Psychiatrist: ‘We are not your adversary’

Sun readers respond to letter writer raising concerns about the efficacy of psychiatry

Psychiatry has problems, but also many strengths

It is true that psychiatry has many problems, but lack of effective treatments is not the major one. Psychiatrists have much to offer patients nowadays, especially for depression.

Letter writer Ann Bracken recently complained about the imprecise nature of psychiatric treatment and theory, remarking that exercise might solve the problem for some with depression (“Forget ‘Field of Screams,’ psychiatry has more than an image problem,” Nov. 4). For some this is true, but regrettably, not for many. Depression is a catchword for the key symptom of what we suspect are many different types of illnesses; most likely with as many different causes. For a great many people, it is a chronic, recurring problem that is not solved by time alone or by “walking (or running) it off.”

What we know about depression (and many other psychiatric illnesses) and the brain is just the tip of the iceberg, but our knowledge and treatment is growing and in keeping with other modern medical treatments. While we remain skeptical of any unproven specific theory of each illness, this does not prevent us from offering effective treatments. Gone are the days when people spend months or years in an asylum because they are depressed. Today’s treatments are mostly outpatient with occasional brief inpatient stays of days to weeks leading to a return to normal life and functioning.

While some serious psychiatric illnesses like tertiary syphilis are mostly eliminated by antibiotic cures and transferred to the care of infectious disease specialists, others like depression remain the purview of psychiatrists and even general practitioners. Our treatment armamentarium is multifaceted, and the vast majority of patients improve with treatment. Just because we know that up to 30% of people receiving a placebo (or sugar pill) for a problem, still respond to treatment, even when they are told up front that they are getting a placebo, does not mean that we should give everyone placebos for their depression or other illnesses. Nor does this mean that the proven treatments we offer are not effective.

What we are missing are the tests that would tell us which medicine will give an individual the best response. This is not a disabling problem, as we have many clues, including family history, which help us find treatments that are safe and effective for each person. The thoughtful practitioner keeps in mind the “natural course” of illness where some get better with time alone. Yet most do not, and should not, wait for time or exercise alone to heal them, as for some this can be fatal with this serious group of illnesses. As many as one of every five people has a mental health issue, with many never receiving treatment.

It is reasonable to hope that genetic and other research will eventually get us to that gold standard where we have tests that specify the exact problem and treatment, perhaps in the lifetime of those reading this for some psychiatric illnesses. Maybe we will even find the “silver bullet” to splice the defective gene(s) to effect a cure for some forms of depression. Until then, finding the best combination of treatments and managing side effects is an important part of the healing process; this is much improved since the introduction of the first antidepressant medication in the mid 1950s. This is always an important part of any treatment program for any illness.

Another problem of psychiatric illness and treatments, especially with depression, is that sometimes people do not understand the chronic nature of these conditions, partly due to some having a waxing and waning history on their own. A depression following a major loss may not re-occur, and might be considered “cured,” but most other depressions, like those related to diabetes and hypertension, require lifelong treatment for patients to remain at their best. Treatments may be stopped when someone gets better, often without any periodic monitoring, then in a few months, or years, a relapse occurs. It has not been unusual for me to see a person who said they got depressed when they lost their job, but upon teasing out the history we reveal that as depression gradually built up, they lost interest and concentration in their work, and as a result got fired, which made things even worse.

Modern treatments can include psychotherapy, cognitive behavioral therapy, exercise, diet, medication, occupational and recreational therapies and transcranial magnetic stimulation (TMS). But for those who need urgent improvement or have not responded to other methods, the gold standard for major depression remains electroconvulsive therapy (ECT). The standard of care is to explain the risks, benefits and alternatives to each treatment being offered in any setting. None of these treatments is a cure, so if some form of treatment is not continued, or if therapy is not maintained at some level to pick up and treat early symptoms of illness, relapses may occur. In treating patients for over 40 years, I have yet to see a patient with depression who I have not been able to help.

— Dr. Bruce T. Taylor, is a psychiatrist, former owner of Taylor Manor Hospital and health care advocate (www.HealthCare-Savings.com).