Chapter 3 of Robert Whitaker’s book, Anatomy of an Epidemic, is fairly short and begins his discussion of the history of psychopharmacology and the changes it brought to the practice of psychiatry.  Much of this section seems to revolve around the concept of the “magic bullet.”

The crown jewel of biological psychiatry is the randomized, controlled trial.  If it is well-constructed, it can be simple, elegant, and powerful.  But in assessing medications, it can have some problems.

How can we assess the value of a tool independently of the one who uses it?  If I give golf clubs to 100 people, the better golfers will use them better and have better scores.  If I give paintbrushes to 100 people, the better artists will make better paintings.  If I give hammers to 100 people, the better craftsmen will make better structures.  What will happen if I give better medications to 100 doctors?

I recently sang at the funeral for the wife of a friend of mine.  The funeral was very nicely done.  It impressed on me the positive role that ritual can have in our lives.  The function like sign-posts and mile markers on our travels through life.  They remind us of the major events in life and encourage us to stop for a moment, get outside ourselves, and share in the intersection between our own personal self-realization and our communal social existence. 

I hope this post will be short.  It seems unfair to expect much out of a chapter entitled, “Anecdotal Thoughts,” but Robert Whitaker felt it was important enough to include, so I will cover it.

I just finished reading Crime and Punishment by Fyodor Dostoevsky.  In it, the main character, Rodion Rommanovich Raskolnikov, commits a double murder, and through the narrator we are given access to all his thoughts and feelings leading up to, continuing through, and following the murders.  In some ways, this is an excellent (thought fictional) case study of an intensely conflicted and unstable mind.  Rodion is sometimes called “mad,” but no diagnosis is ever given.  All we are given are the “facts” of the case in greater detail than any court or mental health provider will ever experience.

So my questions to any readers who happen by here are as follows:

1.  Is Rodion Rommanovich Raskolnikov mentally ill?  How can we know?

2.  If you somehow knew what was going on, would you have involuntarily hospitalized him?  How would you approach the decision?

3.  In the book, Rodion is found guilty of the murder but was given a reduced sentence because of his mental state.  Was justice done?

I hope that these questions will generate some productive discussion and lead some to enjoy this fascinating book.

One recent book that has many people talking is Anatomy of an Epidemic, by Robert Whitaker.  This book is a challenging read and throws the gauntlet down to psychiatrists who believe that medications are helping their patients.  The book is extensively researched and refers to a great deal of data.  Despite this, I believe that his conclusions are wrong.   I hope over the next several months to address his book in several posts.  Today, I will start with his first chapter.

Everyone in my family is a big fan of Disney movies.  Last week, my daughter wanted to watch “Tangled” again, so we took a few hours out of our Saturday and watched it together.  Although (like most Disney movies) the story was significantly altered from the known early versions, I was struck by the portrayal of the relationship between the “mother” and her “daughter.”  The story opens up interesting issues that touch on trauma and “care-giving” run amok.

As I have been reading psychiatry blogs, I have noticed that the idea of biological psychiatry is often the target of strong negative feelings.  This may be due to past bad experiences with psychiatrists who seemed to rely too heavily on the biological model.  It may be due to a simply philosophical difference between the commenter and the biological psychiatry community.  There may be any number of additional reasons not to like biological psychiatry.  Still, biological psychiatry is a science and is based on a sound philosophical basis.

As part of my blog, from time to time I would like to post some ideas that show that biological psychiatry has value.  My goal is NOT to show that it has all the answers or even all the most interesting questions.  My goal is also NOT to defend every assumption or assertion made by every biological psychiatrist.  I would simply like to discuss the ideas underlying the field and how they are used to address the ideas of mental illness and what it means to be human.

The length of my follow-up visits varies from 15 to 30 minutes depending on the complexity of the problem and the stability of the patient.  In general, I prefer the longer time, but some of my patients feel that they can get everything they need in the shorter period.

When I have follow-up visits with my patients, I prefer them to come to the session with an agenda.  Of course, this does not have to be written out, but I think it is important for the patient to be the driving force behind the work done in the session.  Agenda items might consist of (but are not limited to) the following:

1.  Ongoing or new symptoms,

2.  Ongoing or new stressors,

3.  Medication side effects,

4.  Efforts to engage in normal activities of daily living (accompanied by a report of relative successes or difficulties),

5.  New medical problems and treatments, and

6.  Current goals.

Much of the early part of the session is usually spent talking about the above topics, how to understand them and integrate them into the patient’s life, and how they affect the treatment plan negotiated between myself and the patient.  By the end of this part of the session, my patient and I should have a reasonable agreement concerning what issues need to be addressed and a mutually acceptable way of addressing them.  If not, then a brief period of targeted Motivational Interviewing (too long to describe in this post) is used to try to improve mutual understanding, clarification of the patient’s goals, and identification of obstacles to progress (from the patient’s point of view).

Later in the session, we will take time to discuss the types of new treatments or alterations of ongoing treatments that are available to address the patient’s goals.  We will discuss the likely outcomes and side effects of each of the available choices and how to monitor progress (or lack thereof).  No decision needs to be made during the session if the patient is not ready to choose a treatment.  The patient may ask questions or may simply take additional time to consider how he wants to proceed.  Once the treatment decision is made, or we agree to delay the decision to let the patient make a decision later, the session is usually over.  A return appointment (if necessary) is scheduled by the office staff.

Importantly, if suicidal or homicidal thoughts are reported during the session, these will be addressed.  Every effort will be made to protect the safety of the patient or the object of the homicidal thoughts using the least restrictive means available.  Most such thoughts will not be found to indicate imminent harm to anyone, so no immediate action is necessary.  Some thoughts may indicate some danger, though the patient and I will be able to devise a plan that adequately minimizes the danger.  If so, then outpatient treatment may proceed as planned.  Very rarely, however, the thoughts and behaviors observed will raise the possibility of hospitalization, which will be sought voluntarily unless the patient simply cannot cooperate with this procedure.

Many of my patients are nervous when they come for their first visit to my clinic.  Many have fantasies about what will happen or concerns about things they will be asked to talk about.  They may worry about what I will think about their problems or if I will coerce them into some situation they fear.  I am writing this post for my patients and for others who might have concerns about what psychiatrists do.  This post addresses only my practice.  Other psychiatrists may do things very differently.