How to Examine A Psychiatrist: Part One

When I am not studying presidential history, I study and practice psychiatry. Years ago when I was a psychiatric resident at the University of Medicine and Dentistry of New Jersey, a professor asserted that most psychiatric diagnoses can be made in less than a minute into the first session.

After decades of practicing, I am haunted by that assertion. It serves as a constant reminder of how not to deal with patients. 

A Diminished Field

Sadly, I have watched my field dramatically change for the worse. In my opinion, the last generation of psychiatrists has been trained with an emphasis placed using a medical model. My personal perception is that psychiatrists have been squeezed by insurance companies and lack
of intensive training in psychotherapy, see 20 or so patients a day for short visits. For the most part they perform medication sessions after quickly making a diagnosis.

Psychiatry’s Song

To parody an old song,

You say you are depressed/ I say Prozac/ You say insomnia/I say Ambien/ You say you’re anxious/ I say anti-anxiety agent/ You speak too loud and fast, and heartily laugh/ I call you Bipolar/My advice to you is “Let’s call the whole thing off.”

Too many psychiatrists have earned reputations as suffering from a prescription writing reflex. One patient described her psychiatrist as having an itchy finger.

 Psychiatry’s Dirty Secret

One of the dirty secrets of our profession is that we psychiatrists practice in the dark. Think about this. Each year, 21 million Americans suffer a bout of depression. A nationwide study conducted by the National Institute of Mental Health found that only 1 in 3 patients respond to an antidepressant and after 2 additional trials of treatment barely 50 percent fully recover.

Fictional  Diagnoses

Why is that? First, it is because the diagnostic categories that we are most familiar with simply do not exist.  As the chairman of one university school department put it at this year’s annual psychiatric association meeting, “Our DNA never heard of the DSM IV”, our diagnostic manual.

The psychiatric labels that people are saddled with  are inaccurate and
misleading. Symptoms are not diseases, just as a headache is not an illness.  A headache can be a symptom of a migraine, tension, brain tumor and many other causes.

The same goes for depression. The symptoms tell us nothing about which brain circuits may be malfunctioning or what kinds of stressors and psychological make-up helped cause the condition for a specific  individual. Symptoms cannot be really understood if they are not placed in the context of your life experiences.

Qualities to Look For in a Psychiatrist

I would not permit a psychiatrist to prescribe for me unless he or she was  generous with their time and attention. A good psychiatrist approaches a patient with the premise that the patient has a unique and complex illness. He or she gets to know you very well before prescribing. I rarely do so after a single session.

Most of my patients have seen other psychiatrists in past and failed in treatment. Patients are comforted if  I tell them t know that I believe the “enemy” ,or condition is a formidable foe and I need to know as much as possible before prescribing.

A True Collaborative Effort

Optimally, since psychiatrists work in the dark and need all the help they can get, I advise finding a doctor who shares openly the decision making process. The psychiatrist should literally consult with the patient and ask for feedback regarding how he or she understands your experience as well as regarding the various treatment options.

A Good Psychopharmacologist is a Reluctant Prescriber

Many patients have experienced negative reactions from medication and are anxious about that. It is my practice not to begin with recommended initial doses but rather small doses. I also make it clear that I appreciate the distress of having to endure the distress of trial and error. I share my belief that medications are weapons and that I will prescribe for them in the same careful way I would for myself.

Therefore, if the doctor confidently tells you by the end of the first session what your diagnosis is and wants to prescribe, I would be quite skeptical; unless you felt really heard and that the psychiatrist really grasps your situation. More times than not, it is not possible to do so.

Does Your Psychiatrist Shut Up and Actively Listen?

It’s rarely possible to understand the patient’s condition without understanding patient’s experience. This means encouraging patient to speak about their distress, their lives and experiences. I explain to my patients that I will shut up and actively listen and will ask questions later, and that I will not prescribe until the patient feels I
understand how they are feeling.

Does Your Psychiatrist Ever Look Things Up?

And a good psychiatrist isn’t always ready with an easy answer without looking things up. One patient asked me about the possibility of an interaction between the medication I was prescribing and another one. When I started to do so he objected and asked me, “What kind of a doctor are you, if you have to look things up.”

In summary, a psychiatrist is likely to  fail if he or she focuses on symptoms and a biological approach. Many patients have already seen other psychiatrists and their expectation are low. It’s important to effectively convey through action and not just words that you will devote your time energy and skills for the sole purpose of collaborating with patient and his or her achieving wellness.