Physician specialists that treat psychiatric disorders (AKA Medical Directors of Insane Asylums AKA Psychiatrists) in our country are rushing quickly towards a wall of emerging neuropsychiatric/genomic/neuro-immune and neuro-endocrine discoveries, culture changes and fresh syntheses of cognitive neuroscience. Our current cadre of physician-specialists are hurtling at this vast, seemingly impenetrable wall in the not-so-distant future with only a half-assed understanding of: valid/evidence-based psychotherapeutic tools, understanding of evidence-based complementary medical interventions (to include but not limited to nutrition/exercise physiology -- well studied by the NIH among others), and a handful of drugs.
All of these (drugs, ignorance and poor training) carry enormous risks and fewer and fewer benefits as emerging medical literature clearly shows.
Are we just going to rely on newer medicines to make up for our CURRENT shortcomings?
Why not shore-up our deficiencies with what we the knowledge we ALREADY have, and rely less on increasingly demonstrable nefarious interventions of questionable OVERALL efficacy and poor long-term safety.
Let me not be confused for a psychiatrist who disdains medications. On the contrary, my disdain is of those who do not know enough to prescribe an antispasmodic and low-dose benzodiazepine in combination with psychotherapy and appropriate specialist referrals to their anxious/PTSD patients with 'IBS'.
All psychotropic medications available to us at this time can each be life-saving and improve patients' quality of life tremendously. Each of these medications also carries enormous risk - some even more than that (that is likely why they can make such a drastic difference in so many patients; because they are so 'powerful').
As the de-facto experts in the field of psychopharmacology, "with great power, comes great responsibility".
As a GROUP why do we lag in researching/using micro-current DCS (direct-current-stumulation) or rTMS (repetitive transcranial-magnetic-stimulation) in combination with an aggressive psychotherapeutic milieu and even hormonal manipulation and consult with a personal trainer when necessary in our patients. Instead of piling-on more and more of the same and contributing to the morbidity of our patients by contributing to treatment resistance (see STAR-D trial data) and overall medical morbidity/mortality data due to medical ramifications of poor lifestyle choices and pharmaceutical side-effects.
So many men who come to the practice with decreased libido (no body bothered to ask them the 'hard' questions), irritability, depression, fatigue, several failed or part-responses to SSRI's and SNRI's and a simple testosterone panel shows either low free/bio-available testosterone, low total testosterone or all of the above. Do they still need psychotherapy? Some do. Long-time problems in marriage (direct or indirect damage of the low testosterone) coupled with problems in day-to-day functioning at work, loss of drive, problems with friends and hobbies -- yep some of them DO need psychotherapy to learn how to get back into the swing of things and 'deal' with "stuff"; some may need additional escitalopram (or whatever the 'appropriate' anti-depressant would be for him).
Which leads me to the next piece of the rant - which one would be the more appropriate antidepressant for him at this time? How do we chose it? This is a basic therapeutics question for a medical student right? We look at risks and benefits from side-effects and possible interactions in conjunction with the medical history (genetics?, allergies?, past hx of reactions/interactions?). Right? Since we are told that study after study demonstrates EQUAL efficacy to treat depression, how ELSE do we choose between what to ADD to this guys treatment of his depression. We need to look at how else we might shine a light on this VERY IMPORTANT PIECE OF THE PROBLEM (rhetorical at the moment as there are a few 'alternatives' out there but mainstream medicine and evidence-based medicine states they are not 'ready for prime time'). Are there blood/urinary metabolites/salivary or other excretions that might be able to help guide medical intervention?
As psychiatrist we need to be MORE.
We need to recapture the allure of the physiological: the wonder for and mastery over the neuro-immune interactions that we already know about, let alone be ready for all of the mounds of data being produced and published in the medical literature daily. We need to rehash and refine our comprehension of the neuro-endocrine doctrines which WERE TAUGHT TO US IN MEDICAL SCHOOL (for many of us, this was many moons ago!) let alone all of those fascinating inter-relationships being found-out daily and added to our current vast understanding of these things (which far outweighs what we use pragmatically on a daily basis with our patients -- and could be).
And yet, we must not loose that special place we have in clinical-medical science -- singular among the vast medical specialists and sub-specialists - something that seems almost magical to some of our colleagues (and now that we have evidence-based medical literature demonstrating that it's "advanced science that [was once] indistinguishable from magic") - we need to regain that position of authority over the mastery (within medicine) of these techniques. Not to the exclusion of our psychology colleagues and other cognitive therapists, but complimentary to them - and to any other colleagues (acupuncturist, medical massage therapists, yoga instructors, personal trainers) who can help us add value to the treatment and decrease the risks and bad outcomes in our patients.
We need to be more. What is going to happen to us and our patients?
I am optimistic of both. But we need to have a 'fire' stimulate (more than financial gain or the threat of litigation) and drive change. This 'fire', in my personal opinion, needs to be something akin to that which we all had when first learning of all of these things in medical school and residency training - matched by a maturing sense of accomplishment with each patient and continued learning (with each patient and by self -study, CME, etc).
There is so much to read and so little time...but I am optimistic.
