By David Steingart, LCSW
One aspect of psychiatry that distinguishes the discipline from many other forms of medicine is ambiguity. While we know that a biological component likely underlies mental illness, we don’t know exactly how that biological connection works.
Most researchers agree that people with mental health conditions have a genetic predisposition to their illnesses — but they have also found that a strong environmental component underlies mental health conditions. These environmental factors include some form of overt trauma (physical, sexual or emotional) or more subtle stressors, such as chronic stress, a family marked by poor communication, having a parent who has experienced trauma, etc.
Ultimately, experts believe that the combination of genetic predisposition to mental illness and environmental stressors determine whether a mental illness develops.
Unlike other areas of medicine in which a patient may be given a medication to treat an illness, like a diabetic person receiving insulin, a person with mental illness cannot be prescribed medicine that is guaranteed to work. For example, two people with very similar symptoms of depression may be prescribed the same type of anti-depressant, and one person may respond well while the other may have little or no response.
This is because mental illness is different for everyone. We have names for specific illnesses (like bipolar disorder, depression, general anxiety disorder, etc.) but, unlike diabetes or other illnesses, each patient’s specific symptoms are different. Further, because the illness is not a strictly biological problem, each person may react very differently to the same medicine.
What does this mean for a person with mental illness undergoing treatment? It means that psychiatry is a very inexact science, and it’s important for people seeking treatment to be aware of the challenges they may face.
Two psychiatrists may observe different traits in a person with mental illness and subsequently prescribe different medications. For example, a patient may present to one psychiatrist as having major depressive disorder while another prescriber understands the same symptoms as bipolar disorder. These different diagnoses will yield very different treatment options, as the medications prescribed for the conditions are different. One medicine may be effective while another may have no positive impact, or even be harmful to the patient.
One of the tragedies of treating mental illness, especially for people with serious mental illness, is that a person may be “misdiagnosed” for a very long time before receiving the correct diagnosis by a different prescriber. Self-advocacy — taking an active role in the diagnosis and treatment process — can be critical. When individuals and family members prioritize transparency and honest communication about symptoms, goals and experiences with past treatment, it may help the prescriber attain a more accurate understanding of the condition and plan for more effective treatment.
Prescribing medication requires practitioners to make judgment calls. For example, there is not one medicine for bipolar disorder; there are many medicines that work for some and not for all.
This means that prescribers use their own judgments based on the description of symptoms given by their patients, their training and their past experiences. Theoretically, five psychiatrists could choose five different medications to treat the same person. This is because each is using their own subjective opinion of what medication will work best. There is no guaranteed treatment with mental illness; there is ambiguity, subjectivity and, unfortunately, lots of trial and error.
This is another area where self-advocacy can be critical — when a patient is able to clearly communicate what they are experiencing with their symptoms and side effects it may help the prescriber make more accurate decisions about changing the treatment plan.
The most damaging outcome of ambiguity in psychiatry is when a patient does not have an accurate understanding of the process and the potential challenges. A person walking into a psychiatrist’s office for the first time, for example, may not be informed that the medicine their doctor prescribes quite possibly will not work, or if the medicine helps, it may not help enough to provide substantial relief.
Without having this knowledge, the patient may start down a long and difficult path of trial and error. They may lose faith in the person prescribing the medication and, rather than seeking a second opinion, they may feel disempowered to pursue the treatment-seeking process any further.
With that said, any psychiatrist or nurse practitioner should inform their patients about the inexact nature of mental illness and the subjectivity that goes into deciding on medicines to treat it — and about the importance of self-education and self-advocacy. As a therapist, I often find myself in this role even though I am not directly involved in prescribing medicine.
If people are educated about how psychiatric medication works, they can understand the process and feel encouraged to keep trying, to consult with another doctor who may better understand their illness and treat it more effectively and to never give up on finding the treatment that works for them.
David Steingart is an LCSW who practices in Tallahassee, Fla. David received his master’s degree in social work from Columbia University in 2011 and has worked in a variety of settings. He is an active board member of NAMI Tallahassee and currently sees adult patients at Capital City Psychiatry, a group practice.
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