The Semi-Random Pathway To A Psychiatrist

 

Mischaracterizations about how people come to see psychiatrists are an ongoing phenomenon in the media. It is one of many false premises used to build the idea that there is a monolithic psychiatry out there that is really an evil empire. That stands in contrast to psychiatrists going to work every day and seeing a full schedule of patients that was compiled without their knowledge or input. I will try to explain what really happens in this post.  My explanation is complicated by very little research done on this topic.

In my experience and the experience of the colleagues I have worked with, it is rare for a person with mental health problems to be seen by a psychiatrist without previously having seen another physician or mental health professional. That is true for both emergent and elective situations.  It follows that those patients have also been treated with medications and psychotherapy, often many different medications from different classes and different forms of psychotherapy.  The period of treatment before seeing a psychiatrist is typically quite long. As an example, in my last job as a consultant at a large substance use treatment facility – I was seeing people in their 30s and 40s who had an onset of a psychiatric disorder in their teenage years, gone through various treatments, and were seeing me as the first psychiatrist they had seen in their life. That could have been as long as 5-6 years of illness onset with no treatment followed by another 10-20 years of ineffective or sporadic treatment.

This is a hard problem to delineate because of all the factors involved. There may be a preference to not see a psychiatrist because of the connotation that psychiatry is equated with a more serious illness or the misconceptions about psychiatry that are actively promulgated by special interests. In some cases, primary care physicians consider themselves to be the right person to manage anxiety or depression.  The recent collaborative care initiative and physician rather than patient-based consultation may reinforce that idea. I have seen patients who were in treatment with every possible alternative medicine practitioner and getting treatments that could either not possibly help them or in some cases were detrimental. Some of my patients were in cults who claimed to be helping them until they were rescued by family members and brought to psychiatric treatment. Self help is a popular approach and some of it is very good but in other cases it can also be detrimental.  When bibliotherapy is used, the advice often includes instructions on sleep, diet, and exercise.  Many people resort to self-diagnosis and self-medication. Supplements are generally expensive and ineffective. Alcohol, stimulants, cannabis, benzodiazepines, psychedelics, and other intoxicants are uniformly ineffective and often amplify the original problem or create new problems.

In some cases, the person already has a very healthy lifestyle and given popular recommendations it is tempting to just amplify the health factors.  More protein, more sleep, and more exercise. It is very doubtful that any of those factors alone or in combination will address a serious mental health diagnosis.  I have treated world class athletes in the top 1% of all exercisers who got no relief at all from exercise.

Insurance limitations and rationing has been a significant factor in the last 40 years. A study done showed that referrals from managed care companies seldom result in real appointments with psychiatrists – in many cases because the insurance company claims that psychiatrists are in their network when they are not.  These are ghost networks or phantom panels (1).

Practice setting is also an important factor. During my 22 years of acute inpatient care – all of the people I saw were either taken to the emergency department or presented there themselves.  Most were untreated for years.  Some were overtreated with medication combinations and were seeing me because of side effects. It was more likely they had seen a psychiatrist because we had an outpatient department and our colleagues’ patients were hospitalized, but reviewing those histories it was clear they had been untreated for years before being seen in the outpatient department.

I first learned about the importance of the pathway to physician care in medical school.  When you first start seeing patients, there is an excessive focus on the form of the medical evaluation rather than the phenomenology. In other words – you want to carefully document all the history, symptoms, and findings that lead to a diagnosis and treatment plan. You are under the mistaken assumption that is all there is to being a physician.  At least until your first attending asks: “Well – what is the reason this patient sought treatment at this time? Why did they decide to come into the emergency room right now?”  At that point you start to realize that there are not a set number of pathways to care and patient presentations – there are millions.  Your job is to describe that unique pathway for every individual patient that you see – no matter what the problem is.

The pathway to psychiatric care in the United States is semi-random. People rarely make a conscious decision to see a particular psychiatrist and then see that person. At some level psychiatrists are the treatment providers of last resort and you are likely to see one in an emergency that you never planned or when another treatment provider tells you that it might be a good idea.  It is likely that a lot of disability and distress occurs in the meantime, along with a lot of bad advice. I think it is reasonable to try self help and other qualified mental health professionals first.  But if you are not seeing any good results – I would not let it go on for too long.  Like most things – if what you read in the papers about how a certain treatment for your problem seems too good – it probably is.

George Dawson, MD, DFAPA

Supplementary 1: 

Here is a post from about a year ago on involuntary treatment.  Look at the diagrams to see the number of personnel and steps involved in the process - apart from the psychiatrist. In a hospital setting - activating the civil commitment process typically occurs when an emergency department doctor or hospitalist places the person on an emergency hold.  In some states only police officers can initiate an emergency hold and in others any interested person.  An entire series of decisions not made by any psychiatrist determines if that person is eventually held or released.

Supplementary 2:

This is a graphic that I made from another application showing some alternate pathways to psychiatric treatment.  In almost all cases there is no psychiatric contact until the tier of treatments designated by white and green rectangles and possibly in the team approaches.

References:

1:  Malowney M, Keltz S, Fischer D, Boyd JW. Availability of outpatient care from psychiatrists: a simulated-patient study in three U.S. cities. Psychiatr Serv. 2015 Jan 1;66(1):94-6. doi: 10.1176/appi.ps.201400051. Epub 2014 Oct 31. PMID: 25322445.