Do you see any implications here with gender reassignment surgery? Is gender dysphoria—the condition in which a person believes he or she was born the wrong sex—technically a psychiatric condition?
These are heated waters to wade into. It has, at various times, been classified as such. My suspicion is that increasingly, people understand the appropriateness of gender reassignment surgery and have seen enough of those cases and the positive results that can occur that we understand the plight of transgender people better than those with body identity integrity disorder.
One criticism often weighed at psychiatry is the idea of over-diagnosis. What do you think about this?
It’s both true and not true. There are people who are over-diagnosed and over-treated, but many, many patients need treatment. It depends a little on the population. Plenty of people point fingers towards the “worried well,” people who are on psychiatric medications that need not be. That may be a reality in that population. On the other hand, working in a psychiatric hospital, the reality I encounter far more often is people with significant mental illness who are not receiving the care they need.
Is it ever a class issue? Do more privileged classes get over-treated? Do less privileged groups fail to get treatment they need?
Suffering certainly does not discriminate. And mental illness doesn’t discriminate. There are all kinds of socio-economic groups that have members who are very ill, who are afflicted by every mental illness you could list. That said, there’s no question that people with fewer resources have less access to care. I see a lot of college students who experience their first psychotic break, and many of them come from affluent families. They are able to connect with and generate quite a lot of care because they’ve got good insurance, their families may know physicians they can call in the middle of the night for advice, they have the capacity to drive their kids to major medical centers where they may specialize in illnesses their children are facing. Those resources provide greater access to care. A homeless person has few resources and won’t be as able to make the connections needed, have transportation needed. I see so many patients for whom the $4 prescription charge for a month of medication at Wal-Mart is prohibitive.
And what’s at stake for those who aren’t treated?
Not having treatment can have life or death consequences. A man came into my unit who had been living on the side of a highway drinking stagnant water because he feared the government was after him, and he fled his house and was living in the wilderness. We see patients all the time who are so paranoid that they have stopped eating because they believe it’s been poisoned. They barricade themselves into houses. These are patients who are very ill; whose lives become full of suffering if they don’t receive the treatment they need. They’re besieged by voices that are denigrating them and are so depressed that they constantly try to kill themselves.
You write that doctors are “terrible at predicting [which patients] will kill themselves.” How do you come to conclusions you’re comfortable with when you discharge a patient?
We’re trained to ask about risk, to assess risk. We ask people directly if they have thoughts of harming themselves, and if they do, do they have a plan? We want to understand how specific and immediate that danger might be. We’re trained to ask about access to firearms. Many times, that serves us well, and we’re able to intervene and understand where someone is on that spectrum. But just about every psychiatrist will tell you a story of someone they really didn’t think was suicidal who made a serious attempt, or succeeded. You can have a cardiac-catheterization and determine exactly how blocked an artery is in the heart. We can’t do a lab test in psychiatry and check suicidality like we would check a cocaine level. A cat-scan of someone’s brain won’t tell us if they will commit violence in the next 48 hours. We have to rely much more on intuition and training because we don’t have the same kinds of tools that other disciplines have.
Do you worry about the skeptical light you are casting on your own profession?
I think that doctors, in general, all have moments where we feel inadequate or incapable of really getting something right, medically, but we’re in a profession where people are less forthcoming about that. There’s a time in everyone’s medical training where you feel a little fraudulent, like you might not be treating someone the best way they need to be treated. But that’s because doctors are human, just like everyone else. I have a lot of faith in psychiatry. There are people who cast psychiatry as a pseudo-science, or beholden to big pharma, but I don’t believe any of that. Psychiatry is a science, and the people who practice are, for the most part, well-trained physicians who work very hard with evidence behind them to treat mental illness, and we have some great successes. The book focuses on the most frustrating diseases we encounter, but my goal is to humanize and generate empathy for patients who might otherwise be viewed with repugnance or disbelief. I’ve written about the most challenging cases. It’s not that interesting to write about the slam-dunks.