Handcuffed by Managed Care
All of us should applaud Surgeon General David Satcher's efforts to approach suicide as a public health problem ("MDs Can Do More to Cut Suicide Rate," June 2001, p. 1).
A national strategy for suicide prevention is an excellent idea, but how can psychiatrists improve when the tools we use to prevent suicide are controlled by managed care? Acute psychiatric beds are shrinking in number, but acutely suicidal persons often require hospitalization to be stabilized. Lengths of stay on psychiatric units are governed by short stay demands, not by the degree of suicidal risk.
In most mental health offices, psychiatrists only manage medication; they are rarely involved in patients' individual psychotherapy. How well can we actually know patients when we are prevented from conducting in-depth assessments? How well can we ascertain the seriousness of suicidal ideation when we have so little time to explore it?
It often takes several weeks or months to find the correct medications for persons with chronic depression or unstable mood disorders. After starting an antidepressant, patients often require closer monitoring because, as their mood lifts, their risk of suicide may intensify. The number of office visits, however, is not determined by the clinician but by the insurance agency.
Psychiatric disorders such as borderline personality disorder and schizophrenia require intensive psychotherapy in conjunction with medication and social support. Research has borne out that medication alone is inferior to medication and psychotherapy, yet psychotherapy is often absent in the care of these individuals.
If we wish to look seriously at the issue of suicide in this nation, we must first address the significant constraints placed upon psychiatrists in their efforts to assess, diagnose, and treat those who are at risk.
Gina Orton, M.D.
Psychiatry and Politics
The article "WTC Attack Ushers in a New Breed of Terrorist," along with its subhead, "Intelligent, highly skilled, and delusional," reminded me of the practice in the Soviet Union of labeling political dissidents as mentally ill (October 2001, p. 1).
In both cases, the motivation of such labeling (as delusional or mentally ill) appears to be the desire to avoid consideration and discussion of the actual, political motives of the terrorist or dissident. This kind of head-in-the-sand response only preserves the gap in understanding and communication between the parties involved.
David R. Sillars, M.D.
Classification Debate Continues
I was moved to write after reading Dr. David Spiegel's stunningly misguided critique of the ideas on psychiatric nosology taught by Dr. Paul McHugh over the past 25 years ("Crafting the DSM-IV," Guest Editorial, August 2001, p.31).
Dr. Spiegel attacked the view that there are four perspectives from which psychiatric disorders are best considered-disease, dimension, behavior, and life story--by arguing that the DSM-IV's categorical approach to all kinds of psychiatric disorder is more or less right because all disorders are more or less based in human biology and psychology. He wrongly asserted that Dr. McHugh's view "attempts to enshrine in the nosology the idea that some disorders are real biologic diseases while others are simply problems involving failures of learning, behavior, or life circumstance."
Application of Dr. McHugh's four psychiatric perspectives involves no such thing. It is not a nosologic system per se, but a clarification of the methods of psychiatric formulation. We practitioners of the perspectives approach do not over-simplify patients as belonging to one or another perspective, but rather apply all the perspectives to each patient, as appropriate. If a patient with anorexia nervosa, for example, has a syndrome of major depression and an unstable temperament and a horrific background, we understand and treat all these problems, in turn, using the appropriate methods. …