What does patient centered care say about psychiatry as a science?

When asked what makes for good patient care in medicine, a typical answer is that it should be “patient-centered.”  Sure, “evidence-based medicine” and expert clinical guidelines are helpful, but they only serve as the scientific foundation upon which we base our individualized treatment decisions.  What’s more important is how a disorder manifests in the patient and the treatments he or she is most likely to respond to (based on genetics, family history, biomarkers, etc).  In psychiatry, there’s the additional need to target treatment to the patient’s unique situation and context—always founded upon our scientific understanding of mental illness.

It’s almost a cliché to say that “no two people with depression [or bipolar or schizophrenia or whatever] are the same.”  But when the “same” disorder manifests differently in different people, isn’t it also possible that the disorders themselves are different?  Not only does such a question have implications for how we treat each individual, it also impacts how we interpret the “evidence,” how we use treatment guidelines, and what our diagnoses mean in the first place.

For starters, every patient wants something different.  What he or she gets is usually what the clinician wants, which, in turn, is determined by the diagnosis and established treatment guidelines:  lifelong medication treatment, referral for therapy, forced inpatient hospitalization, etc.  Obviously, our ultimate goal is to eliminate suffering by relieving one’s symptoms, but shouldn’t the route we take to get there reflect the patient’s desires?  When a patient gets what he or she wants, shouldn’t this count as good patient care, regardless of what the guidelines say?

For instance, some patients just want a quick fix (e.g., a pill, ideally without frequent office visits), because they have only a limited amount of money (or time) they’re willing to use for treatment.  Some patients need to complete “treatment” to satisfy a judge, an employer, or a family member.  Some patients visit the office simply to get a disability form filled out or satisfy some other social-service need.  Some simply want a place to vent, or to hear from a trusted professional that they’re “okay.”  Still others seek intensive, long-term therapy even when it’s not medically justified.  Patients request all sorts of things, which often differ from what the guidelines say they need.

Sometimes these requests are entirely reasonable, cost-effective, and practical.  But we psychiatrists often feel a need to practice evidence- (i.e., science-) based medicine; thus, we take treatment guidelines (and diagnoses) and try to make them apply to our patients, even when we know they want—or need—something else entirely, or won’t be able to follow through on our recommendations.  We prescribe medications even though we know the patient won’t be able to obtain the necessary lab monitoring; or we refer a patient for intensive therapy even though we know their insurance will only cover a handful of visits; we admit a suicidal patient to a locked inpatient ward even though we know the unpredictability of that environment may cause further distress; or we advise a child with ADHD and his family to undergo long-term behavioral therapy in conjunction with stimulants, when we know this resource may be unavailable.

Guidelines and diagnoses are written by committee, and, as such, rarely apply to the specifics of any individual patient.  Thus, a good clinician uses a clinical guideline simply as a tool—a reference point—to provide a foundation for an individual’s care, just as a master chef knows a basic recipe but alters it according to the tastes he wishes to bring out or which ingredients are in season.  A good clinician works outside the available guidelines for many practical reasons, not the least of which is the patient’s own belief system—what he or she thinks is wrong and how to fix it.  The same could be said for diagnoses themselves.  In truth, what’s written in the DSM is a model—a “case study,” if you will—by which real-world patients are observed and compared.  No patient ever fits a single diagnosis to a “T.”

Unfortunately, under the pressures of limited time, scarce resources, and the threat of legal action for a poor outcome, clinicians are more inclined to see patients for what they are than for who they are, and therefore adhere to guidelines even more closely than they’d like.  This corrupts treatment in many ways.  Diagnoses are given out which don’t fit (e.g., “parity” diagnoses must be given in order to maintain reimbursement).  Treatment recommendations are made which are far too costly or complex for some patients to follow.  Services like disability benefits are maintained far beyond the period they’re needed (because diagnoses “stick”).  And tremendous resources are devoted to the ongoing treatment of patients who simply want (and would benefit from) only sporadic check-ins, or who, conversely, can afford ongoing care themselves.

The entire situation calls into question the value of treatment guidelines, as well as the validity of psychiatric diagnoses.  Our patients’ unique characteristics, needs, and preferences—i.e., what helps patients to become “well”—vary far more widely than the symptoms upon which official treatment guidelines were developed.  Similarly, what motivates a person to seek treatment differs so widely from person to person, implying vastly different etiologies.

To provide optimal care to a patient, care must indeed be “patient-centered.”  But truly patient-centered care must not only sidestep the DSM and established treatment guidelines, but also, frequently, ignore diagnoses and guidelines altogether.  What does this say about the validity, relevance, and applicability of the diagnoses and guidelines at our disposal?  And what does this say about psychiatry as a science?

Steve Balt is a psychiatrist who blogs at Thought Broadcast.

Comments are moderated before they are published. Please read the comment policy.

  • John C. Key MD

    This is a good article which addresses so many of the problems we see today in psychiatry. I went to medical school to be a psychiatrist. I didn’t end up following that discipline, but I’ve remained a close observer of the field. And what I see isn’t very nice.

    Balt correctly points out the negative effects of governmental and insurance company involvement, problems that are common to every area in medicine. At times he sounds almost like Szasz in decrying the lack of scientific markers for diagnosis and treatment.

    As a generalist looking from the outside, the biggest problems I see in psychiatric practice today are (1) sloppy diagnosis–in 2012, who isn’t “bipolar” and (2) polypharmacy. Maybe I am just a Neanderthal but when I trained thirty-some years ago, no self-respecting psychiatrist would have given a patient six or seven meds for treatment, yet today I see that commonly: a mood stabilizer, an antidepressant or two or three, an anxiolytic or two, perhaps an atypical antipsychotic, all topped off with a sleeping pill. I don’t see how the patients can even walk. What sense can this possibly make?

    Back in my early years, psychiatry didn’t have much to offer: phenothiazines, tricyclics, and psychotherapy. Now we almost never see psychotherapy recommended or done any more, and the availability of new drugs seems to have provoked an insatiable desire to use as many of them as possible.

    Psychiatry as a discipline needs to get its act together. Its services are badly needed, but current practice doesn’t do much to recommend itself.

  • Jody Berger

    I appreciate the problems you describe and, at the same time, I question one of your base assumptions. “Obviously” you write of patients and doctors, “our ultimate goal is to eliminate suffering by relieving one’s symptoms.”

    For many patients, the ultimate goal is to uncover the root cause of the symptoms and eradicate it. Or, in other words, patients want to heal, which is different than relieving symptoms. Painkillers can relieve pain but they don’t mend a broken bone.

    I wonder if this is a semantic difference or a philosophical difference. I fear it’s the latter–which points to part of the disconnect between patients and doctors and a gap in so-called patient-centered care.

  • Molly_Rn

    Physicians and nurses should be patient centered. Not every patient read the guidelines or the DSM so they present with multiple problems and they don’t respond the way the book says on page 375 (read your part with feeling). Medicine and also nursing is a weird science because humans are so different and you can’t just do one thing and everything is connected to everything else. Life is messy and so inexact. That’s the “fun” of it and the challange. Sometimes we can’t reach our goals or even fully articulate them. We do the best we can as humans caring for other humans, each of us vulnerable and real.

Most Popular