Answering the Psychiatrist's Questions

The following was originally posted as Questions for Clink on the HCPLive network blog Shrink Rap.

One of our readers sent me a number of questions for our podcast, but since Dinah is away and we won't be podcasting for a week or so I thought I'd answer the questions here.

Snowtigress62 asks:

1. I am curious to know where a psychiatrist would go if they needed to seek professional help for personal problems they might be having.. would you go to a fellow psychiatrist you know or someone you don't?

---Depending on where the psychiatrist practices, the psychiatrist may not have any more choice about health care professionals than anyone else. The psychiatrist might be the only psychiatrist (literally) for hundreds of miles. When there is a choice, the psychiatrist would probably always choose to be treated by someone other than a professional acquaintance.

2. Is there stigma in the psychiatric community about a psychiatrist seeking help from another one?

---I don't think so, at least not to the degree that one might find among the general public or among other professionals. Many psychiatrists seek out therapy as part of their training experience and this is generally accepted. Many states also have physician assistance programs affiliated with the state medical board that can help doctors with substance abuse or psychiatric problems, and the treatment is provided confidentially.

3. Do you feel in general that psychiatrists and psychotherapists are becoming too quick these days to dispense medication due to patient overload rather than working with them to deal with their problems without use of medications? what did we do before anti depressants where around?

---I don't think psychiatrists are quick to dispense medication, although this decision can be affected by the treatment setting. A doctor working on an inpatient unit will be under pressure to keep length of stay down and initiate treatment as soon as possible. The psychiatric inpatient will also generally be more ill than someone treated in an outpatient setting and may require medication sooner. Outpatient doctors, on the other hand, are more at leisure to gather more information, observe the patient for a longer time before making a diagnosis, and to wait to see if symptoms start to resolve spontaneously. As a general rule though I think people don't go to see a psychiatrist now unless they've had symptoms that are severe or longstanding. Less severe syndromes are more likely to be treated by a family doctor, internist or nurse practitioner. When people talk about psychopharmacology they often forget that most psychotropics are now prescribed by non-psychiatrists.

Regarding what people did before antidepressants were invented: they suffered. Although untreated depression can resolve spontaneously, episodes can last for months and can be extremely debilitating. In the "old days", patients were sometimes admitted purely for custodial care since there were no actual treatments available. Non-pharmacologic interventions were pretty crude: cold wet packs and insulin shock. Although electroconvulsive therapy has been around for a long time, it can still be an effective treatment for immobilizing, life threatening or treatment resistant depression.

4. What would you say to someone who is the victim of a violent crime and is furious when they find out that the person responsible for the crime is getting free psychiatric and mental health care through the prison system, and they can't get a psychiatrist for help getting dealing with their trauma from this crime due to lack of medical insurance and lack of psychiatrists?

--I don't think this reaction is limited to the victims of violent crime. Many people don't understand why prisoners get free treatment when non-criminal citizens don't (at least, not here in the United States). Prisoners don't have a right to treatment per se; the government is just barred from blocking access to care. If you incarcerate someone in a facility with no doctor, the state has effectively barred that person from seeking care on his own because he has lost his freedom. An analogous free society situation would be if the state called out the National Guard to surround your local hospital and prevent people from entering. The U.S. Supreme Court has said that it's unconstitutional to bar prisoners from access to medical care.

Fortunately, some states have something known as a victim injury compensation board. This board reviews applications submitted by crime victims, and provides limited financial support for things like therapy, medical treatment or funeral expenses. Victim assistance programs also may provide referrals for support groups for families of homicide victims.

5. Do you deal with prisoners on death row and if so how does this affect

you?

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