Toll Free Zone is Needed

 

Like many psychiatrists who watched Twitter implode under current management – I decide to try more time on LinkedIN.  I can recall a few years ago hearing that it was supposed to be a more “professional” site.  I tried the paid version to see if that might be true.  After giving it an adequate trial – I can say unequivocally it is not.  There are the usual social media maladies and more. 

For psychiatrists looking for collegial discussion that basically involves being trolled. The trolling comes in various forms, but it typically involves some absurd remarks about psychiatric practice or psychiatrists.  The usual absurdities still apply (see graphic).  There are people who will be repeating them until the end of time.  That strategy works for some politicians.  But there are a couple of variations.  I recently saw the claim that because psychiatrists only prescribe medication they never cure anyone and that it takes a psychotherapist to cure people.  One of the premises of that post was that psychiatrists get the first chance to treat people and that makes it even worse because they will not see a therapist and get cured.

That scenario is both statistically and clinically improbable.  There will never be enough psychiatrists to see everyone who needs to be seen. And psychiatrists are generally tertiary providers of all types of treatment.  As I have written about on this blog in several places – the average person I saw in practice had already seen 2-3 therapists and 1-2 non-psychiatrist medication providers before they saw me.  Prior care had often occurred over a period of many years or decades before they got in to see me.  Psychiatrists are also not pulling people in off the street.  Despite the fact we are tertiary care providers – our schedules are generally full of all those people who have seen somebody else and not found that treatment satisfactory. 

Some might say that I am speaking about just a biased group or patients and have left out the group that may have improved with other treatments.  That is called selection bias and it applies in a couple of ways here.  First, all the treatment failures of other providers is a select group.  I don’t know how many improved and did not need to see psychiatrists. On the other hand – the people who did not improve are the people I want to see.  The reason I went into psychiatry was to see people with the most severe forms of mental illness.  Second, the people who are saying they are the only people who can cure mental illness with psychotherapy are only seeing the people who respond to their specific psychotherapy and most importantly who keep showing up.  Drops outs don’t count as cures.

The attitude also presents a false dichotomy.  I don’t know of many psychiatrists who you can see and the conversation is like seeing your internist or family physician.  Whether they make it explicit or not – psychiatrists are trained in psychotherapy, they know how to talk with people in a psychotherapeutic manner, and they can often accomplish psychotherapy interventions in a short period of time.  I have seen people in weekly, biweekly, and monthly sessions for psychotherapeutic interventions in addition to medical treatment.  It is also the nature of psychiatric practice that long term patients will be seen in crises that occur to most of us over the course of our lifespan and that will need to be discussed.  The skillset necessary to do that requires training and exposure to the relevant resources.  As an example, I coteach a 2-hour seminar each week on psychodynamic psychotherapy and case formulation each week for psychiatric residents.  My colleagues in that seminar are all skilled psychodynamic and psychoanalytical psychiatrists and clinicians.  This week I am presenting on the psychodynamics of prescribing – a much more detailed discussion than the headlines or trolling remarks about psychiatric medications.     

If none of that sounds like the psychiatric practice, you read about on social media – it is not.   I have rarely seen an adequate description of how real psychiatrists practice psychiatry in social media.  It is usually a fleeting collegial discussion among experts.

Beyond the overt trolls there is also subtext.  How many times have you seen the same criticism of the DSM?  Repeatedly - even though it is a marginally significant document.  By that I mean – it is indexed to ICD codes that are the only relevant codes for diagnostic and billing purposes. The only advantage is that the DSM does elaborate more on criteria for codes, but it is very doubtful that the people using the codes are looking them up in a DSM.  Most of the diagnoses are not used.  Most of the physicians using the codes don’t own a DSM or even refer to it.  If I had to speculate, I would say that trainees in mental health fields probably purchase it as an obligatory item thinking they will learn about psychopathology.  But it is not a book about psychopathology.  It is basically a crude attempt to classify patterns of mental illness observed over the centuries of mental illnesses and refine those patterns. 

That brings up another common criticism of the DSM that can rise to troll levels. And that is - the DSM is deficient philosophically or as a diagnostic or classification system.  More pointedly psychiatry is deficient because they make, use, endorse, and sell the DSM.  The obvious problem is that psychiatry is much more than the DSM.  In all my years in acute care settings – the biggest part of my job was not deciding what page of the DSM applied to my work. My job was making sure that nobody died. Making sure they did not have a critical illness because it is hard for anyone to diagnose it in those settings.  Making sure they did not die from suicide or kill or injure somebody else.  Making sure my medical interventions did not adversely affect their medical conditions and making sure I knew what that comorbidity was.  Making sure that those catatonic and severely depressed patients were not getting dehydrated, starved, or a pulmonary embolism.  Making sure that patient with chest pain was not really having a heart attack.  Making sure that everybody on the treatment team was on the same page and not experiencing any countertherapeutic attitudes or emotions.   It is no accident that you don’t hear about that job on social media – the people criticizing psychiatrists have no idea what we do.

The DSM and psychiatry bashing can be accompanied by self-promotion.  Many people cannot promote their ideas without coupling it to criticism of psychiatry.  There is a better system.  Let’s use all the DSM symptoms and count them and rearrange them in different ways and say we have a superior system that will allow us to have superior models of mental illnesses. It reminds me of the debates of clinical versus actuarial judgment from 40-60 years ago (1).  In that reference, actuarial methods specifically the Minnesota Multiphasic Inventory (MMPI) were considered superior to clinical judgment.  But over that same period – that test was adopted to predict DSM diagnoses, was noted to be invalid for sociocultural subgroups and had to be restandardized, went from being a general psychopathology screen for law enforcement and professional schools to being used much less, and is used far less clinically. 

In the 1980s, I was interested in quantitative EEG (QEEG) research.  There were manufacturers that marketed machines with proprietary algorithms that they claimed were correlated with psychiatric diagnoses.  The analysis involved statistical probability mapping of EEG frequency bands and then cluster analysis using non-Euclidean geometry. Even more than that - it required adding clinical data to the algorithm – like whether the person was drinking alcohol, using other drugs, and what medication they were taking.  The resulting reports were not only inaccurate, but they also restricted the application to very few patients.  I have no more confidence that newer systems of phenotyping with old metrics and symptoms will get better results.

The reality that is facing every psychiatrist is that they are face-to-face with a person that needs some degree of help.  Depending on the setting that person will recognize it to varying degrees. It takes a lot of discussion, relationship building, and analysis.  It involves talking with and building relationships with some people that most people would actively avoid.  Those kinds of relationships are critical. It takes a lot of attention to detail at the medical, social, familial, and cultural levels. It takes pattern recognition involving experience in training and in practice to determine what is the best intervention. It is a serious job that very few people want to do.

A realistic social media setting where psychiatrists can aggregate would be a plus for exchanging information, posting research and relevant papers, and discussing relevant treatment modalities.  A setting that is free of the cartoons and slogans designed to ridicule psychiatrists written by people who have no idea of what the experience of a psychiatrist is like. So far – I have not found that site.  Like I started out saying in this essay LinkedIn is like all the rest.  There are certainly many valued colleagues and references over there, but the trolls are building.

Let me know when there is a troll free site with standards and moderation and I will be there.  Let me know if you are interested in making that site and I will give you my ideas of how it can be done.  Until then this blog is my troll-free zone.                      

 

 

George Dawson, MD, DFAPA

 

References:

1:  Dawes RM, Faust D, Meehl PE. Clinical versus actuarial judgment. Science. 1989 Mar 31;243(4899):1668-74. doi: 10.1126/science.2648573. PMID: 2648573.

2:  John ER, Karmel BZ, Corning WC, Easton P, Brown D, Ahn H, John M, Harmony T, Prichep L, Toro A, Gerson I, Bartlett F, Thatcher F, Kaye H, Valdes P, Schwartz E. Neurometrics. Science. 1977 Jun 24;196(4297):1393-410. doi: 10.1126/science.867036. PMID: 867036.

3:  John ER. The role of quantitative EEG topographic mapping or 'neurometrics' in the diagnosis of psychiatric and neurological disorders: the pros. Electroencephalogr Clin Neurophysiol. 1989 Jul;73(1):2-4. doi: 10.1016/0013-4694(89)90013-8. PMID: 2472947.

4:  Fisch BJ, Pedley TA. The role of quantitative topographic mapping or 'neurometrics' in the diagnosis of psychiatric and neurological disorders: the cons. Electroencephalogr Clin Neurophysiol. 1989 Jul;73(1):5-9. doi: 10.1016/0013-4694(89)90014-x. PMID: 2472951.