Psychiatric clinics are full of young adults who struggle with unprecedented levels of anxiety and depression. They don’t feel capable of running their own lives.
Psychiatry has been trying, it seems for 3 decades, to adopt a biological model of treatment. “Depression is a chronic disease, like diabetes,” we are taught to tell our patients. “You wouldn’t skip your blood pressure medicine?” we ask when patient don’t buy into this approach.
What’s wrong with biological psychiatry?
1. Look around. It isn’t working.
Biologic psychiatry took off as the new way of thinking after Prozac. The field of psychiatry was tired of long sessions of psychoanalysis that didn’t produce a cure for many illnesses that were clearly stemming from brain problems. But the health of the population has not improved with the biologic approach. If anything, mental health is a bigger, more expensive, more out of control problem than at any time in history. If pills are the answer, why aren’t patients universally better?
2. We cannot simply ignore environment.
Children who live in poverty, abuse, or neglect cannot just take a pill and feel vibrant. Neither can a recent widow who is steeped in grief, or a lonely elderly man who has no one coming by to check on him. It’s absurd to imagine biology is the magic key for these people, and so many others with financial strain, work stress, unaddressed past traumas, or poor coping skills. If we don’t address the whole person, how can these people be expected to feel better?
3. Intuition tells people there is more.
Sometimes patients come in and ask, “But how is a pill going to make me feel better?” Even non-experts can clearly see that taking a medication might be a tool, but it’s not going to put a broken marriage back together. There will still be stress and pain in the areas that helped fuel a mental health crisis in the first place.
4. Focusing on medication treatments alone is ignoring a large pool of research on psychotherapy, case management, and other psychosocial interventions.
There is a growing body of research showing that patients with a wide array of mental health problems simply improve faster and more completely when they also have psychotherapy and social support. Psychotherapy plus meds performs far better than meds alone in independent trials. Social determinants of health affect outcomes, and when we help address social determinants, patients get better and illness relapse decreases. This research is just as important and useful as the studies showing how drugs outperform compared with placebo, and we (professionals) cannot ignore it.
5. People will not be restored to wellness with only a pill.
Medications are important tools to reduce mental health symptoms, but they won’t get you a job after you were fired during a manic episode. Even for the most highly biologic of the mental health disorders, stabilizing symptoms with medications is only the beginning. Helping people achieve a state of health, wellness, and perhaps even happiness is a bio-psychosocial and spiritual endeavor. Putting a life back together is bigger than a trip to the pharmacy, and that needs to be our goal in mental health.
Every year around the start of October, mental health professionals see a rise in consultations for struggling students. Most commonly, these consultations are to diagnose and treat anxiety, depression, or attention deficit disorder. But sometimes psychosocial factors prove to be at play more than brain biology.
Last week, I had a patient tell me that she had been in mental health treatment for 30 years, and no one had ever told her her diagnosis. She is a smart lady, and knew that the medication she was taking was an antidepressant, so she assumed she was being treated for depression. With a little information she had seen on the internet, she concluded that having depression meant that she was unable to live a normal life. She thought that she must be quite impaired because of the dosage of medication she was prescribed, which she knew to be on the high end. Her previous provider never challenged those assumptions, and, in fact, never talked much about the patient’s perspective at all.
I also heard a teen say that when she experienced her first episode of depression after the death of a grandparent, she was told that she had a mental “disability” and would need to take medication for the rest of her life. She had been trying to convince herself to give up on her dreams since hearing that prognosis.
What we tell (or fail to tell) people about their mental health condition alters the course of their condition. People look to healthcare providers for explanations and interpretations of the facts. We often don’t give patients much explanation, or talk about what they think their diagnosis means. Believing one is disabled or seriously impaired is likely to prevent them from trying to live a full life.
Leaving patients to Google their diagnosis for information is no substitute for hearing the opinion of their treating doctor. Who knows what information they may find? And when we do educate, we need to remember to include the bet case scenario, not just the worst. Neither of the patients referenced above were disabled or impaired. Both were responding well to treatment, and could be expected to live normal lives. They might even be expected to thrive. They both will benefit from hearing that in their future care.
And telling teenagers with stressor induced depression to expect a life of disability is just giving out bad information. Complicated grief can cause a single episode of depression, and some people only have one bout of depression.
I know time is limited, but I think we in the health professions can do better. We are burdened by administrative concerns, but we need to take a few moments to connect with our patients and give them accurate information, and reassurance.
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