Friday, March 14, 2014

Why Aren't Mental Conditions Like Physical Ones?

Earlier this week, Dr. David Rettew tweeted me his article on Psychology Today, "What If We All Got Mentally Ill Sometimes?" I thought it was well reasoned and thought-provoking. Here's the last paragraph, which summarizes his argument:
What I am really trying to say here, I think, is that scientifically there is very little to go on to help us figure out where the lower thresholds of psychiatric disorders actually exist. To deal with this reality, we can either reserve the term mental illness for those with the most extreme levels of pathology or admit that the brain, the most complicated thing that has ever existed on this planet, gets a little off track once in a while for most of us and needs a little maintenance.  This maintenance does not and should not be confused with prescription medication or five times per week psychotherapy for all.  There needs to be some productive middle ground between a response of, for example, “It’s ADHD and you need this medication” and “It’s not ADHD (or there is no ADHD) so go home and fend for yourself.” 
My quick response was:

Here, I'd like to expand on my thoughts a bit more.

In an ideal world, everyone would recognize that the brain is the most complex organ that we have, indeed the most complex object that we know of in the universe. Thus, it would not be surprising that it does not function perfectly all of the time, and putting a label on what (we think) is going on would be as unremarkable as calling an upper respiratory viral infection "a cold." Just as most people get sick with colds twice a year, or suffer multiple orthopedic and soft tissue injuries throughout their lives, shouldn't mental conditions be as commonplace and non-stigmatized?

The problems, though, are many-fold. The first is what happens when someone shows up at the doctor's office looking tearful, depressed, or anxious. The majority of psychiatric medications are already being prescribed by primary care providers. As a medical student, I got to see many general internists rushing from one patient to another, spending 10-15 minutes on each encounter. These doctors had very little time to spend delving deeply into their patients' lives (this answers 1boringoldman's question, "what's the hurry?"). The more patient docs would listen empathetically for a few minutes, and then offer an SSRI or benzodiazepine, letting the patients make the choice as to whether they would like to try medication. So if more people thought that they had some kind of mental condition, more would probably opt for the meds. Psychiatrists, of course, should know better, but we are often just as culpable in taking a "medication-first" approach to treatment, especially when working in settings where we function as little more than medication prescribers/consultants. As the saying goes, if all you have is a hammer…

Dr. Rettew tweeted the following response:

I think it's wonderful that his clinic doesn't do 15 minute med checks. Most child psychiatry clinics at least acknowledge the importance of parents in a child's life, so the minimum is usually 30 minutes to allow time for a psychiatrist to work with the whole family. Unfortunately though, that method of practice is not the default for most mental health care that takes place in this country, and I worry about what will happen with the increased adoption of collaborative care models (nice anecdote here).

What Dr. Rettew proposes requires an adequate framework to provide checks and balances, i.e. using a true biopsychosocial model so that what is happening in the brain is not the only point of emphasis. A (very) rough analogy would that the use of needles to inject medications directly into the body can be a good thing, but it requires a framework of basic sanitary practices like sterilization of used needles and/or disposal, without which the technology could actually cause more harm than good. In The Hot Zone, for example, Richard Preston described how re-use of dirty needles led to ebola outbreaks in Africa. Another example, detailed by Steven Pinker in The Better Angels of Our Nature, is that when democracy replaces autocracy in places that don't have a culture that values pluralism and human rights, the result is often even more chaos and bloodshed.

Additionally, the effect on people of telling them that they have a brain condition is vastly different from telling them that they are suffering from indigestion or hypertension because of the stigma associated with mental illness. I don't think that labeling a significant proportion of the population with a mental illness is a good way of overcoming this stigma, especially when most doctors do not have time to explain the nuances behind psychiatric diagnosis to their patients. To the average patient, a diagnostic label implies a level of knowledge that we do not have. I have seen multiple cases where after receiving a diagnosis with inadequate explanation, patients have felt that there was something wrong with their brains, which for many resulted in more harm than good.

Overall, I agree with Dr. Rettew's message that there should be some middle ground between "diagnose + medicate" vs. "no diagnosis + no treatment." However, I don't think that the medical model is well suited for much of mental health since what contributes to both mental anguish and well-being is so multifactorial. That is why I love NOS/NEC, and I often find myself using "no specific diagnosis + multimodal treatment."