As a resident, I treated a patient who had suffered from schizophrenia for years. He had finally achieved some stability on a cocktail of antipsychotic medications as he was passed along through the clinic, year after year, from trainee doctor to trainee doctor. Despite doing relatively well, he continued to have auditory hallucinations, lack of interest, and low motivation. Antidepressants had been thrown into the mix, as well as a mood stabilizer or two, but he continued to suffer these symptoms.
One day, though, he showed up for his appointment looking completely different. His complaints had nearly disappeared; he was cheerful, optimistic. I felt like I was sitting in the room with a different person. Inquiring about what had changed, I found out that with the assistance of the hospital work program, he had gotten a job for the first time in nearly 30 years. He was working as a busboy in a restaurant, and felt a sense of purpose and meaning in his life again. "Doc, I finally have somewhere to go, where people need me."
In many places psychiatry has become a biological enterprise, with some psychiatrists even introducing themselves as "psychopharmacologists." In no other specialty does a physician define themselves by the medication that they use. As one of my psychiatry professors once commented, "I have never met an oncologist who says "I'm an onco-pharmacologist." Increasingly, we are convinced that medications are what make patients better -- and that if only they would stay on them, if only they would take them as we have prescribed them, if only they were on the right one or the right dose -- they would get better.
In reality the process of getting better is much more complicated. Medications can play a large role, but other factors are enormously important -- environment, sense of purpose and meaning, the person's perception of their illness, and their relationship with the people who treat them. Studies have shown that patients taking placebo who have a good relationship with their psychiatrist have better outcomes than patients taking the active drug who do not have that strong personal connection. In the outpatient setting, a well-trained psychiatrist will follow what's called the biopsychosocial treatment model -- which values the biological, psychological, and social aspects of a person in considering their treatment -- and consider these other parts of the patient's healing process, in addition to medication.
For the person whose first encounter with psychiatry involves the inpatient psychiatric hospital ward, however, these psychosocial interventions are frequently left behind. Often under pressure from insurance companies, inpatient psychiatric units experience a tremendous push to medicate patients quickly and discharge them as soon as possible. During my time working on psychiatric units I saw instances where insurers balked at paying for the visit if the patient was not placed on any sort of medication.
Where once a psychiatric hospitalization meant a long stay working closely with a familiar staff and doing daily therapy -- with medication as an aide -- most modern experiences of psychiatric inpatients are far from this. Often involving numerous rotating caregivers working in shifts, moonlighters, or trainees on one rotation and off to another, patients often complain, "I only saw my doctor for ten minutes!" The more well-funded units have some form of therapy, usually group therapy with a behavioral focus, but many have very little of this to offer.
Overpopulated psych units resulting from hospitals trying to keep out of the red often lead to burned out staff members who would rather silence a psychotic, agitated, or complaining patient with medication than sit down and talk to them. I have seen nurses and doctors who do not give in to these pressures, who take the time with their patients, but they are sadly not the norm, not because others do not care, but rather because the system rewards efficiency, not empathy.
I remain baffled by the expectation that patients could easily begin the process of recovery from mental illness on most inpatient psychiatric units. Seeing the often poorly lit and drab rooms, I am reminded of Andrew Solomon's description of how people he met from Senegal could not understand how the Western practice of "tak[ing] people into these dingy little rooms and having them ... talk about bad things that had happened to them" would be helpful.
These units are designed to keep patients safe and prevent adverse outcomes like a suicide in the hospital or emergency room. However, the therapeutic value of the physical setting is often overlooked as strapped hospital budgets prioritize other needs.
Fed up with the apparent "mill" of psychiatric hospitalization, a process that seemed to lose the person in the cycle of checkboxes and protocols, I wondered out loud to one of my supervisors whether anything like the old asylums existed. Though these institutions had many flaws, it seems as though things have swung too far the other way. The value of fresh air, therapeutic work, and a community of peers seems to have crumbled away in our quest for quicker and faster discharges and a focus on crisis management.
It doesn't surprise me that the highest risk for suicide occurs right after hospitalization. Psychiatrists explain this finding by stating that these are very ill patients in the first place. However, experiencing a psychotic or manic "first episode" or a depressive episode that has gotten so bad that suicide has suddenly become the only option is undeniably traumatic. People who have just recovered from psychosis often experience depression afterwards. Added to this, a psychiatric hospitalization by its very definition involves a loss of control, which is not always, but often, uncomfortable and traumatic for someone trying to process the internal realization of not being able to trust their own appraisal of reality. These experiences often raise philosophical questions, identity questions, emotions, and fears that the inpatient unit is sadly unequipped to deal with. Unless there is a particularly invested trainee, nurse, or other staff member, patients are often alone with their thoughts, and before long discharged home with their belongings and prescriptions. Ideally such existential crises should be addressed soon after hospitalization with the outpatient psychiatrist or therapist, but this fails to occur all too often.
This issue is not limited to the inpatient setting. In the outpatient world, "medication management" visits with psychiatrists who accept insurance often last just 15 minutes, which is hardly enough time to address the many psychological implications of the medication and the way that the person's identity and past inform their current symptoms and state. Dr. David Mintz of Austen Riggs Institute has coined the term "psychodynamic psychopharmacology" to connote the idea that despite the division between "therapy" and "medication," there is psychological meaning in taking a medication and in the relationship with the doctor who dispenses it. Dr. Mintz points out how some patients who are labeled as "treatment resistant," or who have "failed multiple medications," often struggle with the psychological issues that lie untouched beneath the surface of the superficial "medication management" visit. Many psychiatrists opt out of insurance to control how much time they can spend with patients to address these complex issues, but unless one can afford these rates, there are few options, effectively creating two tiers of care based on ability to pay.
This isn't to say that people don't need to be on medication -- but this psychopharmacological myopia is dangerous in that most psychiatrists of my generation pay lip service to the "psychosocial" part of the biopsychosocial treatment model while failing to put it into practice. This is no fault of our own. I come from a generation of psychiatrists who will never see someone come into a hospital, be taken off all medications, and get better. And for many in my generation, if you don't see it, you won't believe it's possible.
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