How Good is Your Psychiatrist? Finding Roses Among Thorns

Several months ago, I posted “An Open Letter to Parents from a College Psychiatrist” about the emotional distress that some college students with mental health issues experience when thinking about going home for the holidays. I wrote the piece, in part, to encourage parents to be more open to psychiatric treatment for their college-aged children who might benefit from it. In response, a parent wrote in to the comments section sharing the heartbreaking story of their daughter who had received poor psychiatric care in college and whose condition worsened significantly as a result. Several other readers then sent in comments agreeing that modern psychiatric treatment (psychiatric medications) is dangerous, unnecessary, and should be avoided at all costs. In my 15 years as a practicing psychiatrist, I have unfortunately heard stories like this all too often.

I have also heard plenty of people tell me about psychiatrists who dramatically improved their quality of life.

These responses got me thinking about the very real problems inherent in the field of psychiatry and the frustration so many people face when trying to find quality psychiatric care. Why is it so hard to find a good psychiatrist—one who can actually help you feel better, instead of worse? How do you go about searching for a good psychiatrist, and if you already have one, how do you know if you are receiving good care? I offer some insider's tips further below, but first, a look at the issues.

For better or worse, the field of psychiatry suffers from some unique challenges:

Psychiatrists work behind closed doors

Most outpatient psychiatrists work one-on-one with individuals—and often in isolated single-office practices. Therefore we rarely benefit from the kind of scrutiny that other medical professionals do. If something goes awry in a session between a psychiatrist and the individual receiving care, there is usually no third party in the room to witness it and voice an opinion about what may have gone wrong, or could have gone better. Most other physicians work in teams that include clinical associates, such as nurses, assistants, and physician peers who can provide valuable feedback and support.

Psychiatry is a young profession

The field itself is young, and psychiatry is still more of an art than an exact science. Our understanding of brain science is still in its infancy, and diagnostic imaging or blood tests don’t exist for most psychiatric disorders. Textbook diagnostic criteria leave a lot to be desired, as they are not rooted in anatomy or physiology, but instead are “descriptive” or symptom-based. Many conditions have overlapping symptoms, making accurate diagnosis difficult. As a result, finding the right medication for any given individual relies largely on trial and error, frustrating psychiatrists and patients alike.

Psychiatry has few standards of care

The quality of professional training for psychiatrists can differ substantially from one institution to the next and from one decade to the next. As a result, no single agreed-upon treatment approach exists for any given psychiatric condition—rather, each psychiatrist relies on their own preferred medicines and methods. Ask 10 psychiatrists, get 10 different answers…

Most other professions benefit from online reviews or word-of-mouth referrals, but psychiatric care still carries such a stigma that most people who see psychiatrists keep their (positive and negative) experiences to themselves. People don't tend to feel comfortable posting public reviews and may not even tell their close family/friends about their psychiatrist. As a result, you probably know precious little about your psychiatrist in advance of your first appointment.

Psychiatry is not a competitive field

Dare I say this publicly? Most medical students do not view psychiatry as a particularly desirable specialty, so residency programs across the country struggle to fill their available positions. This results not just in a shortage of psychiatrists, but a tendency for some training programs to turn to weaker candidates—some of whom may not even be interested in psychiatry, but were unable to secure a training position in more competitive fields. I fell in love with psychiatry while in medical school, but I understand it is not everyone’s cup of tea. The work is stressful, complicated, time-consuming, and under-respected by many physicians in other specialties.

Shortage of psychiatrists reduces choice

Most areas of the country don't have enough psychiatrists to meet the high and ever-growing demand for psychiatric services. In many areas, there may be only one psychiatrist to choose from, and if you don’t like that psychiatrist, or their practice is full, you are out of luck. The most personal of medical professions, psychiatry demands a good fit between patient and doctor for maximum success. If you don’t feel comfortable with your psychiatrist, you are unlikely to share the sensitive information he or she needs to be able to help you.

Psychiatry is undervalued

Clinics usually hire psychiatrists strictly to provide medication services, often requiring them to see three to four patients per hour to maximize patient access and insurance reimbursements. This is a recipe for poor care and burnout, and can transform even the most thoughtful and caring psychiatrist into a psychiatric Pez dispenser. Good psychiatric treatment takes TIME, and time is expensive—too expensive for many insurance companies to properly support.

The best places to look for good psychiatrists are settings which attract the best talent. Academic institutions such as teaching hospitals offer psychiatrists prestige, teaching opportunities, and intellectual stimulation—and best of all, these institutions accept a wide variety of insurance plans, including HMOs, Medicare, and Medicaid. Psychiatrists who want more control over session length, caseload, income, and practice style usually open a private practice, but the many of the best private practice psychiatrists accept few if any insurance plans. Plans that allow out-of-network care will partially reimburse you for your fees...once you've met your annual deductible.

Blessing or Curse?

So, yes, psychiatry has its special challenges, but I love my chosen specialty, as do many of my colleagues, partly because of its unique position within the medical field.

Working unobserved allows me to focus 100% of my attention on the person in front of me. Fortunately, I work in a group practice where I benefit from collaboration with some wonderful colleagues, to whom I turn regularly for guidance and support. The fact that psychiatry is a young, evolving profession is exciting to me, because there is so much to learn and discover. The lack of a clear clinical roadmap allows me to follow my intuition, work creatively with patients, and draw upon the richness of my clinical experiences to improve my skills. I am naturally curious about people and find my work endlessly interesting--most cases of high blood pressure present the same way, whereas each case of depression manifests differently. I feel privileged that people share their most personal concerns with me, and I take seriously my responsibility to do my best to help people feel and function better.

Unfortunately, negative experiences with psychiatrists lead some people who suffer to stop seeking the treatment they need and deserve. So, if you or a loved one struggles with mental health issues, how do you know if your treatment is up to par?

WHAT TO LOOK FOR IN A PSYCHIATRIST

A typical initial evaluation appointment lasts about an hour. In some cases, this is sufficient, but in many cases, it requires two or three sessions to conduct a good diagnostic assessment. Often, clarity emerges about a case only after months of getting to know someone.

Follow-up visits ideally last 20 to 30 minutes for medication management and 45 to 50 minutes for therapy or combined therapy+medication sessions. Many psychiatrists, particularly in community clinic settings, are under significant time pressure due to overbooked schedules and high, complicated caseloads.

Frequency of visit varies tremendously, depending on the complexity of your symptoms, your psychiatrist’s availability, and your psychiatrist’s style of practice. If you feel your visits are too short or infrequent to be productive, bring it up with your psychiatrist to see if anything can be done.

A thorough assessment

A good psychiatrist takes a complete history—not just of your symptoms, but also your family history, your health, your habits, your personal circumstances, and your medications. He or she is thoughtful in their assessment of your situation, and doesn’t jump to conclusions. Your psychiatrist should share with you what he or she thinks about your situation—often referred to as a “working diagnosis.” For better or for worse, psychiatrists are trained to think diagnostically, and insurance companies insist on textbook diagnoses for billing purposes. Not every psychiatrist cares for this philosophy, and some de-emphasize the role of diagnoses in their work.

Feeling at ease

A good psychiatrist listens carefully, asks illuminating questions, and creates an environment in which you feel comfortable, respected and heard. A good psychiatrist communicates clearly and transparently and is easy to understand. You should gradually feel that you can trust your psychiatrist enough to disclose the personal information necessary for him or her to help you without feeling judged. You should feel comfortable bringing up difficult topics and asking questions about your treatment. The process should feel collaborative.

A variety of treatment options

A good psychiatrist discerns the difference between someone who is going through tough times and needs support, and someone who suffers from a biologically-based illness that may benefit from medication. This can be very difficult, and it is NOT an exact science—all of us make mistakes in this regard, but a good psychiatrist remains open-minded, and flexible in their thinking—willing to consider alternatives and to change the treatment plan as time goes on.

A good psychiatrist discusses with you not just your medication options, but non-medication approaches as well—psychotherapy, support groups, mindfulness training, exercise, dietary changes, substance use reduction, and skill-building in the areas of relationships, work-life balance, sleep habits, etc. Many private practice psychiatrists enjoy conducting psychotherapy themselves in addition to (and sometimes even instead of) “psychopharmacology” (medication treatment).

Sound prescribing practices

A good psychiatrist reviews medical data such as blood tests, EKGs, vital signs, and weight, as appropriate, before prescribing medication. It should be clear that the decision about whether or not to take medication is yours (except in the rare case of court-ordered treatment). A good psychiatrist answers questions about medication usage, risks and benefits to your satisfaction.

Ideally, a psychiatrist prescribes one medication at a time, and if a medicine doesn’t work out, he or she discontinues (or at least begins tapering down) that medicine before prescribing a new one. A good psychiatrist takes you seriously if you say a medicine is giving you a side effect—even if isn’t listed in the package insert as a possibility. In straightforward situations, a single medication will suffice, but in some cases, combinations of low doses of two or even three medications may work better than a single medication. It is rare to require more than three medications.

Final Thoughts

Psychiatric disorders are biologically-based brain conditions which often require biological intervention. However, I completely agree that psychiatric medications are not the only approach, and strongly advocate for non-medication biological therapies, particularly nutrition interventions, which can have a powerful impact on brain chemistry in many cases. After all, food is where our brain chemicals come from in the first place! Nevertheless, I do believe that the careful, thoughtful use of psychiatric medications has an important place in the treatment of disabling brain symptoms such as severe anxiety, suicidal ideation, and psychosis. I see people benefit from medications every day, often in profound, life-changing ways. For those who don’t want to try non-medication therapies, those who have tried other approaches without success, and those who need fast relief as a stabilizing step before they will be able to work on lifestyle changes, psychiatric medications can be extremely helpful.