The woman was clearly uncomfortable in my office. She had been sent by her family doctor to see me. This was our first visit. Her physician had assured her that her severe mood swings were caused by a chemical imbalance and that I could help her with medications.
But he had failed to tell her that I was a psychiatrist; if he had, she never would have come. She knew about psychiatrists. She knew what they did -- lengthy talk therapy, mind probes and difficult sessions focusing on painful feelings.
I tried to assure her that although psychotherapy might well help, we now had medications to stabilize her moods and prevent the terrible depressions she had been experiencing. She remained skeptical, frightened and particularly incredulous at the notion of psychiatrists dispensing medications to people who were not certifiably "crazy."
The woman found it hard to grasp that her illness was just as medical as any other, largely biological in its origin, and could be treated with medications. She repeatedly told me that if she needed medication, she would rather get it from a "real" doctor, not a psychiatrist. At best, she would allow me to remain involved as a consultant, giving advice to her family physician on how to prescribe the proper medications.
The patient's fear of being in a psychiatrist's office, feeling "tricked into it" by her family doctor, may be extreme these days. But her confusion about my role is quite common.
It is not that people have not heard of some of the advances in brain chemistry and medical treatments for the severely disturbed. They have learned that powerful antipsychotic drugs such as Thorazine and mood stabilizing medications such as lithium have revolutionized the practice of hard-core psychiatry -- the work done in mental hospitals.
But few people really understand that a much broader spectrum of patients, most of whom will never need hospitalization, can now be treated successfully with psychiatric medications. Patients with conditions such as depression, mood swings, anxiety attacks, emotional instability and even the underlying mood-states that drive people to abuse food, drugs or alcohol, can now be helped dramatically with psychiatric medications.
Tranquilizers such as Valium, which have an undeservedly bad public image, are in fact the best and safest drugs yet invented to treat anxiety. And antidepressants, such as imipramine and amitryptiline, will some day be as well-known for the treatment of the ambulatory depressed patient as Thorazine and lithium are for hospital patients.
The public does not come to this blind spot regarding psychiatric medications by accident. Mental health professionals themselves have only reluctantly come to appreciate what the modern psychiatric medications can do. Clinical psychologists and social workers, who have no medical training and frequently little experience with these medications, as well as many psychiatrists trained and steeped in the psychotherapeutic tradition, often are hesitant to use the so-called psychotropic medications. Probably even more conservative on this issue than the public, most people in the profession have clung to the conventional wisdom that medications are at best a necessary evil and useful only in emergencies -- or as a last resort. In fact, these medications are seen as actually psychologically dangerous, giving the patient an "easy fix" solution to what are really complicated psychological problems, and will prove to be detrimental in the long run because the patient will be allowed to escape working out "underlying" emotional problems. This in spite of the fact that current studies are showing that people with depression probably do best with a combination of medication and psychotherapy.
The younger generation of mental health professionals -- those finishing their training in the last five to 10 years -- do feel more comfortable using medications and talking with their patients at the same time. But even they are put through an ideological wringer by the seriously depressed patient who responds very favorably to antidepressant medications within a few weeks but is not interested in classical psychotherapy. In fact, such a patient can frequently be managed with fairly brief supportive psychotherapy, continuing on the medication for a period of six months or so and riding out the depression. But as long as it is assumed that any psychiatric or psychological symptom is just a manifestation of some deep, underlying, unresolved emotional conflict dating back to childhood difficulties and ultimately resolved only by in-depth psychotherapy, the medication and brief psychological approach will be seen as superficial and inadequate treatment.
Medications have their drawbacks. All drugs have risks and side effects, and the newer psychiatric medications are no exception. For example, many antidepressants can cause dry mouth, constipation and weight gain or loss. In most cases, however, these side effects are minor, and really no more difficult to manage than the side effects caused by medications used for other medical conditions, such as high blood pressure.
Contrary to the popular notion that the American public is overtranquilized by doctors and rushed out the door, the use of the newer psychiatric medications has been underappreciated by the public and underused by mental health professionals.