The most common complaint I have heard on my psychiatry rotation is that of stress. Their job stresses them out, their husband stresses them out, the mountain of housework stresses them out, their to-do list stresses them out, their kids with ADHD stress them out. “Just something, just anything, doctor, to take the stress off.”
After the first week I could hear these complaints and realize that I did not have to have an opinion of the patient – I did not have to think they were whiny, or weak, as so many physicians not in psychiatry seem to do (or psychiatrists think and do not verbalize). I also did not have to judge that they were actually strong people who had had horrible things done to them in childhood and throughout life. I could just listen and evaluate dispassionately because, in the end, I was not responsible for figuring out the cause of their problems, nor, really, with their success in treatment. I could accept that this was the way this particular patient experienced the world. They saw stress everywhere, the world was overwhelming, and they believed that upon seeing the psychiatrist they would be presented with a pill, much like Morpheus (such a carefully chosen name) presented a choice of pill to his patient in The Matrix. In psychiatry, however, the patient cares not whether the pill is Red or Blue.
Note that, up until this point, I have not said anything judgmental of any patient I have seen, and that if you are feeling a rise of resentment in your chest at this uppity jerk who is posting some inconsequential reflection on his time in psychiatry…well, what does that say about you? I am going for introspection, not for judgment or valuation.
I have had multiple psychiatrists talk with me philosophically about the role of drugs in their field. One felt like prescribing medications just reinforced the belief of the patient that a drug would solve their problems. The medicines, in a sense, were preventing the patient from developing the coping skills they had never been raised to have by their parents, who usually were not around. He was an addiction specialist, and his argument frequently pertained to prescribing benzodiazepines. More interesting, however, is the discussion I had with another physician about anti-depressants.
There are times, I think, when physicians take a step back and realize how little they know. We prescribe these drugs that have been “evaluated” in randomized controlled clinical trials, which tell the public that a drug is legitimate, but just raise more questions to more than a few people. Not everything can be evaluated in numerical form. The fact that you answered the right questions on a depression screening does not necessarily mean that you have depression. The same goes for ADHD – “yeah, I suppose I do have times of distractibility,” the patient said yesterday, while playing angry birds on her iPhone.
Anti-depressants, as we know from the almighty trials, help in depression, and help to a degree that is directly proportional to how severe the depression presents. But what, really, are the long term effects? I am not talking about symptoms – sure you can have headache, or sexual dysfunction, or you pick your side effect as you read the package insert, but what about qualitative life outcomes?
You see, in our discussion we talked about how the Prozac you take may make you able to handle the stress in your life a little better. Your job is more manageable, your relationship more tolerable, your kids less ADHD-ish, but what if this outcome is not good? What if you just stay in a dead end job or an abusive relationship because you are better able to tolerate it? Is that successful treatment? I don’t think so. Or what if the reason why you have all your stress is not because of external circumstances but because of You? You, as a person, unconsciously desire a certain amount of stress and find ways to seek it out. Prozac lessens your stress, so you seek out circumstances that send it back to where your actual “set point” is. Scary. You take a bad situation and make it objectively worse, even if your subjective experience is the same.
The psychiatrist said that he didn’t believe that the case was as I described above, but he did say that some psychiatrists feel like it is, that medication may not actually help. What if the problem is not the red or blue pill, but the choice itself? Maybe the right choice is the hand you do not see and holds in its palm a mirror.
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