Why this is an exciting time to work in psychiatry

Today, I celebrated mental health care.  And this was after a morning of battling with insurance companies, patching together community care plans, trying to create an inpatient bed for a suicidal patient where none exist, and arguing with agencies for better patient support.

I work on a busy inpatient psychiatric unit that provides a daily reminder of the beauty, heartache, and pain that define living with mental illness.  The diverse stories of each patient I treat range from energizing to hilarious to heart-wrenching.  They are always unique and ever compelling.

Lack of access, violence and escalating suicides suggest inadequacies within mental health care policy.  But there is one more thing — there is hope.

Patients and their families succumb to overwhelming frustrations and feel nothing more than desperate on a daily basis.  They are overwhelmed by the stigma of “madness” not to mention the poor funding and lack of resources that stunt their potential.

When psychiatry makes the news, it is usually due to some national catastrophe.  We know about the extreme cases.  We can also document those patients who manage to reach out for help during a lucid moment or are committed involuntarily.  But of the estimated one quarter of the United States population that will suffer from mental illness, many suffer in the isolated dark because of their fear, shame, and helplessness.

Historically, a diagnosis of a severe mental illness meant a “grave” prognosis, or worse, indefinite commitment to the “madhouse.” Patients who got help took heavy duty medications, the side effects of which were sometimes worse than the disease itself.  The older antipsychotics, for example, might have given patients involuntary muscle spasms, thus necessitating other drugs.   So began the Whac-a-Mole phase of living with mental issues.  The pills might slow the ravaging of the cerebral cortex, but they would clobber the liver, requiring another pill, which put something else at risk … and so on and on.

Thankfully, psychiatric medications are improving, research is thriving, and clinical training is invariably rigorous.   Diagnoses have also evolved from wastebasket terms like “hysteria” to a more thoughtful classification system.  Although not perfect, the Diagnostics and Statistical Manual (DSM), in its fifth edition, arranges target symptoms interfering with an individual’s ability to work, play and love in a way that can be tracked, studied and modified.

Just like any other chronic illness, mental illness bends the arc of a patient’s life but it does not have to define it.  Surviving a major mental illness and achieving success in this world are not dissonant.  Ellyn Saks (law professor) and John Nash (Nobel Prize Laureate) are proof of success despite a major mental illness.

In 2013, The American Foundation for Suicide Prevention honored Sergeant Kevin Briggs for his tireless efforts with the California Highway Patrol.  He is credited with stopping many suicides from the Golden Gate Bridge, an iconic structure and site of over 1,600 intentional jumps to death.  He is one of many heroes who remind us that if one person can significantly impact a life, then collectively, the nation could effect a dramatic change.

The urgency for enhanced mental health services could not be more compelling.  Congress has started to take notice.  In 2008 they responded with the Mental Health Parity and Addiction Equity Act, intended to end longstanding insurance practices that discriminated against people with mental illness and drug and alcohol addictions.  But parity legislation was only a first step to stopping discriminatory mental health coverage practices.

A new bill is being offered to Congress which is the most ambitious overhaul plan in decades for the mental health care system.  It offers much hope to patients, families, and practitioners who work tirelessly every day in a system that is broken.  The prospects for the bill were proposed by Representative Tim Murphy, Republican of Pennsylvania.  Helping Families in Mental Health Crisis Act provides more than two dozen measures that could go a long way in fixing the nation’s mental health system.

The legislation does everything from clarifying the Health Information Portability and Accountability Act (HIPAA) privacy rule to fixing the shortage of inpatient psychiatric beds to promoting court-ordered “Assisted Outpatient Treatment” (AOT).  The latter is by far the most controversial issue and most important.

Rather than curtailing a person’s civil rights, as opposition to the bill insist, it strips away the real force impinging on a patient’s freedom — their severe and disabling mental illness.  These are not mild disorders.  The targets of the bill are the seriously mentally ill who are at high risk for death, homelessness or incarceration if left untreated.

Despite the challenges, this is an exciting time to work in psychiatry and a very hopeful time for clinicians, patients, and families affected by mental illness.  We are moving towards integrated care as practitioners, with primary care physicians and other specialists coordinating closely with behavioral health providers for everyone’s benefit.

At the same time, we need Congress to continue to pass legislation that closes that ever-widening chasm between fighting mental illness and achieving mental health.

Helen M. Farrell is a psychiatrist who blogs at Frontpage Forensics and can be reacted on Twitter @HelenMFarrellMD.

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  • DeceasedMD

    “Helping Families in Mental Health Crisis Act provides more than two dozen measures that could go a long way in fixing the nation’s mental health system.”

    Agree this is a step in the right direction.

  • QQQ

    Dr. Micahel Savage Ph.D talks about psychiatrists with ties to drug companies


  • JR DNR

    “Need to Treat” is an unnecessary and dangerous idea. There are ways we can provide help to people with illnesses that cause emotional regulation problems or cognitive problems.

    Is someone’s disability or illness prevents them from caring for themselves, providing food and shelter – yes, we have a right as a society to intercede. This is not a criteria that is based on “need to treat.”

    If someone’s illness causes them to commit crimes, then yes, we as a society have a right to intercede. Again, this isn’t based on a “need to treat” criteria.

    We don’t do that by deciding a few illnesses count as “mental illness” which is a sub-human category that is deprived of personal rights, just because we don’t really know what causes them or how they work.

    The new DSM-V is not scientifically based and opens wide “mental illness” in an alarming way. Combine the DSM-V with this law and we have trouble.

    We already have cases like Justina Pelletier – where an intern dismissed her illness, diagnosed by a reputable institution, and decided she had Somaform disorder. She was subsequently removed from her parents home to force treat her for a mental illness she doesn’t have.

    Let’s not forget – we don’t know how many illnesses that impact emotional regulation or cognition even work. Our treatments control behavior but have horrible life shortening side effects. They aren’t cures. They sometimes make the patient even worse while we take shots in the dark trying to find a medicine that will help. There may not be a medicine that will help.

    This bill is dangerous and should not be passed. Let’s stop putting “mental illness” in a separate category. They are “physical illnesses that cause emotional regulation problems or cognitive problems.”

    • guest

      The term “physical illness that cause emotional regulation problems or cognitive problems” is not accurate, however. The vast majority of psychiatric illness for which involuntary treatment is required is associated with symptoms such as psychosis, where the patient is not in contact with reality, or very impaired insight, where the patient has lost the ability to recognize that they have an illness. These are both unique conditions that are not typically found in any other sort of medical illness, and create difficulties in treating these patients which most medically trained clinicians cannot overcome, hence the term “psychiatric illness” as a separate entity from “medical illness.”

      • JR DNR

        This bill doesn’t specify “psychosis” nor limit it’s power to those in psychosis.

        We know that cortisol disregulation plays a role in PTSD. More and more, PTSD is being seen as a real medical illness.

        Schizophrenia? We still know almost nothing about it. And please, I have two family members with schizophrenia, don’t insultingly tell me we can come anywhere close to treating this disorder. I would estimate it takes about 60 seconds for someone who doesn’t know them to realize there is something very seriously “not right” about them.

        At the same time, I find it completely insulting that you think they have anything other than a medical illness. Obviously, there is something wrong with them, and it’s not “just in their heads” – there are biological processes that we don’t understand.

        Sleep related hallucinations occur in about 25% of the population according the the American Sleep Assoiation. Yet, how often do people talk about experiencing hallucinations on tv, in the movies, in the newspapers or magazines? Never. Because that’s how afraid people are that their benign, completely normal experiences could be a sign of mental illness. What if they did go for evaluation? Seeking help is now classified in DSM-V as evidence you have a mental illness!

        • SarahJ89

          Ditto on dissociation, a phenomenon that is at times perfectly normal, sometimes a healthy reaction to an insane situation. It’s almost never talked about and when it is often is medicalized as an aberration.

          • JR DNR

            I agree with that. Fight-flight-freeze: dissociation during a stressful incident is frequently the freeze response at play. We used to think of freeze as a “prey animal only response” so of course humans don’t do it (but we do).

            I remember watching a video of a person being attacked by a killer whale. They survived by freezing. The whale eventually got bored and left them alone and they escaped. Good example of freeze as a “normal” response.

            I think the DSM4 at least made an effort to separate normal from problematic by stating that the issue has to have a significant impact in your work and personal life. I believe that requirement has been removed in the DSM5.

            When someone starts having a freeze response during normal life to normal daily situations at home, work, and school, then something is wrong. The body (not the “mind”) is over responding to stimuli. We’re only barely starting to understand it, and are far from effectively countering it.

            I think it’s also easy to confuse micro-sleeps with disassociation.

          • SarahJ89

            Interesting, JR. Freezing is a sort of forgotten response. Very few therapists I’ve known address it. It’s as if flight or fight are the only options.

            As I’ve worked on my own PTSD issues and worked with many abuse survivors I’ve come to realize that children who grow up in sadistically abusive homes actually *are* prey animals. This has profound implications that are pervasive and long lasting.

            I am in my mid-60s. My life is happy. I love my work, love the life I’ve built with my husband of 35+ years. I am in probably the very best part of my life and I am well aware of this so I savor every day.

            But… as we were walking over to the nearby pond for our daily early morning swim today I was observing that one of the reasons I love this swim is because I can go out into the middle of this nearly deserted lake, look around me at all the water separating me from shore and the humans thereupon. And feel safe. Safe in a deeply wired way that I doubt other people would understand.

            The fact is my early experience as prey will never leave me. The things I learned them saved my life and it will probably never feel safe to give them up. I never feel safe among members of my own species. When stressed I head to the woods where no one can see or find me or onto water where I can see anyone coming. It sounds totally insane, I’m sure, but this is what goes on beneath the surface on a very deep level.

            There is a huge barrier between people who feel comfortable when within sight of houses with humans in them and those who do not.

          • JR DNR

            Thank you for sharing this.

          • SarahJ89

            Check out a book by Anna Salter, Ph.D. called Transforming Trauma. She has done some interesting research.

    • J Rizzo

      I agree with your point that the stigma of shame should be removed from mental illness. However, psychiatric medications work, they relieve suffering, and they help people live lives in recovery. Fear of institutions abusing these medication and their patients is not justification to think that mental illness is simply an issue with “emotional regulation”. Good clinical psychiatric diagnosis present predictable manifestations of specific brain functions that work differently on an organic level. To disregard mental illness as a “cognitive problem”, well, THAT is demeaning.

      • JR DNR

        I will disagree with you that psychiatric medications work. Do you have family or friends, people you know outside a medical setting, that have serious mental disorders? Do you know what they say to their family and friends when the doctors aren’t around?

        I see Dementia and Schizophrenia as being one in the same: Illnesses that cause mental impairment.

        I think treating diseases or symptoms of diseases as if they are simply mystical, incurable, mysterious “mind disorders” is much more stigmatizing and demeaning.

        • J Rizzo

          Why would you assume that I don’t have family and friends that live with and recover from serious mental illness. Why do you think that I am not one of those people?
          We differentiate dementia and schizpohrenia because they have different symptoms and we use different medications to restore our patients to the best health possible.
          Who says mental illness is mystical? I’m sorry if you or some one you care about has been treated unfairly or (mis)labeled. I think psychiatry is about optimal wellness, not illness.

          • JR DNR

            Why would I assume you don’t?

            Because you said “psychiatric medications work, they relieve suffering, and they help people live lives in recovery.”

            I see dementia and schizophrenia as the same: diseases. I hope you can overcome your prejudice someday.

      • SarahJ89

        How can you make a blanket statement such as “psychiatric medications work”??? You must know the newer antipsychotics, which are being prescribed and marketed directly to patients wholesale, cause serious metabolic problems, massive weight gain and diabetes. I have two many friends who are not psychotic who were sold this bill of goods as “add ons” to their barely better than placebo SSRI’s who are now stuck with diabetes and weight they’ll never lose to let this statement pass without comment.

        I also have two friends whose schizophrenic siblings died in their late forties of massive MIs after years of these antipsychotics which caused the usual weight gains. In the latter cases they were between a rock and a hard place in terms of symptom management. But don’t confuse partial management at great cost with something that “works.”

        By the way, I do not think dementia and schizophrenia are the same illness. In fact, dementia is often a symptom, not a disease, of an underlying problem.

        • DeceasedMD

          A criminally mentally disturbed pt open fire on his psychiatrist and CM in Philly last week. Must have been a rough place. MD had a gun so survived.

          • SarahJ89

            Ah yes, I remember reading about that. Didn’t remember it was in Philly.

            We had a social worker murdered in our State Hospital by a patient. They’d turned some of the campus into state offices so anyone could wander in with a gun. And did.

        • J Rizzo

          Side effects suck, agreed.

        • James O’Brien, M.D.

          Antidepressants don’t work any better than TCAs of forty years ago, they have less side effects. Antipsychotics have less dystonia but more problems with metabolic syndrome.

          I wish there were great breakthroughs in psychiatry during my career but honestly, I don’t see it. And the past twenty years has been corrupted by pharma/KOL collusion that calls everything into question.

          I do see continuous cycles and patterns of a new treatment being overhyped, overadopted, questioned, then demonized. This is the very definition of hysteria.

          The one thing that does work in neurotic and mostly high functioning patients is psychodynamic psychotherapy, a low tech but wonderful learning process that psychiatry seems to have very little time for these days.

  • DeceasedMD

    I would not think this is an exciting time for anyone in medicine. Many people here on this blog, voice distrust of psychiatry. Quite understandable with what they have allowed to have happen.

    In psychiatry in particular, they have allowed Big Pharma’s influence to change teh DSM, despite many well known psychiatrists’ objections. Big Pharma has successfully changed ADHD so that somewhere between 10-20 percent of HS students are on stimulants for so called treatment. This is well documented in the news. DSM is no longer a diagnostic tool for psychiatry, but one for Big Pharma.

    And whatever you do medical student who thinks you are going into psychiatry, don’t work in Philly, unless you plan to bring a gun to work and an armed guard with you.

  • James O’Brien, M.D.

    If DSM5 were simply not perfect, that would be one thing. The problem is that it is a highly political, nonfalsifiable pseudoscientific document. This is not just the opinion of a gadfly but of NIMH and the former editor of DSM4.

  • http://blog.stevenreidbordmd.com/ Steven Reidbord MD

    Yes, it’s an exciting time to work in psychiatry. The field is often slammed in public forums. We’re embroiled in public dilemmas (homelessness, gun violence) without any clear resolution. We fight each other tooth and nail within the specialty over whether our colleagues are Pharma shills, cobwebbed Freudians, or simply overcharging to do the job primary care docs already do. We’re loathsome, power-mad agents of the state — except when your sibling stops her meds and starts wandering the neighborhood, at which point we’re insensitive to the plight of your family and far too ineffectual. We force meds down people throats, except when we’re withholding jerks for refusing to rubber-stamp scripts for tranquilizers whenever a patient asks.

    I have about all the “excitement” I need, thanks. As in any other field, thoughtful, sensitive psychiatrists reflect well on the field, while the cynical, bored, or troubled reflect poorly. I’m suspicious of any opinion that either idealizes or demonizes my complex field.

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