Tuesday, November 29, 2005

A relatively standard day on the psych ward. A patient trying to avoid jail time claims to be suicidal and homicidal. The patient with borderline PD has decided to start hitting on the patient with MDD, who actually shows some mild improvement with the attention, and a patient with paranoid schizophrenia who thinks that "they" are watching all the time keeps peering over at the group of doctors discussing her case, maintaining a knowing, watchful expression.

Psychiatry would be great if it weren't so depressing. The hours are short, roughly 7 to 4, which is phenomomally brief compared to OB or surgery. But there is something quite depressing about dealing with patients who lack the insight to know what is wrong with them. And with some patients, you wonder if there really is something wrong with them. For example, when a patient comes in complaining that her husband is trying to kill her, and the husband is denying it, who do you believe? Sure, she has some factors in her history which imply she might be psychotic, but she seems to make sense, and she isn't acting psychotic now.

Every day I wrestle with the idea of what exactly constitutes mental illness. How hyperactive does a patient have to be before they are considered "manic"? Sure, the DSM-IV gives us strict guidlines, but how much of that is just conjecture? Is being sad, or melancholic, always such a bad thing? In days past, some of the people on this ward, or being seen in this clinic would have been poets. Now they take their anti-depressants and go out to be "normal." I'm sure some of the painters or composers whose works we admire today would be treated now with quetiapine or ziprasodone. What do we lose as a culture by leveling everyone's performance? I'm sure it helps some, but how many does it hurt?

A lot of that may be idle speculation. Some of these patients, and maybe all of them, are indeed ill. Bio/Psycho/Social factors really have gotten the best of many of these patients and with help some of them can go back and lead what we see as normal lives.

Also, the steadily increasing amount of respect and attention my recommendations for patient care command is fulfilling. When I posit that a patient may improve with 10 mg Geodon bid, my chief actually agrees and countersigns an order to that effect. I am feeling more responsible for my patients, and I enjoy the feeling.

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