The Seven Deadly Sins of Psychiatrists

What makes a good psychiatrist?

If you ask patients to talk about their bad experiences with psychiatrists (or just ask psychiatrists who have taken over care of a patient from a bad psychiatrist), you’ll certainly get an earful!

Herewith, a highly unscientific list of “sins” that can arise in psychiatric care.

Selective Attention

“You didn’t hear a word I said!!!”

Whether due to unreasonably short appointments, or quickly focusing on only one small aspect of the problem(s), there’s nothing more infuriating than feeling like you haven’t been heard, or your concerns not taken seriously. If the sole response to a half hour of tearfully recounting your struggles in work and relationships is “you should drink less coffee”, you’d have a legitimate right to wonder why you waited six months for this appointment.

Good psychiatrists: Take the time to listen and acknowledge patient concerns. Even if they can only help with a small part of those concerns today, they’ll put small changes into a larger plan or context, and set overall expectations for moving forward.

Dehumanization

Are you a person or just a diagnosis? While a specific diagnosis can be helpful to help narrow down appropriate treatments to consider, ultimately the bigger question is how your symptoms are impacting your overall quality of life. Not everything needs to be treated, and the success or failure of any treatment needs to be measured against that. It’s great if a medication can help with anxiety, but if it causes an athlete to gain 50 pounds or a writer to be unable to concentrate, is that really fixing the problem? This might be the equivalent of a surgeon’s “the operation was a success, but the patient died”.

Good psychiatrists: Look at the whole person. They don’t believe in “one size fits all” treatments, and are cognizant of potential side effects. Their goal is to help improve overall quality of life, as seen by the patient, not themselves.

Polypharmacy

For some psychiatrists, it’s too easy to just add medications to deal with every new problem, or every side effect of the previous medication that was added. It doesn’t take long before someone ends up on four different benzos, a few antidepressants, a couple antipsychotics, a mood stabilizer, and several other drugs to deal with akathisia, insomnia, etc.

Unfortunately, taking people off medications and trying others takes more time and has the potential of destabilizing them for short periods of time. And cleaning up an overly complicated medication regime can be a long-term process. Just adding something else to an existing mix is an easier way out.

Good psychiatrists: Don’t turn patients into walking pharmacies. They realize finding the right combination of medications for a patient, taking into account efficacy and side effects, is worth it in the long term, and will find ways to make sure that happens.

Short Sightedness

If someone has a broken limb it may be well enough to cast them up and send them on their way, but if it happens every few months because they have a habit of jumping off their roof, you might want to look at that. Similarly, prescribing something to control a panic attack may be useful in the short term, but it may be more helpful in the long run to also address the cause of those panic attacks.

Good psychiatrists: Consider root causes and context. They understand that learning better coping strategies or engaging in therapy (even if they aren’t the ones providing it) can help solve many problems in the long term. Medications can be part of the solution, and often are needed to get people to the point they can benefit from other techniques.

Overspecialization

The old chestnut about “if all you have is a hammer, everything looks like a nail” can apply here too. A psychiatrist who specializes in mood may see everything in those terms, and overlook an obvious PTSD. More generally, some psychiatrists may assume every problem they see is as a result of a mental health cause, and try to solve it using psychotropic medications. Psychiatrists who forget they are physicians first may try a patient suffering from poor concentration and energy on five different antidepressants and give up when none of them work, but not bother to find out if their iron levels are in their boots. A psychopharmacology specialist may ignore therapy even when it may be more appropriate to the problem.

Good psychiatrists: Recognize other problems that can present with psychiatric symptoms. They understand that psychiatry makes up only one part in an overall health team, along with a variety of other professionals.

Discontinuity

Some patients who see a psychiatrist regularly can walk out of the office each time with a different diagnosis and a different medication. If their psychiatrist only looks at the symptom of the day, and ignores the patient’s overall history, patterns and changing circumstances, they’ll end up on a never-ending medication roller-coaster.

Good psychiatrists: Take a thorough history and work in the context of an overall treatment plan. They often have frighteningly good memories of seemingly trivial statements or incidents from previous sessions. They differentiate between regular behaviour patterns for each individual, normal human reactions to external circumstances, and unexplained mental status changes requiring further investigation.

Narcissism

Beware the psychiatrist who knows everything, has no need of opinions or help from others, and prides themselves on knowing exactly how to solve a patient’s every problem within two minutes of meeting them. They see themselves on high, separate and better than their patients, dispensing wisdom to those patients who should feel fortunate enough to be seen. They are quick to dismiss advice or treatments you may have received from others in the past, as those people don’t know what they’re talking about.

Good psychiatrists: Become partners with their patients and other caregivers. They demonstrate empathy, not hubris. They recognize the limitations of their own knowledge and skills, and how much time it takes to really understand another human being. They value rather than shun other opinions and perspectives.

 

On Antidepressants, Still Anxious

Antidepressants, despite the name, are first-line treatments for anxiety as well as depression.

Choosing the right antidepressant is hard, a topic we’ll come back to frequently. It involves a lot of trial and error, but there is both some science to it and some knowledge to be drawn from practical experiences.

Here are two pieces of practical experience that don’t seem to be as well known as they should be:

  1. Wellbutrin tends to increase anxiety in a lot of people.
  2. Higher doses of SNRI’s (e.g. Effexor, Pristiq, and Cymbalta) tend to increase anxiety in a lot of people.

Usage of Wellbutrin

Wellbutrin, generic name bupropion, can be used by itself to treat depression. It’s also used as a smoking cessation aid, marketed under the name Zyban. But more often, it’s added to another antidepressant to either complement it, or reduce the impact of the first antidepressant’s side effects.

For people who get “slowed down” a bit when taking an antidepressant, sometimes Wellbutrin can help give them a little bit more pep. It’s also very commonly used to combat the dreaded sexual side effects brought on by many antidepressants.

Using Higher Doses of SNRI’s

SNRI’s like Effexor (venlafaxine), Pristiq (desvenlafaxine), and Cymbalta (duloxetine) are commonly prescribed antidepressants that can help with a wide range of anxiety and depressive symptoms.

Everyone is different, but most people start at a low dose of each and may gradually increase. Most people top out around 225mg of Effexor, 100mg of Pristiq, or 60mg of Cymbalta. But you can certainly go quite a bit higher on all of them. After all, if you’ve gotten a good response at a particular dose, maybe you’ll get a better response at an even higher dose?

Taking a Step Back

Before going any further, let’s take a step back and get a refresher on what antidepressants actually do. Your brain has a set of chemicals called neurotransmitters which help control your mood. There are several different neurotransmitters, most notably serotonin, norepinephrine and dopamine, which all affect slightly different aspects of your mood.

Different antidepressants target different neurotransmitters. They don’t actually create more of them, but they make sure that they’re all available right where they are needed. Selective Serotonin Reuptake Inhibitors (SSRI’s) work to maximize the availability of serotonin. Serotonin-Norepinephrine Reuptake Inhibitors (SNRI’s) work to maximize both serotonin and norepinephrine availability. And so on.

Neurotransmitters and Anxiety

For most people, increasing the amount of serotonin available will help improve anxiety symptoms. That is why SSRI’s and SNRI’s tend to be the first meds prescribed for anxiety.

What isn’t most recommended to try first for people with anxiety? Antidepressants that increase the amount of dopamine that is available, which makes many people more anxious, not less.

Guess what neurotransmitter Wellbutrin tends to target? Dopamine.

So what about SNRI’s? The current generation do, as the name suggests, primarily target serotonin and norepinephrine. But they also weakly target dopamine as well. However the larger increase in serotonin tends to more than offset the small increase in dopamine availability for most people.

As you move to higher and higher doses, the amount of extra serotonin made available gets smaller and smaller. That is why increasing the dose of some drugs past a certain point doesn’t greatly improve symptoms. In contrast, at the higher doses of current SNRI’s, the amount of extra dopamine made available does actually get larger.

As an example, somebody taking Cymbalta 60mg will have only a very small amount more dopamine available. That same person taking 90mg or 120mg may have quite a bit more extra dopamine, which can cause nervousness or anxiety.

Every drug has a different behaviour at different doses, which is known as the dose-response curve.

Take Action!

Are you on Wellbutrin and experiencing anxiety? Ask your doctor about reducing or removing the Wellbutrin, and see if it helps your anxiety. If so, will you still need to find something else to replace it?

Are you on an SNRI and experiencing anxiety? Particularly if it’s a higher dose, talk to your doctor about the possibility of going down to a lower dose and seeing it it makes a difference. If it does reduce your anxiety, and the lower dose isn’t enough to help with your other symptoms, you may end up discussing a switch to another antidepressant, or something else to augment the lower dose of your current SNRI.

There are lots of other reasons you may be anxious, which I’ll have more to say about in a future post, but these two kinds of medication-induced anxiety seem to very commonly get missed.