When I started my work at Mid City TMS, I had a lot of assumptions of what people with mental illness look like: disheveled, unorganized, disoriented, disturbed, out-of-touch with reality. I assumed that psychiatrists had the tools to treat these symptoms and return people to a more balanced place. It turns out “returning to a balanced place” is pretty rare for people who have been battling mental illness for a long time. In fact, these individuals are relatively unaffected by medication and therapy. Their depression (or other illness) seems to be “hardwired” into them. For these individuals medication is used to treat the symptoms but not the underlying disease. (I am not an expert, but I don’t think any psychotropic medication actually treats the underlying disease. We don’t understand it well enough to do so.)
When psychiatrists are treating patients it seems like they just make things up as they go along. Obviously, their past experiences inform their decision making process, but what works for one individual seems to never work the same way for another. Each psychiatrist seems to have their favorite SSRI, favorite augmentation therapy (when you use more than one medication to treat depression, anxiety, etc.), and their favorite novel treatment (ketamine is the best current example). Again, while this is informed by years of treating patients, I can’t help but wonder, how often is their go-to list updated? Presumably, the best psychiatrist are up-to-date on the current literature, but how much does that inform their behavior? Often, psychiatrists work in private practice and don’t interact with other practitioners. Medicine is a collaborative field, so this does not make much sense. Maybe they all have mentors or other practitioners in the field who they can ask advice. But maybe not. I really can’t judge the group as I am not part of it, but I am allowed to ask questions about the field I am potentially interested in working in one day. I think there is a lot to think about when trying to decide if I want to enter this field. One such topic is severe mental illness.
As mentioned earlier, medication cannot “fix” the underlying disease. What medication does is alleviates some of the symptoms. This is especially true in people with severe forms of mental illness; for example, in people who have been battling depression for decades. Medication is a great way for these individuals to find some relief in their most debilitating symptoms. It can work well for a period of time. However, because it does not fix the underlying disease, their medication is constantly being changed and modified because it stops being effective. A Professor once described mental illness as a a “disturbed homeostasis.” The body is constantly trying to maintain homeostasis, even a disturbed one. So this means that if medication once helped someone with depression use their serotonin more effectively, the body wants to return to its previous depressed homeostasis and will down-regulate serotonin receptors making the medication less effective. This happens with long-term use of the drug. Therefore, people with the most severe forms of mental illness are more likely to be affected by this phenomena. This, of course, is unfair, but a reality of the disease and its treatment.
This means that a psychiatrist has to constantly work with this patient to adjust their medication. They also have to trust that their patient is taking the prescribed medication as directed. Further, a psychiatrist’ only information comes from the patient. So they are relying on (typically) unreliable narrators. This means they have to be really good at spotting the (pardon my french) bullshit.
Ok so medication masks the symptoms and becomes less effective over time. But these patients need medication to feel that “balance” I was talking about earlier. So this means that a psychiatrist could work with a patient for years, change the medication a dozen times, and then the patient still does not feel any better than when you first started. How depressing is that. Oh and you are charging them $400 a session (which is great for you, but a huge loss to the patient who just wants to feel better).
Over my 6 months at Mid City TMS, I realized how depressing I would find treating people in with severe mental illness. As a TMS coordinator, I saw people 5 days a week for 6-8 weeks. I got to know my patients very well and felt invested in their (hopeful) improvement. While I did see some people improve, there were others who never got any better. One patient in particular really stood out. In the beginning, the TMS was working. Her scales (self-report scales we use to measure the severity of their depression) were improving, she was more positive, and had more energy. She even acknowledged her improvement. She told me stories about being able to do things (like riding a bike) that made her happy. But as soon as she got noticeably better, it was like a switch turned off. The depression and anxiety crept right back in. When she finished her TMS course, her scales were worse, her energy was gone, and her mood was dysregulated. She called the office almost daily with a new complaint. Dr. Bruno changed her medication at least 6 times over the months (months!) I worked there. This is why I think severe mental illness is hardwired. When I say severe mental illness, I am not including things like seasonal depression, acute/situational depression, or acute/situational anxiety. While those are all legit health-concerns, I don’t think they are the same as someone who suffers from hallucinations and delusions. I don’t think they are the same as someone who has never once in 30 years felt relief from the overwhelming dark cloud of depression. The category of people I am talking about will never get better. Mental illness will be a struggle for them for the rest of their lives. There will be no happy periods that are longer than a few days. And psychiatrists can’t “fix” them. All they can do is change their medication and hope that the regimen is effective for more than a few years (or months). Psychiatrists watch them get slightly better and then break over and over again.
And that is why I don’t think I want to be a psychiatrist. If we don’t have the tools to change someone’s hardwiring, then we are not doing any good. Until I know that psychiatrists are doing good, I am not sure I want to be part of the field.