A Neuroscientist and A Psychiatrist Want Better Care and Development of Testing Tools | Karen Lankford, PhD, and Dierich M. Kaiser, MD
Karen Lankford PhD. – Neuroscience Researcher
Before my skin turned boiled lobster red all over my body and began itching so intensely that I wanted to tear my skin off, I would have told you that I did not have any serious allergies, and certainly none to yellow jackets, which I have been stung by several times during the course of my life, and even once before during the same season.
But that is the way the immune system works. Past performance is no guarantee of future outcomes.
The same is also true of your nervous system. You might think that because you have weathered other serious health or life stresses in the past and have a positive attitude, that you are not vulnerable to clinical depression, anxiety disorders, or PTSD, but you would be wrong. Your brain ages, just like the rest of your body and different stresses or repeated life stresses can have different outcomes. Most people do not realize that the median age of onset for diagnosed clinical depression is in the early fifties, but it makes perfect sense to doctors. Health conditions such as heart attacks and strokes, which are imported causes of clinical depression tend to occur later in life, as do major psychological stresses, such as the loss of a spouse. If you add an additional physiological or psychological stress to an aging nervous system and a lifetime of combating other stresses, it can push someone into a severe depression.
I had one great advantage with my allergic reaction in that the symptoms of my condition and the need for treatment were so obvious, that I was able to receive immediate care. After presenting myself to the desk at the urgent care center, I was waltzed directly into a treatment room, ahead of the half dozen or so patients waiting patiently for their turn to see a doctor, and without a peep of complaint from any of them.
Once the blood tests confirmed the presence of high levels of antibodies to yellow jacket venom, the doctors and nurses also accepted my identification of the source of the reaction and stopped asking me whether I was certain my assailant had not been a bee or some other insect or if I had possibly taken some illicit substance. No one ever questioned whether I was “faking it” or just seeking attention. No one tried to tell me an insect sting was no big deal and I should just suck it up because a lot of people had it much worse than I did.
My insurer never disputed my need for two years of therapy in the form of first weekly and then monthly injections and monitoring in the doctor’s office to ensure that I did not go into anaphylaxis after each small increases in yellow jacket toxin dose. None of this of course is true for patients suffering from depression or anxiety disorders. The symptoms are not obvious from the outside. There is no blood test for any mental illness. People regularly accuse someone having an anxiety attack or acute depressive episode of being a drama queen and just looking for attention. ER staff treat every patient with psychiatric symptoms as though they must be on drugs.
People continue to believe mental states and emotions are just something people can control if they want to. Insurance companies treat psychiatric care as a Band-Aid to keep the patient out of the ER and constantly try to limit the number of treatment sessions a patient can have.
Maybe if there was a blood test for depression or suicidality the medical system would treat these conditions differently, but, at present, doctors must rely on self-reported symptoms.
Dierich Kaiser, MD. – Psychiatrist
It can be difficult for physicians to recognize signs of clinical depression, even in themselves or their colleagues. 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 training, 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. We talked about our struggles and how we fought the forces that tested our resilience. However, when my friend was challenged by the sudden death of his father, his grief was intense and added to the already-present stress of our studies.
We talked more, worked harder, and grew even closer as friends. I thought that we were both on the right path and would get through this together. Despite having a promising career ahead of him and supportive friends, 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 had planned to check into an on-campus hotel and do it there, so as not to burden or frighten his roommate or anyone else. Fortunately, 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. That one obstacle to immediate action 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 to the point where he was able to push on. True healing would take much longer, but at least he found a treatment bridge over the abyss he had wanted to jump into. This and other lessons still resonate profoundly in my daily clinical practice as a psychiatrist.
One image keeps coming to my mind. Human emotions exist within a landscape filled with hills, valleys and vistas that are sometimes visible and sometimes shrouded in fog. 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 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 language for describing that landscape. There-in lies a great challenge in understanding and diagnosing mental illnesses. Many people will not reveal emotional pain because of a fear of societal rejection or pessimism that anyone will care. They may even believe “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 do not understand the potentially tragic consequences of denying or suppressing emotions. Symptoms of their illness, such as hopelessness, guilt, fatigue, fear, anxiety, hallucinations or delusions can also work directly against the will and motivation needed to seek care. I mourn the suffering and loss of all the patients I never got to see because other forces steered them away from seeking treatment.
There is tremendous relief when a person finds their way into treatment surmounting all obstacles, but the challenge does not end there. Mental illnesses exist within a labyrinth of medical conditions that can masquerade as psychiatric problems or coexist with them. Hypothyroidism can cause depression.
Intense menstrual periods can cause anger, mood swings and insomnia. Infections, especially in the elderly, can cause profound confusion and agitation. Proper assessment and diagnosis are essential. What may look, on the surface, like a mental health problem, might be something else entirely. A primary care physician, often working in ER or urgent care settings, is typically the first doctor a patient sees for “emotional” symptoms. This places a burden on primary care providers to do the right diagnostic tests on the front end before a mental health diagnosis is attached to a condition which calls for a different treatment protocol. This is where better collaboration between primary care and psychiatry is so crucial. I have found that the best medical diagnostics occur 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 must make a special effort to collaborate to get the diagnostics, and treatment plan, right.
Even when the need for psychiatric care is clear, other challenges must be confronted. None of the diagnostic work matters if a patient cannot get into treatment and no treatment plan can be successful if a mental health practitioner cannot earn the trust and confidence of the patient. Therapeutic rapport with the patient is necessary to establish as working relationship 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. Symptoms do not always present themselves in the same way and patients do not always have the language to explain what they are experiencing internally, even if they are willing to share all of their thoughts with their doctor. The preliminary diagnosis might not be right.
The first medication might be ineffective or have unacceptable side effects. Patients need to trust their
doctor enough to believe that they are trying to help and will be able to help. (And do not even get me
started about working with insurance companies to get approval for medications, therapy sessions or
inpatient hospital care.)