When is Psychiatry Effective?

[Dave1001]

You keep calling it diagnosis by checklist. It's not that simple. They use diagnostic criteria from the DSM-IV, but in my experience, psychiatrists in general also spend plenty of time trying to rule out other possible causes of the patient's symptoms. Remember that psychiatrists are MDs. They know the body as a whole and have been through the same rigorous medical school training other MDs have. They simply have a specialty that relies heavily on subjective symptoms as reported by their patients, without the benefit of a battery of laboratory tests or technologically sophisticated equipment like MRI machines.

I think competent ones exercising ordinary care take a full history from their new patients. I think it is you who is being flip by dismissing their diagnostic process as being able to render an opinion that a given patient suffers from a chronic illness from a single one hour visit. I think it more often takes multiple visits and some treatment and feedback before such a diagnosis can be made confidently. Even then, the patient has to return at regular intervals for monitoring, and in my experience the doctor is usually asking questions and getting feedback and constantly reassessing the situation. I think that's all they can do at the moment.

AS

I agree with you about the "competent ones". But, I think a substantial number of psychiatrists (perhaps even the vast majority) are not "constantly reassessing" whether patients were incorrectly diagnosed with a chronic mental illness that entails a lifetime of pharmaceutical treatment. And I think protocols for such reassessment, propagated as norms for professional conduct, would be of great benefit to the more authority dependent patients, who won't simply quit the pharmaceutical treatment on their own when they sense that it's not necessary.

 

[calebprime]

How often can mental illness(say psychosis) be detected in such absolute manors, instead of saying "you know the guy running around ranting about the turkeys is probably not all that sane"?

On a lighter note:

In my suburban neighborhood, something I'd never seen before: A wild turkey with 3 offspring. They're growing faster than can be explained by the laws of physics! They're tying up traffic!* I'm for tough legislation to stop this menace!

and:

I dreamed about stingrays. Two days later, the Steve Irwin tragedy!* Here comes my JREF challenge!

That early morning waking can be a real [rule 8.] Miss one night's sleep and I'm hypomanic already. (In fact, sleep deprivation can be used, briefly, as a treatment for depression.)*

Um, carry on.

------------------------------
* It's true!

 

[Dancing David]

However, others have "relapses". They may indeed have chronic illnesses. I think it would be prudent for psychiatric medicine to have an in-built mechanism to reappraise people diagnosed as having chronic mental illnesses as actually having suffered from temporary mental illness, and to take them off medication. Otherwise, the more authority dependant types may end up taking pharmacueticals, often with significant side effects and costs, for decades, without a true need to do so.

The term chronic mental illness which has been replaced by severe and persistant mental illness is not a medical term, it is a social term used by people in social settings to talk about the more severe forms of mental illness.

Something you may not be thinking about:

How many people take all the antibiotic that is perscribed to them? How many diabetics and heart patients take thier medications irregularly.

My poibnt is that very few people taking medications do so regularly, psychiatrists do review a person's mental staus on a regular basis, that at least is best practise. In my experience most people will stop taking the medications on thier own about 60% of the time, without even talking to thier doctor.


authority dependant types

if you have ever worked in mental health you would realize this is not an issue, and when it comes to over perscription thier are other medications that are more likely to be overperscribed, ie: pain medications, steroids and anxyiolitics (which are a psych medication).

So while there may be those who take a medication without benefit, that is a general issue not limited to psychiatry.

 

[Dancing David]

To further clarify, the DSM-IVR states very clearly in the introduction of the text that it is what, a categorization to make communication easier. It has all these loaded in caveats about the fact that these are not your standard medical diagnosis but that they are guidelines to diagnosis that will hopefully lead to more effective treatment.

That said, do the conditions exist, yes. if you have ever met a manic or psychotic person, they are definitly off the base line.

Do all people with these conditions need treatment, no. that is a personal decision to make, when has the functioning reached the point of treatment.

Do doctors overuse the terminology and forget that the DSM is a categorization, yes.

Do personality disorders exist, no. But they are a short hand for condencing a complex set of behaviors to a label.

 

[Dave1001]

Something you may not be thinking about:

How many people take all the antibiotic that is perscribed to them? How many diabetics and heart patients take thier medications irregularly.

My poibnt is that very few people taking medications do so regularly, psychiatrists do review a person's mental staus on a regular basis, that at least is best practise. In my experience most people will stop taking the medications on thier own about 60% of the time, without even talking to thier doctor.

I have thought about it and mentioned it in previous posts. I think this is problematic because it is outside of medical supervision. Much better that a psychiatrist supervise someone going off their medication in my opinion. I think this problem has at least as a partial cause the fact that many patients don't perceive a way to be reevaluated as not having a chronic/persistent mental illness, so they decide to unilaterally quit psychiatric treatment when they think they no longer have such illness.

Can anyone direct me to good readings on people who were initially incorrectly diagnosed with a chronic/persistent mental illness, and later had their diagnoses changed by psychiatrists and were taken off medication?

 

[blutoski]

I'm not sure about that. It's a question I always ask psychiatrists who are open to discussing this topic with me: how exactly does one get de-diagnosed from having a chronic medical illness? I haven't gotten a clear answer yet. As for as I know a specific protocol doesn't exist. A person gets diagnosed as having a chronic mental illness by a checklist, often from a single 1 hour session. And since they're then expected to stay on medication for the rest of their life, if they are authority compliant, that's it. I consider that problematic, and I'm skeptical that it's the best course of treatment for such people. Your flippant answer here doesn't cover these concerns, in my opinion.

Hm. While it's true that the history remains in the patient's chart, a patient can be considered recovered. Medication is stepped back when patients show improvement. If the problems recur then they will restore the dose. The goal of any program is to get the patient to the point where he no longer requires treatment.

When you no longer meet the criteria for the diagnosis, you are released, and it remains on your chart as either a past 'incident of' or redesignation as 'in remission', depending on diagnosis.

 

[Dave1001]

Hm. While it's true that the history remains in the patient's chart, a patient can be considered recovered. Medication is stepped back when patients show improvement. If the problems recur then they will restore the dose. The goal of any program is to get the patient to the point where he no longer requires treatment.

When you no longer meet the criteria for the diagnosis, you are released, and it remains on your chart as either a past 'incident of' or redesignation as 'in remission', depending on diagnosis.

I've heard of that being done for some types of anxiety and depression, but I've never heard of that being done in a mainstream way for bipolar disorder, for example.

All the literature I've read has said that someone diagnosed with bipolar disorder should continue to take their medication for the rest of their live, including during periods of "remission".

 

[blutoski]

Can anyone direct me to good readings on people who were initially incorrectly diagnosed with a chronic/persistent mental illness, and later had their diagnoses changed by psychiatrists and were taken off medication?

Are you looking for examples of an incorrect original diagnosis, or of a patient who improved enough to go into recovery or remission?

 

[blutoski]

I've heard of that being done for some types of anxiety and depression, but I've never heard of that being done in a mainstream way for bipolar disorder, for example.

All the literature I've read has said that someone diagnosed with bipolar disorder should continue to take their medication for the rest of their live, including during periods of "remission".

What kind of bipolar?

 

[Dave1001]

What kind of bipolar?

All types of bipolar, as far as I know. I haven't heard of a type of bipolar disorder that mainstream psychiatrists describe as not being a lifelong condition.

 

[Dave1001]

Are you looking for examples of an incorrect original diagnosis, or of a patient who improved enough to go into recovery or remission?

I'm looking for a standard protocol to determine that an original diagnosis is incorrect, a study examining incorrect diagnoses and determining how they happened, or for examples of patients a mainstream psychiatrist determined to have recovered from bipolar disorder sufficiently to no longer need pharmaceutical treatment.

 

[blutoski]

I'm looking for a standard protocol to determine that an original diagnosis is incorrect, a study examining incorrect diagnoses and determining how they happened, or for examples of patients a mainstream psychiatrist determined to have recovered from bipolar disorder sufficiently to no longer need pharmaceutical treatment.

OK: so these are two different things. The first is a request for examples of misdiagnosis leading to release, and the second is examples of recovery leading to release.

I'm not sure that there would be studies of this. The examples I'm aware of are some of my wife's patients.

Regarding the first situation: my wife has occasionally taken over part of a retiring peer's portfolio and concluded that the peer has misdiagnosed. Usually, the patient is polymorbid and doesn't get released due to other illnesses, but some do. This is usually misdiagnosing a personality disorder as a mood disorder. eg: suicide attempts misattributed to depression, when they are histrionic in nature. Another example is extreme selfishness misinterpreted as social disorder, when they are actually bipolar I.

Regarding the second situation: You asked specifically about bipolar. Certainly with bipolar when a patient has been off medication for 12 months without a cycle, they are in remission and no longer need to be monitored. It's much more common with bipolar II than bipolar I.

 

[Dave1001]

Regarding the second situation: You asked specifically about bipolar. Certainly with bipolar when a patient has been off medication for 12 months without a cycle, they are in remission and no longer need to be monitored. It's much more common with bipolar II than bipolar I.

Are you saying that both:
1. They no longer need to be monitered, and
2. That they no longer need to be taking pharmaceuticals?

Because I've never heard that before.

Sources, please?

 

[blutoski]

All types of bipolar, as far as I know. I haven't heard of a type of bipolar disorder that mainstream psychiatrists describe as not being a lifelong condition.

Mm. Well, for example, there is a type called "Single Manic Episode" Patients are rarely medicated, and usually monitored outpatient for 12 months.

The other varieties of bipolar I and II do appear to be lifelong. This is more observed than theoretical, though.

There is a point where if patients have no episodes for a specified period (usually 12 months) without medication, it is considered unnecessary to continue monitoring. I've never heard of it happening, though.

 

[Dave1001]

Mm. Well, for example, there is a type called "Single Manic Episode" Patients are rarely medicated, and usually monitored outpatient for 12 months.

The other varieties of bipolar I and II do appear to be lifelong. This is more observed than theoretical, though.

There is a point where if patients have no episodes for a specified period (usually 12 months) without medication, it is considered unnecessary to continue monitoring. I've never heard of it happening, though.

definitionally, wouldn't "Single Manic Episode" not be bipolar? Also, it wouldn't be in the larger category I mentioned being concerned about, people diagnosed as having chronic/persistent mental illnesses.

 

[blutoski]

Are you saying that both:
1. They no longer need to be monitered, and
2. That they no longer need to be taking pharmaceuticals?

Because I've never heard that before.

It's rare. In all cases, a psychiatrist will want to cut back on a patient's doseage in principle. The course of therapy often looks like this: stablize patient, reduce dosage, if patient is still stable, reduce again, if not, restore original dose. Some patients slowly reduce dosage until they're completely off meds.

After a fixed period of time, which probably varies from region to region, if a patient does not relapse and is not on meds, there is no reason for medical supervision, and the patient is officially released.

A recent case was a woman who came in with bipolar II and had about 3 months of ect and therapy and was 12 months without meds or remission. My wife bumped into her on campus a few months ago. She seems fine, and has returned to school, which is good news.

Sources, please?

I don't know how to provide documentation for these patient histories without violating patient confidentiality. I'll ask my wife it the protocol is documented, and if it's OK to publish it.

 

[blutoski]

definitionally, wouldn't "Single Manic Episode" not be bipolar?

Not really. It's called "Bipolar I Disorder of the Single Manic Episode type." The 'other' mood would be a baseline of depression.

Also, it wouldn't be in the larger category I mentioned being concerned about, people diagnosed as having chronic/persistent mental illnesses.

No, but it is a type of bipolar, which is why I asked for some more details in an effort to address your question.

 

[Dave1001]

Not really. It's called "Bipolar I Disorder of the Single Manic Episode type." The 'other' mood would be a baseline of depression.

I'm far from a psychiatrist, but if the person has a baseline of depression I query why patients with it are rarely medicated. What happens during those 12 months of subsequent monitoring? Do they stay at a baseline of depression and are they then sent packing as a functional, non-medicated depressed person? Or is it the same as you describe BP1 and BP2, where they are only no longer monitored once they are 12 months without episodes?

One other question, how is someone diagnosed with BP1 or 2 ascertained as being ready to try to go off medication while being monitored? So that those 12 months of being off medication while being monitored can be attempted?

Is there a standard protocol for this assessment?

 

[Dave1001]

I'll ask my wife it the protocol is documented, and if it's OK to publish it.

Thanks. I'm sure it will be fascinating to read. I had every impression such a protocol didn't even exist.

 

[blutoski]

I'm far from a psychiatrist, but if the person has a baseline of depression I query why patients with it are rarely medicated. What happens during those 12 months of subsequent monitoring? Do they stay at a baseline of depression and are they then sent packing as a functional, non-medicated depressed person? Or is it the same as you describe BP1 and BP2, where they are only no longer monitored once they are 12 months without episodes?

It depends on the quality of the baseline of depression. Some may have been severe enough to be diagnosed with depression, others would merely have chronic dysthymia, or cyclothymia. Medication and therapy for this latter group is typically voluntary, since they are not a danger to themselves or others.

In the case of bipolar ii single episode, it's rare for the patient to have been followed previously. They are usually young and this is their first connection with the system. It's usually a forensic situation.

One other question, how is someone diagnosed with BP1 or 2 ascertained as being ready to try to go off medication while being monitored? So that those 12 months of being off medication while being monitored can be attempted?

Is there a standard protocol for this assessment?[/QUOTE]

It's standard for the region in question. In this case, my wife is in Nova Scotia, and I reviewed the timeframes with BC and they're identical, so it may be a Canadian standard. Medication is gradually reduced for bipolar i in 6-month timeframes. It is possible that after a series of increments, the patient is totally unmedicated.

The real question is: what does 'stable during the review timeframe' look like? This usually means no sign of mood cycles typical for bipolar. Cyclothymia or rational mood swings would be excluded, of course.