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.

 

Get your Ferritin and B12 Levels

If I could only give out one piece of advice when it comes to people suffering from depression or anxiety, it’s this: find out your ferritin (stored iron) and Vitamin B12 levels.

If every family doctor checked just these two things before putting someone on an antidepressant, it would save an incredible amount of grief. Such a simple thing, but not having recent ferritin or B12 levels, or them being too low, is one of the most commonly-missed and easily treated causes of depression and anxiety.

Why Ferritin and B12 are Important

Iron and B12 are used for a variety of things in the body, including assisting in the process of creating neurotransmitters like serotonin which help regulate your mood. If you don’t have enough iron and B12 available, you don’t produce enough neurotransmitters. You can end up severely fatigued, with low energy, poor concentration, bad memory, more anxious, etc.  In other words, low iron or B12 mimic many of the usual symptoms of anxiety and depression.

Antidepressants are designed to keep the number of neurotransmitters available in your brain at a high enough level. But no antidepressant is going to help you if you don’t have enough neurotransmitters to begin with. Experimenting with antidepressants under these circumstances is an incredible waste of your time and money.

What Causes Low Ferritin and B12?

There are lots of causes. For example, excessive bleeding can reduce iron. Inadequate dietary intake can be an issue, as can inadequate absorption of what you eat. Many medications can decrease absorption, as can some foods. Many people gradually lose the ability to absorb B12 as they get older, and develop all kinds of cognitive problems as a result. Too many, whose B12 isn’t checked, may be mistakenly assumed to have some kind of dementia. If the low B12 is corrected (e.g. via injections), the cognitive problems often quickly go away.

What you Need to Check

There are multiple different blood tests to check for iron levels, but for this purpose you need to make sure your serum ferritin is checked. This is a measure of the amount of iron stored in your blood that’s not already part of other things like blood cells, and so is available to help create neurotransmitters. Vitamin B12 levels are more straightforward. So ask your doctor if you’ve recently had a ferritin and a B12 level done, and if not, get them to order it. Then ask for the actual result of each.

Within Normal Range Isn’t Good Enough

You probably know that different blood tests have a range that’s considered normal, and anything above or below that range gets flagged in the lab reports that go back to your doctor.

Here’s the problem: for people with mental health symptoms, the normal ranges are too low.

The normal range for ferritin is 12–300 ug/L. That’s good enough to make sure there’s enough iron for building blood cells, but not enough for neurotransmitters. To avoid problems with fatigue, memory, concentration, etc. your ferritin level must be at least 50.

Similarly, the recommended level of Vitamin B12 is a minimum of 150 pmol/L, but for optimal mental health your B12 level should be at least 240.

Consequences in Practice

Many doctors, if they’ve ordered these tests at all, see them come back normal, and that’s the end of it. This is not good enough. The clinical difference between the official normal range and the optimal range for people with mental health symptoms can be substantial. I’ve seen many people have their symptoms improve, in some cases dramatically, simply by correcting these deficiencies.

Becoming deficient can happen anytime too. Some people are on antidepressants for years, with good effect, when they gradually start developing symptoms again, which worsen over time. Too many doctors are quick to assume that their antidepressant has “pooped out” and try to switch them to something else, instead of first checking if there is a new or worsening ferritin or B12 deficiency.

There is so much research and evidence behind this, that it is one of the few things that I would recommend truly pushing with your doctor if they are hesitant. Too many doctors (and pharmacists) are reluctant to treat low ferritin or B12, as long as the numbers are close to the normal range. Unless they can offer a good reason that supplementation to these higher minimum levels would be harmful, this is one worth fighting for.

Take Action!

Go to your doctor, check if you’ve had recent ferritin and B12 levels measured. If not, get them to order it. Ensure your ferritin is at least 50, and your B12 at least 240. If not, ask them how best to correct it. Make sure it gets checked again several months later.

Further Reading

Effect of iron supplementation on fatigue…  Canadian Medical Association Journal, August 7 2012.

It Could Be Old Age, or It Could Be Low B12. New York Times, November 28 2011.