General Practitioner vs. Psychiatrist for Medications

by Irene Kitzman MD Monday, August 22, 2011

Antidepressants

Question: My general practitioner can prescribe anti-depressants...why bother also seeing a psychiatrist? 

Most psychiatric medication in the United States is prescribed by General Practitioners. This is probably the result of at least two factors: 1) most visits to General Practitioners are motivated by physical symptoms which at least in part are caused by emotional problems; and 2) most people feel less likely to be stigmatized if they tell their General Practitioner that they are depressed, or anxious, or overwhelmed, because expressing these concerns in the primary care setting doesn't suggest you are mentally ill. In our society, even going to see a psychiatrist for help with emotional symptoms is often seen as 'proof' that a person is mentally ill. 

Unfortunately, this often leads to people not getting the specialized help they need.  It has been shown that more than half of anti-depressants given in a primary care setting are not given at the right dosage, are not monitored carefully, and do not result in ongoing treatment or resolution of patients' emotional symptoms.  Patients have side effects to anti-depressants given at incorrectly high starting dosages, and stop their medicine prematurely.  Alternately, if the starting dose is too low, patients won't feel like the medicine is helpful, and will simply stop taking it, rather than taking higher doses of the medicine until their symptoms resolve.  Without close monitoring, people don't know what to expect and how to cope with side effects.  This leads to a situation where more than 75% of the prescriptions written by General Practitioners for anti-depressants and anti-anxiety medications are never filled at a pharmacy.  People have reached out for help, but most often they do not receive the kind of help that will end their emotional problems, and related loss of normal functioning.

For this reason, seeking help from a Psychiatrist for depression (or any other emotional problems that are interfering with normal functioning) is much more likely to lead to these problems being properly treated so that patients will regain normal functioning. Psychiatrists are able to understand both the biologic, psychological, and social/family components of emotional illness. They can order diagnostic laboratory tests and prescribe medications at the proper dose and monitor closely for side-effects, increasing the chances that you will be able to continue taking the medication. They can also assess whether the emotional symptoms might be caused by an underlying physical or hormonal problem, such as thyroid disease, diabetes, or anemia. They can provide a wide range of different kinds of psychotherapies to help change feelings and behavior.

Unlike General Practitioners, Psychiatrists are specially trained in understanding the causes and treatment of emotional problems, and are more knowledgeable about the use of anti-depressants and other medications used to treat these emotional problems.  They are also trained more extensively than other therapists to take primary responsibility for their patients' total care, which can include providing both medication and therapy, making sure that underlying medical problems are adequately treated, and they can provide long-term follow-up.  They can more completely distinguish the different kinds of emotional problems and how to treat them:  is the problem only depression? is there both depression and anxiety?  is the depression part of a manic-depression cycle?  is the depression or anxiety a normal reaction to stress or grief?  In clarifying the nature of the problem, Psychiatrists are more able to choose the correct treatment,  in terms of medications and also with psychotherapy.  They can carefully monitor the patient's response to treatment and therefore minimize side-effects, allowing patients to remain on medicine that could lead to the resumption of normal functioning.

For all these reasons, getting help from a Psychiatrist rather than a General Practitioner is the best way to be sure that emotional problems don't continue to interfere with normal functioning and having normal relationships, at work as well as with family and friends.

Irene Kitzman MD

About the author: Irene Kitzman MD has been practicing general adult Psychiatry since 1984. She graduated from the Yale University Department of Psychiatry, where she was a Chief Resident at the West Haven Veterans' Administration Hospital. Most recently, she was appointed Clinicial Associate Professor at the University of AZ and was Director of the Outpatient Clinic at Kino-UPH hospital, where she taught doctors in training to be Psychiatrists. She evaluates and treats adults, couples, and families for a number of issues including depression, anxiety, post-traumatic stress disorder, and psychiatric symptoms of Lyme disease. Dr. Kitzman received the honor of being named one of "America's Top Psychiatrists 2006" by the Consumer Research Council of America. For more information, visit her website

 

*Top photo credit: Amada Hatfield 

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Therapy for Children - Children and Emotional Healing

by Stephen E Knezek RN LCSW Monday, August 1, 2011

More than one colleague or client has asked me how I came to work with children. I used to work mostly with adults and when time, after time, these adults turned to me in session and said, "Steve, I wish someone had recognized the amount of emotional pain I was in when I was a child--then maybe I wouldn't be 40 years old and sitting in your office now!" When I reflected upon what those adults were saying to me, then I decided to do something about the emotional pain of children. 

I like to think of my work with children as preventive medicine--i.e. treat the child before their emotional difficulties become a chronic condition. Some people are concerned about the meta-message being sent to children who are brought to counseling. I've been asked, "What does this do to their self-esteem--especially if siblings or peers find out?" In my experience is rarely a problem. I think the much bigger problem is what it does to a child's self-esteem to leave depression or anxiety or other disorders untreated. When a child has had difficulties for months or years and is brought to me, one of my first interventions is to counter their sense of worthlessness and guilt for having problems. The earlier the child is treated, the less their self-esteem is eroded. 

Some researchers think that a large number of children with childhood disorders have a genetic predisposition to the disorder, then this predisposition is activated by environmental problems or other stressors. The following case illustrates this paradigm: A six year old was brought to me with feelings of sadness, isolation and withdrawal following the death of a loved one, continued for four months, and was accompanied by school and social problems. Both parents had a history of multiple losses and depression. After a month of psychotherapy the client's depression was greatly reduced and the client's grief was on track to being resolved. It appears that the stress of losing a loved one had triggered in the client a depression stemming from a biological predisposition toward depression that was inherited. 

Children come to counseling with a need to be listened to and respond positively to attention, encouragement, empowerment, and assistance with their emotional and practical difficulties. Research shows that children have a high need for sharing personal experiences and feelings, which they do with relatively few reservations. I create a safe, friendly environment so the child feels free to express her/his stress and concerns. I find the child responds openly to suggestions for change when presented in a caring manner. 

When providing counseling to children, I use imaginative play, games, books, puppets, various toys and art therapy to facilitate self-expressiveness and empathy to connect them to their inner feelings and to develop insight. After a therapeutic alliance is formed, even young children are quite capable of clearly talking about their thoughts and feelings. I find an easy give and take between play therapy and talk therapy facilitates the healing process. 

The goals of counseling are to improve the child's immediate adaptation to her or his life situation, build ego strength and teach problem-solving skills. Sometimes what a child needs is more structure, discipline and attention from parents and that involves family therapy, but that is a topic for another article.

*Photo "India Whistling" by apdk

Stephen Knezek RN LCSW

 

ABOUT THE AUTHOR: Mr. Knezek is a clinical social worker in private practice in New Haven, CT. His practice consists of 50% children/adolescents and 50% adults. In addition to his clinical work, Mr Knezek is a Practice Building Consultant who helps clinicians realize their dream of a thriving private practice, and a clinical supervisor. www.stephenknezek.com

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