[ed. note: This is an introductory piece from longtime reader Peter Tilton, who has proposed writing a regular column for Stock Gumshoe readers about psychiatry. Not an investing topic (though the behavior of many of us in the markets may well be something that’s in need of a diagnosis), but we thought you might find it interesting. Please share any feedback either in the comments below or on our contact page — we’d like to know if you’re interested in reading more of Peter’s work. Thanks!]
In my first article of Psychiatry Simplified, I’d like to start with what modern day psychiatry is about. Simple. Diagnosing and treating mental illness with medication. But before delving further, I’d like to tell you a bit about my medical career. I have been a psychiatrist for 20 years. Before that I worked in primary care in many varied capacities—free clinics in the 1970’s, emergency rooms, private practice and a holistic medical practice. As a psychiatrist I have worked in private practice, alone and in a large private multi-specialty clinic. I have done forensic work and treated workers’ compensation patients. But for most of my career I have worked in the public sector, inpatient and outpatient. For ten years I worked in a county outpatient children’s clinic and spent some time at a county juvenile hall and boys’ camp. I have treated adults in a small acute inpatient hospital and have worked in several types of outpatient clinics as well as a crisis outpatient center. If I have a specialty, it is treating severe, chronic and persistent mentally ill patients with psychotic disorders (schizophrenia, etc.) and mood disorders (bipolar disorder, etc.) with medication. That is not to say that I don’t use psychotherapy in various forms with my patients. While in private practice I treated people with short term (brief, paradoxical, hypnotherapy, etc.) and long term psychoanalytical psychotherapy based on Heinz Kohut’s self psychology model.
In the public sector my main role, besides taking part in team meetings and decisions, is diagnosing and treating my patients with medication. I am very conservative, meaning I try to use the least amount of medications needed. While polypharmacy (using more than one medication) is more the rule these days, I try to limit this approach. On the other hand, I am also very aggressive in that I will do what it takes once I start, meaning I will continue to raise the dose based on symptom relief versus emerging side effects—a risk/benefit approach. I am not averse to adding medications, but unlike many of my colleagues, I also take away medications or lower a dose when warranted. I must admit that there have been times when I have lowered a dose or stopped a medication and discovered my mistake by the reemerging of symptoms.
I have also had the privilege of working as a psychiatrist in New Zealand, both north and south islands.
Psychiatry is different than all other fields of medicine in that we have no lab tests, scans, x-rays or procedures that accurately help us with a diagnosis. No fracture on an x-ray, tumor on a scan, positive urine culture and sensitivity to guide us in our treatments. There are, in the domain of psychology, tests like the MMPI, etc., which can be used for diagnosis, but I believe a thorough history in a one-to-one situation to be the most accurate way to obtain a diagnosis and overview of the person seeking treatment. Add that to input of any family members or friends and the picture becomes more accurate. The information gathered goes into a sort of thinkolator (after all, this is a Gumshoe website) and out comes a working diagnosis.
In psychiatry this thinkolator is most often the DSM-V (Diagnostic and Statistical Manual), the bible of psychiatry for much of the world—although many use the ICD 10 (International Classification of Diseases) and there is good correlation between these two sources.
While the DSM offers brilliant descriptions of mental disorders and lists the criteria for making a diagnosis, there are problems. There is not universal agreement among the members of each work group and politics (surprised?) plays a part in what gets included and what does not. What is missing is the possible origin or cause of the current symptoms or disorder. “Why now” doesn’t matter. It is the constellation of symptoms that does. Another way of putting it: does the patient have the requisite number of symptoms to be given a diagnosis, let’s say having met 5 criteria out of a list of 9 needed to make the diagnosis of major depression? If a person fails to meet the criteria, the DSM offers an NOS diagnosis. NOS means not otherwise specified. Meaning if it walks like a duck, looks like a duck, but may not quack like a duck, it is still a duck. Sort of. It is a Duck NOS. This can be helpful in what is known as a spectrum disorder. There are some symptoms suggestive of the disorder but not the full blown picture. This is very common in today’s literature regarding bipolar disorder and autistic disorders.
So, getting back to making a diagnosis and deciding upon treatment, a well-trained clinician will ask, “Why now?” And that should include why are you now coming in for treatment, and what if anything has happened recently in your life to cause (whatever the symptoms are). Using the example of depressive symptoms, what led to the symptoms should lead to treatment considerations. If I’m presented with a patient with an adjustment disorder with depressed mood, I need to understand the source of the stressor—this is paramount to deciding on treatment, and most often some type of psychotherapy is tantamount to successful treatment. Antidepressant medication may or may not be needed, and a short term prescription for anxiety or insomnia may be needed, because reduction of symptoms is a major goal and sleep a must, as is freedom from anxiety.
I’ll go into depression and all other mental disorders in later articles. Depression was only used here to show the complexities of psychiatry.
Now, unlike the great Dr. KSS, who imparts his MD and PhD knowledge to enlighten us about investment opportunities, I will not. Mainly because, if I did… well it would be like the blind leading those who can see. I am no expert in giving investment advice.
However, I will disclose that I have been a paid speaker and consultant for Pfizer, Novartis and Forest, but have only presented talks about medications I have used and felt were beneficial and among the best in their class. In future, I will only refer to medications by their generic names. When appropriate I will mention any company that is part of my portfolio.
Also, I cannot give the kind of medical guidance, often so brilliantly offered by Dr. KSS. One, because I cannot be sure that whomever you asking about has been diagnosed accurately. Basically, I trust no one but myself. That is not to say the diagnosis is not correct—I just have no way to corroborate it. Two, prescribing for mental disorders is not (sometimes) as simple as other medical conditions and the results may not be seen for weeks. I will be happy to answer some general questions about treatment, symptoms, medications, side effects, etc. but I expect you to do your own research first. Google or Bing or Yahoo will be happy to help you with general questions. And finally, absent the intimate doctor-patient dyad (therapeutic, placebo, luck, etc.) I can be of little personal help.
In these columns I will attempt to simplify what is known and probably ignore what is not practical for today’s treatment options. While there may be tests available (like assessing serotonin transporter genomes) they are not in everyday use and as yet don’t prove who will or will not respond to antidepressants that presumably work on the serotonin system. When it comes to medications, I can tell you now, no matter what you read or think, no one actually knows how and why most psychotropic medications work. Yes, it is known that medications work on specific receptor site as agonists, antagonists, etc., but that is not necessarily the whole story. I will talk less about the arcane science, since I am not a researcher, but will discuss what I think to be relevant. In this way I will attempt to offer you Psychiatry Simplified.