Go Retire Psychiatrist

I read an interesting article in Clinical Psychiatry News the other day, written by Dinah Miller, MD in the Shrink Rap News column, “Psychiatry and semantics.” Dr. Miller’s point was that it’s sometimes hard to define terms when discussing mental illness and stress.

Can stress be defined as a mental illness? What the heck is the definition of mental illness? What does it mean to say that someone is depressed?

Way back in 2006, when I was an Associate Professor in psychiatry, I wrote an introductory article for a series of articles about stress for Psychiatric Times. The title was “Stress and the Psychiatrist: An Introduction.” I had a tough time defining stress also. In fact, the first 2 paragraphs of my article say it all:

“Defining “stress” and how it is expressed and managed in both psychiatrists and patients is a difficult proposition. This Special Report focuses on stress and the middle ground between the impulse to say there is no such thing as “stress” and the tendency to describe many explicit addressable issues under the monolithic term, “stress.”

I remember what my ward supervisor once told me about stress when I was a resident in psychiatry. I was presenting a case about a patient who was depressed and complaining about all the stress in her life. At that point, he barked testily, “There’s no such thing as stress!” He went on to direct me to be more specific in my interviewing techniques in an effort to identify the concrete problems that my patient was experiencing, instead of substituting a sort of shorthand (i.e., “lazy”) method of indicating the source of her depression. In his view, the term “stress” was being overused and it had become virtually meaningless.”

At the time I wrote that article, there was surprisingly little data about stress in psychiatrists. On the other hand, it was well known that psychiatrists are prone to stress, burnout, and suicide.

As I read my own article, I was surprised at how little things have changed over the years. In fact, they have gotten much worse. There is a lot of talk about The Great Resignation. Health care workers are leaving their jobs in droves, often due to the pressures of the pandemic.

I was and still am a fan of Stephen Covey’s wisdom:

Covey disparages the “Great Jackass” theory of management, in which the carrot-and-stick style of leadership dominates. Adopting a principle-centered leadership paradigm entails a commitment to change at the individual level, working from the inside out. This means building self-awareness, identifying one’s own vitally important goals, and creating a balance that includes a devotion to living, loving, learning, and leaving a legacy. In turn, this might lead to identifying a personal mission and a vision for an organization that empowers others to find their own motivation to service. Many of the problems that Covey finds in big business exist in the mental health care sector-low trust, low productivity, and environments in which the cultures of blame and victimization, political gamesmanship, and apathy spread. These are often the issues that get subsumed under the name of “stress” in academic departments, community mental health centers, and private practice groups.

Of course, despite how wise I sounded back then, I still ended up with burnout. It took a lot out of me, but it didn’t destroy me.  According to some figures, about 40%-60% of physicians are burned out.

One guy I admire a great deal is Dr. George Dawson, MD. He writes the blog Real Psychiatry. He has been fighting the pressures in the health care system for decades and signs that he’s still going strong are in the Psychiatric Times article “The Bureaucratic Takeover of American Psychiatry: George Dawson, MD, DFAPA.

The interviewer for that article, Dr. Awais Aftab, MD asked George what he thought about the system that psychiatrists must work in which tends to discount the effect of social adversity, poverty, and trauma on the psychiatric distress of their patients, yet corner them into a pill-prescribing role.

George replied, “I heard repeated stories about how child psychiatrists and pediatricians were expected to provide a miracle medical cure to address complex psychosocial problems.

As the number of prescriptions increased there was concern that children were being overmedicated and treated with inappropriate prescriptions like atypical antipsychotics. At that point a consultation line with a child psychiatrist was provided for these prescribers to discuss the prescriptions. At no point were the psychosocial parameters addressed and they still have not been addressed to this day.”

In response to Dr. Aftab’s question about George’s recommendations for how to address this situation:

“I have been writing and speaking about this in various capacities for the past 30 years. During this time very few physicians have been interested in a political fight. The only major figure in psychiatry I can recall is Harold Eist, MD, when he was the president of the American Psychiatric Association. Practically all other professional organizations are silent about managed care and pharmacy benefit managers as malignant forces. There is a lot written about burnout and how these companies waste physician time to the tune of billions of dollars a year. Nobody seems to talk much about all the free work physicians have to do to support the conflict-of-interest-driven decisions these companies make. There is some current interest in the Maintenance of Certification (MOC) issue that professional organizations have also ignored. But in general, nothing will happen until many more physicians get activated and unite. There is still the escapist dream out there that “I can still do private practice,” but that is vanishing fast.

After decades of elaborate planning and recommendations, I am back to the beginning. The course of action at this point is fairly simple. There has to be united agreement on the fact that managed care companies and pharmaceutical benefit managers work against the best interests of physicians and their patients. Once that recognition is there, a rational course of action may follow. But it does take physician professional organizations taking a clear stand against these business practices.

I do think there is a lot to be said for specialty clinics that are outside of the administrative scope of managed care companies. The first groups I noticed were radiologists and anesthesiologists. They were followed by surgical specialists. I do not see many large free-standing psychiatric practices. I think it is possible to practice with a group of like-minded psychiatrists and provide excellent care based on an agreed upon practice style that will result in greater degree of professional satisfaction than is possible as an employee of a managed care company. The required business expertise and planning is a deterrent to most but knowing what I know about the landscape today I would have tried it much earlier in my career.”

George announced his retirement in January this year. But he’s not done.

Dr. Miller suggests that we come up with a lingo that’s more precise to clarify what mental illness and mental health are and what our positions as practitioners and patients ought to be—and what we should do.

So that naturally led me to Allen Frances, MD, who wrote the book on the subject several years ago, “Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM-5.” Dr. Frances was also interviewed by Dr. Awais Aftab, MD, leading to the article “Conversations in Critical Psychiatry: Allen Frances, MD, published in May of 2019.

Dr. Frances says this about what he believes is “among the noblest of professions”:

 “I fear that too many psychiatrists are now reduced to pill pushing, with far too little time to really know their patients well and to apply the rounded biopsychosocial model that is absolutely essential to good care. We also have done far too little to educate the primary care doctors who prescribe 80% of psychiatric meds on the principles of cautious prescribing, proper indications, full consideration of risks, and the value of watchful waiting and tincture of time.

 I despair the diagnostic inflation that results from a too loose diagnostic system, aggressive drug company marketing, careless assessment, and insurance company pressure to rush to judgement. Diagnoses should be written in pencil, and under-diagnosis is almost always safer and more accurate than over-diagnosis. And, finally, I object to the National Institute of Mental Health (NIMH) research agenda that is narrowly brain reductionistic; it has achieved great intellectual masterpieces, but so far has not yet helped a single patient. So, in sum, I have loved being a psychiatrist, but wish we were better organized to end psychiatric suffering.”

He rejects the dichotomy that mental illnesses are either diseases or problems in living as far too simplistic.  He deplores the tendency of the DSM 5 to confuse mental disorder with “everyday sadness, anxiety, grief, disappointments, and stress responses that are an inescapable part of the human condition.” He says the DSM should be only a tool to help guide clinicians’ judgment, not replace it.

So, let’s stop stressing ourselves out looking in the dictionary for definitions of mental health and mental illness.