Education Homelessness Informal-curriculum Observations Policy


Two recent events inspired this post:

1. My husband and I had dinner at Farestart, which is

… a culinary job training and placement program for homeless and disadvantaged individuals…. As members of [this] community are placed in housing, the need for job-training will play a critical role in ensuring the self-sustainability of these individuals.

While eating the tasty food and learning about the mission of Farestart, I reflected on my experiences working with the homeless. I have encountered them outside of the health care system, in emergency rooms and psychiatric hospitals, and in medical hospitals as a psychiatric consultant.

I realized that, as a group, psychiatrists are skilled at prescribing medications for the homeless. Unlike Farestart, however, we offer little to help the homeless help themselves.

2. Since starting my new job in Seattle, several patients have come to me with the chief complaint[1. “Chief complaint” is a medical phrase that refers to the reason why a patient has come to see a physician. It is not a sardonic comment.] of wanting to stop their psychiatric medication(s).

One of the greatest pleasures of my job is helping people taper off of their medication(s).[2. To be clear, there are instances when I actively discourage people from tapering off of their medications, as some people end up in psychiatric hospitals when they stop taking medications. A personal goal of mine is to help keep patients out of hospitals.] My colleagues and I have all seen patients who are taking large numbers of psychiatric medications for unclear or invalid reasons. There is also data to suggest that certain classes of people are more likely to receive psychiatric diagnoses that may not be valid, which results in prescriptions for medication that they don’t actually need.[3. African Americans are more likely to be diagnosed with schizophrenia. Anecdotally, I’ve worked with several African American patients with diagnoses of schizophrenia who were taking antipsychotic medications, though neither the diagnosis nor the medications seemed indicated. We gradually tapered off the antipsychotic medication and nothing happened. They were fine. Which makes me wonder.]

Some people eventually come off of all of their medications without incident. Some people significantly reduce the number of medications they take. And, unfortunately, a few people end up in the hospital during the tapers.

That never feels good.

I realized, again, that psychiatrists are skilled at prescribing medications, but we know little about stopping medications. (In my brief review of Pubmed, I found only one article that offers suggestions about stopping medications.) Furthermore, as a group, we lack the knowledge about treatments other than medications and psychotherapy.[4. Psychiatrists in private practice are more likely to offer both psychotherapy and medication services. Psychiatrists who work in medical centers often only provide medication services due to the institutions’ financial systems.]

Perhaps this is due to the belief that patients who come to see psychiatrists have already tried everything else. They have gone through trials of exercise, counseling, deep breathing, meditation, naturopathic medications, etc. Because none of that has been helpful, they come to see a psychiatrist as a last resort.

That could be true.

This may be a function of our training. Contemporary psychiatry, for better or for worse, follows the medical model. The medical model focuses on biological causes of illness and disease. Current medical treatments (i.e. medications) aim to correct the presumed underlying biological causes.[5. The underlying biological causes of psychiatric conditions remain unclear. Discussions about “chemical imbalances” are still hypotheses, not theories. Psychotropic medications are primarily empirical treatments.] Thus, psychiatrists end up prescribing medicine because that is what we were trained to do. Furthermore, patients often expect us to prescribe medication. (Like other human beings, psychiatrists sometimes feel the pull to “do something”, even though “doing nothing” may be the most prudent choice.)

Psychiatrists, often rightly so, have reputations as “medicators”. A friend of mine works as a psychiatrist in Canada. She came to the US for fellowship training. An administrator told her that her role in the American clinic was that of “the medicator”. My friend was horrified. Because of the funding system, Canadian psychiatrists routinely provide both medication management and psychotherapy services. She could not believe that her role would be limited to the prescription of medication.

“What? You believe in the biopsychosocial model? You think context matters?” the American fellowship cohort dryly commented.

If the knowledge and practice of psychiatrists is limited solely to medications, of course the general public will believe we are simply “medicators”. This is problematic, as we have incomplete knowledge of how psychotropic medications work. (All psychiatrists should read Healy’s The Antidepressant Era. Healy does not outright dismiss antidepressant medication, but he provides data that strongly argues that antidepressants are not as effective as the public believes.)

I cannot speak for all psychiatrists, but I believe most of us did not choose to enter this field to become “medicators”. Thankfully, many psychologists were involved in my education. I’d like to think that, as a result, I am less inclined to pursue medications as the sole mode of treatment. I must admit, though, that I am unfamiliar with the literature for non-pharmacological treatments. (I am familiar with the literature for housing as treatment…. but what is the evidence—or lack thereof—for exercise? meditation? diet changes?)