In the United States, a country of vast resources, there is an ironic existence of a healthcare system which cares for human beings’ physical and mental health, which in itself is in need of repair. Certain medical specialties are more vulnerable to the shortcomings of our current healthcare system and its’ limitations. Psychiatry, in my opinion, and the patients the field serves, is one of the specialties most affected. Each medical specialty possesses its’ own respective limitations, but also their strengths and resiliencies. I see more resilience when it comes to the more tangible, concrete specialties like surgery, internal medicine or radiology, where there has been an existence of more tangible, concrete tools to diagnose and treat patients. These specialties are able to exist, not optimally, but more effectively, within this broken system without significantly compromising diagnostic accuracy and treatment. Psychiatry is not as resilient.
Unfortunately, the inherent building blocks of the field itself render psychiatry vulnerable as it depends much more on intangibles and it relies much more on time.
Those of us who treat patients with mental and emotional diseases are dealing with an abstract concept: The mind. We can’t palpate, auscultate, or obtain an MRI of the mind. We treat disorders of emotions, feelings, behaviors, perceptual disturbances, and thought.
Yes, there are advances in neuroimaging, measurement of biomarkers, and metabolic rates, but this is still a novel concept when it comes to its mainstream utilization. We do not have the luxury, if you can call it that, of physical examination, diagnostic imaging, laboratory results, or biopsies to assist us in diagnosing or treating.
Psychiatrists rely on an interview with patients who are often depressed, anxious, manic, psychotic, and in many circumstances incapacitated and unreliable. In any setting, from emergency rooms, to inpatient floors, to outpatient offices, we rely on a semi-structured diagnostic clinical interview to guide us to the most probable diagnoses and ultimate treatment. This requires time, and this is where the big problem lies. In my experience, when matched with this health care system, the creation of a giant mismatch has occurred.
A field compromised both by the system and the individual practitioner. Our patients have often filtered down the socioeconomic ladder with poor support and have no means or the appropriate state of mind to hold the mental health practitioner accountable for their actions, question the treatment they receive, or demand for their deserved rights as a patient.
In any setting, from emergency rooms, to inpatient floors, to outpatient offices, I cannot count how many times I have heard from countless patients, “I’m Bipolar”, “I have Major Depression”, “I have ADHD”, or some other singular or combined diagnoses. Some start out requesting specific medications for these diagnoses which they have carried around for years. When I attempted to elicit criteria for such a diagnosis, past or present, they did not meet any such diagnoses.
Further history taking revealed that many were diagnosed by a physician or mental health practitioner who spent a reported 5 to 15 minutes going through a checklist of criteria or having them fill out a questionnaire without placing their symptoms and presentation in the appropriate context or considering the influence of illicit substances.
No collateral or corroborative information was obtained, or in the case of minors or incapacitated individuals, only a parent or guardian’s history was taken into consideration. Most of these individuals did have a true mental health disorder but sometimes not the one they believed they had, and were placed on years’ worth of ineffective trials of psychotropic medications leading to lack of improvement, exposures to unnecessary side effects, and frustration with the medical field and psychiatry as a specialty. Often these individuals were unable to accurately explain their symptoms, as they had difficulty discriminating their thoughts or emotional feelings from physical feelings, and needed help to articulate what was “The chief complaint” and “History of the present illness”. Over the years, many patients intoxicated with alcohol or cocaine made pit stops at emergency rooms and were diagnosed with depression or bipolar disorder inaccurately and placed on psychotropic medications, only to carry them along adding medication and additional diagnoses by subsequent practitioners without addressing their true substance abuse diagnosis. The reverse has occurred, where the client on cocaine was diagnosed with cocaine intoxication and dependence but never had the possibility of a mood disorder thoroughly explored, diagnosed or treated.
Patients who were previously diagnosed ended up often being treated solely on their self-reported “past psychiatric history” without any attempt by the physician to explore and elicit the appropriate criteria warranting such a diagnosis and ultimate treatment, which only can be done by conducting a thorough diagnostic psychiatric interview. So essentially, they are stamped and labeled with their previous often self reported inaccurate diagnoses and then additional diagnoses are added on by various providers solely on the history of presenting symptoms or illness without “truly diagnosing them”. It is a conveyor belt of sorts, assembling a trail of misdiagnoses and inappropriate treatment.
Patients with emotional and mental illness need a thorough, sophisticated diagnostic evaluation. It incorporates appropriate history taking from birth to the present, considering biological, psychological and social influences as well as placing symptoms in the appropriate context and domains while seeking out any necessary collateral and corroborative histories. This is the minimum that needs to be done.
Again, this takes time. All aspects from the chief complaint, history of present illness, past psychiatric/suicide and substance abuse history and treatments, family psychiatric/suicide and substance abuse history, legal history, birth and developmental history, medical and surgical history, current and past medications history and trials, educational history, social history and a mental status examination needs to be conducted on all patients who are to receive a diagnosis by that practitioner. That practitioner has to elicit the diagnosis and be able to validate it. Necessary medical and lab work-ups should be done. I am pretty sure a neurologist is not going to make a diagnosis of right sided hemiplegia and left sided stroke and treat that patient for it without doing the appropriate diagnostic testing and physical examination, not solely based on a the patient’s self report of “past neurological history”. So why are so many people getting prescribed bipolar meds, depression meds, and ADHD medications, to name a few, without the appropriate workups and diagnostic evaluations?
Psychiatrists, and especially mental health practitioners, who make up the majority of those treating mental illness, have a duty to ensure the patient they are evaluating gets the appropriate evaluation, treatment and recommended follow up. This cannot be done in fifteen minutes or thirty minutes for that matter. Our field of psychiatry is too complex, one which we cannot compromise our time with our patients. We are doing them a disservice if we do it any other way.
Psychiatry is not a specialty suited for quantity but quality. Everyone deserves a first opinion, or at a minimum, an accurate second.
Ash Bhatt is Medical Director, The Recovery Place, Chief Medical Officer, EBH Florida Region, Diplomate, American Board of Addiction Medicine, Diplomate, American Board of Psychiatry and Neurology, Adult Psychiatry, Diplomate, American Board of Psychiatry and Neurology, Child and Adolescent Psychiatry.