article discusses all of this with eloquence and depth. But what's most moving is how he weaves in his own life story. His mother suffered from a severe mental illness. During his junior year in college she committed suicide. "Psychiatry," he tells us, "then became personal, a way for me to come to terms with her illness."

After discussing the flaws in the "split treatment" model, Danny describes the kind of integrated treatment that I had the good fortune to be able to apply. But he doesn't just talk in the abstract - he makes the topic as personal as could be. Here's how the article ends:

During my mother’s last months, she isolated herself from her family, so I don’t know what kind of treatment she was receiving before her death. But I do know what kind of treatment I would have hoped for her. She needed medication to combat her paranoia and the emotional pain of her depression. She needed someone who could expertly probe her thought process, in order to understand the fateful logic that led her to conclude that the only solution was to end her own life. She needed treatment that was intensive and exquisitely coordinated.

Such care is not always capable of saving damaged lives. But it is the best that we can do. It’s what we owe our patients — and ourselves.

I couldn't agree more!

I encourage readers to follow the link to Danny's article. It's full of hard-earned wisdom!