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.