Ten common questions put to psychiatrists
Unlike psychologists, psychiatrists are medically trained, and although many psychologists have the title ‘doctor’ in front of their name, this is because they have completed a research thesis known as a PhD.
Psychiatrists undergo a six year undergraduate training in medicine before specialising in psychiatry, which can take up to an additional seven years. At this point they are usually appointed as a consultant. Psychologists training is equally rigorous but does not include any training in physical medicine or the diagnosis of mental illness, nor are psychologists permitted to prescribe drugs.
Psychology is the scientific study of mental processes and behaviour and the work of the clinical psychologist involves assessment and treatment in a number of different areas. These include estimating intellectual functioning, assessing personality, offering behavioural and cognitive therapies for the treatment of specific disorders and assisting with the implementation and supervision of rehabilitation programmes. There is some degree of overlap between therapeutic work carried out by clinical psychologists and psychiatrists.
Traditionally, patients are initially assessed by psychiatrists who are trained to take detailed histories, conduct mental state and (sometimes) physical examinations and after formulating a diagnosis, may then refer the patient on to a psychologist for ongoing treatment.
Psychiatrists medical training enables them to deal with situations where physical and psychological medicine overlap. For example, an overactive thyroid gland presenting with symptoms of anxiety and weight loss or a pain syndrome that is due to depression rather than organ dysfunction.
Once your GP has referred you for specialist help, contact your health insurer to find out if the condition or symptoms that you are suffering from is covered. Insurers will sometimes provide cover for an initial assessment, and then decide if further treatment is to be supported following a report from the specialist.
The insurer will usually provide you with an authorisation code which guarantees payment for the treatment to be undertaken. However, it does not cover any excesses or shortfalls that may be applied to your policy. For example, some insurers cap the fees of some specialists requiring the patient to make up the difference.
We don’t know with absolute certainty, but we believe that they affect the levels of chemical messengers in the brain, which include serotonin and noradrenaline, that are involved with mood regulation. The current theory is that a deficiency of these chemicals leads to the condition we know as depression, whilst an excess leads to a state of enhanced wellbeing and elation referred to as hypomania.
Antidepressants don’t work immediately and it may take before two and three weeks before their mood lifting properties become evident. Side effects, however may come on immediately so that for the first week or two of treatment some people may feel that the medication is making them worse not better. With perseverance, this situation is soon reversed.
The simple answer to this question is ‘no’. Many patients who are offered or prescribed antidepressants fear that they will become addicted to the medication, but there is no evidence to support this commonly held belief. Addictive substances are those in which tolerance and dependence may develop. Tolerance refers to the way the body adapts to the repeated presence of a drug, so that the user has to increase the dose to achieve the original effect. Dependence describes a compulsion to take the drug following its repeated administration.
When antidepressants are stopped, particularly suddenly, the patient may experience discontinuation symptoms. Discontinuation symptoms may be similar to those of the original illness for which they were prescribed (eg agitation, sleeplessness) or different (flu-like symptoms, dizziness, shock-like experiences). Their onset is usually within a few days of stopping the drug or can occur if several doses are missed. They are usually mild and pass off fairly quickly, although they can occasionally be more severe, requiring a phased withdrawal of the drug over a much longer period.
Discontinuation symptoms are best avoided if the medication is reduced over a three to four week period (with the noable exception of Prozac (fluoxetine) which does not need a phased withdrawal.
As part of their duty of care to their patients, doctors are required to keep detailed contemporaneous notes. It is usual practice after a consultation to write to a patient’s family practitioner to ensure that the GP is aware of any drugs or other forms of treatment that have been prescribed. The GP is of course bound by the same rules of confidentiality as the specialist. Any requests for medical information from third parties such as employers, government bodies, solicitors, the police or relatives requires written consent of the individual before it can be released.
Sometimes doctors may have to decide to override patients’ requests for information not to be forwarded if it is deemed not to be in their own or the public interest to do so. For example, a patient who is suicidal and doesn’t want their GP to know or is taking non-prescribed or illicit drugs which could interact with another prescribed substance if unknowingly given by their family doctor. Sometimes, patients may have conditions which make it unsafe for them to drive, and if they are unwilling to voluntarily inform the appropriate authorities of their condition, their doctor is obliged to do so, with or without their consent.
It is my usual practice to show patients any report or letter that is requested by a third party in order to approve its content before it is sent. Patients need to be aware that some health insurers make it a condition of providing benefit that the subscriber gives signed consent for the company to have the right of access to any medical documents that they deem fit to see.
Psychological illness takes many forms, can be short-lived or life-long in terms of the symptoms that are displayed, and may lead to personal suffering, difficulties with functioning and impact on relationships at all levels. Sometimes, the cause of the disorder is self-evident and reactive to a change in personal circumstances such as death of a loved one, loss of a job or financial difficulties. Under such circumstances, treatment may focus on helping the individual come to terms with their changed status through a process of talking, listening and on occasion offering practical advice and help.
In other situations, psychological changes may appear to occur ‘out of the blue’ and the link with external events is less clear cut. The rationale for prescribing any drug must be its potential benefit outweighing any adverse effects that are likely to occur.
Drug treatments and talking therapies are not mutually exclusive, and indeed in many cases are co-administered. In some cases of depression where physical changes are evident in association with lowering of mood (such as disturbances of sleep, appetite, energy, libido and concentration) a good response to antidepressant medication can be anticipated and a lifting of mood by such drugs may then enhance the benefit of talking treatments, so that the patients feels more able to enact aspects of the work undertaken. In some major mental illnesses, such as schizophrenia and bipolar disorder, drugs are often prescribed to eliminate or minimize disabling symptoms which could not be achieved by talking therapies alone.
In the majority of cases, no. Only in rare instances do patients need to take medication on an ongoing basis. Antidepressants are usually prescribed for six to twelve months from the time that an individual’s mood normalises, and anxiety reducing drugs (such as diazepam) and hypnotics (sleep inducing drugs) for much shorter periods due to the medication’s addictive potiential.
Patients with some conditions such as bipolar disorder, may need mood stabilizing drugs on an ongoing basis to prevent relapses and others with schizophrenia require long-term treatment to keep disabling symptoms under control.
Psychotropic (mind acting) drugs act on chemicals in the brain which are involved with mood regulation, levels of alertness, and the content of thoughts. Although it discomforts us to some extent that we are no more than a ‘bag of chemicals’ certain aspects of mental functioning and mood are affected by brain chemistry and the drugs which alter it. For this reason the effects of drugs is not a case of ‘mind over matter’ and benefit can be derived from such drugs whether or not the person taking them has faith in their effectiveness.
Yes you can. I provide a Saturday morning clinic for patients who find it difficult to take time off work mid-week. There are also early morning appointments for those who are able to start their working day a little later.
10. My doctor has changed my medication, and the new preparation is ten times the number of milligrammes as the last drug. Won’t this mean more side effects as well as a stronger effect?
Quite simply no. Each drug has its own ‘footprint’ and the number of milligrammes formulated in a tablet is determined by rigorous research that has been undertaken to determine the dose that is clinically effective before the preparation is made available to the public. For example some antidepressants may produce a clinical effect on 20mgs a day, whilst another requires 375mgs per day. This does not mean that the latter is between 18-19 times ‘stronger’ than the former.
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