The Psychiatrist’s Perspective on Depression | Dierich M. Kaiser, MD, Diplomate of the American Board of Psychiatry and Neurology and Western Tidewater Community Services Board
As a medical doctor and practicing psychiatrist, I realize that my devotion to this profession has been forged and shaped through personal challenges that stay with me to this day. During my medical school years, a dear friend in my medical school class showed me the depth and difficulty by which emotional strain can affect even the more prepared and protected person. My friend and I often studied together and truly faced the rigors of medical training as a tightly knit team of two. We talked about how we felt and how we fought the forces that tested our resilience. Despite our best efforts, my friend was suddenly challenged by the sudden death of his father. The grief he faced was clear and difficult amidst the already-present stress of our studies. We talked more and worked harder. We grew even closer as friends. We thought we were on the right path to get through this together. Despite all of that, one rainy Friday night my friend made a decision to take his own life using potentially lethal chemicals easily accessible to us at the medical school. He planned to check into an on-campus hotel and do it there, so as not to burden or frighten his roommate or anyone else. When he got to the small hotel to check-in, he was told that the hotel was fully booked because of a basketball game the next day. Interestingly, that obstacle was just enough to nudge my friend back to our talks and away from his deadly plan. Ultimately, we got him the help he needed to cope and recover – at least enough to push on. For him, true healing was far off. But at least he found a treatment bridge over what could have easily been his demise.
This and other profound lessons still resonate daily through my execution of my clinical practice as a psychiatrist. One predominant concept regarding the human mind keeps recurring to me. That is, human emotions live within a landscape filled with hills, valleys and vistas that are in-part visible and in-part invisible. We have to exert effort to see as much of our own emotional landscape as possible so that we can understand our emotional limitations and capabilities. Our emotions are shaped and reshaped by all of our experiences, and especially our stresses and traumas. Each person manifests their own unique emotional landscape, their own unique understanding of its layout and their own unique ability to discuss the state of the landscape to the people around them. There-in lies a great challenge in understanding and diagnosing mental illnesses. Many people will not reveal emotional pain because of a societal fear of rejection or a pessimistic thought that no one will care – or even a conclusion that “this is how life is supposed to be and I need to just deal with it.” Such unhelpful thoughts are often, and unfortunately, taught by parents, peers and even professionals who don’t realize that our emotions are very consequential. Also, many people will not reveal their emotional pain because their illness causes symptoms like hopelessness, guilt, fatigue, fear, anxiety and even hallucinations or delusions that directly work against the will and motivation needed to seek the very care that they desperately need. I mourn the suffering and loss of patients who I never get to see because they are steered away from care by such a multitude of forces.
There is tremendous relief when a person finds their way into treatment against such strong headwinds. Even then, real challenges remain. Mental illnesses lie within a quagmire of possible medical conditions that can masquerade as psychiatric problems. Hypothyroidism can cause a true clinical depression. Intense menstrual periods can cause anger, mood swings and insomnia. Infections, especially in the elderly, can cause profound confusion and agitation. So, proper assessment and diagnosis is of tremendous importance for all medical practitioners. What looks like a mental health problem on the surface may be something else entirely. And primary care doctors, often in emergency rooms, are usually the first doctors seen for “emotional” symptoms. This makes the burden on these doctors all the more heavy to get the right work done on the front end before a mental health diagnosis is assumed and attached. This is where better collaboration between primary care and psychiatry is a necessity. I have found that the best medical diagnostics gets done in multidisciplinary settings where the psychiatrist and the primary care specialists work down the hall from each other. Unfortunately the real world often does not make things that easy; and practitioners have to make the effort to collaborate to get the diagnostics, and ultimate treatment plan, right. The science of wellness demands it. And our patients lives depend on it.
Finally, when the need for psychiatric care is clear, the new challenges must be confronted. None of this work can be successful if a mental health practitioner cannot earn a patient’s trust and confidence. I have seen numerous practitioners fail coming out of the gate, dooming their effort at getting this important work done. The all-important therapeutic rapport is a necessity for this delicate process to move forward. A functional working relationship has to be formed so that the patient and doctor can work as a team to determine the right diagnosis, establish an effective treatment plan, and finally embark on the therapeutic trials of treatment regimens that apply for that specific patient.
Along that road, the patient and doctor must acknowledge that mental illnesses not only get misdiagnosed due to deceptive medical problems, but they also present in many different ways when they truly are on the march. Depression, for instance, can be subtle and slow, causing mild but daily sadness and apathy that allows the patient to still function as a parent and coworker. But there will be very little joy, sense of accomplishment, self-worth or contentment for their daily life. This can go on for years and even become accepted by the patient as “just the way life is supposed to be.” In contrast, depression can be overwhelming, intense and fast-moving enough to cause profound hopelessness, despair, guilt and tragically a desire and plan to end one’s life – as was the case with my dear friend in medical school. This is just one example of one mental illness that has to be accurately recognized and defined for its type, severity, course and rate of progression. Only then can mental health treatment be properly matched to the illness. This situation demands that practitioners have the ability to follow a patient closely enough to make the clinical observations needed to get this job done right. And, to my dismay, no medical exam or blood test is yet available to assist this psychiatric work.
Other obstacles to this process pop up when practitioners are too busy, or overloaded, to see their patients often enough. Also, an insurance company may not allow enough sessions at frequent enough intervals for the practitioner to meet the patient’s needs. Still, even under the best circumstances, a mental illness may lead a patient to break off care or conceal a crucial symptom from their doctor or therapist. Such an obstacle could derail the treatment plan in a detrimental and even destructive direction. Thus, the all-important therapeutic rapport and trust referred to above comes back into play and affects the very health of the bond of communication between the patient and the practitioner. This circle has to complete itself for treatment to stay whole and for outcomes to be good and productive. Many other obstacles and surprises will occur on any journey to wellness. No practitioner should rest on their laurels and take a perceived treatment success for granted.