Peter Forster MD
Point Of View
As physicians, psychiatrists begin with a perspective that has been called "the medical model." There are many definitions of this term; mine is "the predominant Western approach to illness, the body being a complex mechanism, with illness understood in terms of causation and remediation, in contrast to holistic and social models." One key aspect of the model is the notion of diagnosis. The psychiatrist identifies conditions, known as disorders, that are felt to underlie difficulties that the patient is experiencing in daily life.1
The disease model represented a significant advance in the approach to people with depression and bipolar as contrasted to models that were common in the late 19th century. The close connection between a disease model, which is often associated with biological explanations, and reductions in stigma has been noted by many. In fact, advocates for those with bipolar and depression generally favor a disease model as contrasted with other models which, for instance, might result with having people who are manic incarcerated as opposed to treated.
Modern imaging techniques have pointed to changes in both structure and function of the brain. It is now clear that similar kinds of brain changes take place when people are treated with medications, or with psychotherapy. Most psychiatrists don't view psychiatric disorders as either biological or psychological, but instead tend to view these conditions as having psychological, biological, social, and spiritual dimensions.
"Does it work" is the question psychiatrists focus on. This pragmatic approach can be frustrating in that it may make people feel as if they're simply undergoing a series of experiments. At best, it reflects a willingness to try a varied approach as outlined in this book. At the same time, it demonstrates a willingness to change what is done based on new clinical research.
Integration With Team
Psychiatry is often defined by the effectiveness of its collaborative skills. One of the trademark features of the Bipolar Advantage Program is the commitment that team members have to work with each other. In out-patient settings, most people practice on their own and have a set of other practitioners that they often collaborate with. It is beneficial to have a psychiatrist and a therapist who have worked together successfully in the past. This way, communication is far simpler. Occasionally, it may be important to schedule a team meeting for the different providers to share opinions with each other.
This type of integration doesn't happen as often as it should. In part because it isn't covered by insurance and because most health care professionals, both mental and physical, are more comfortable with an individual practice model. The integrated approach outlined in this book challenges the status quo by taking integration to the next level.
Assessment Process
Much of psychiatric assessment is based on a very careful and methodical history-gathering process. The goal in the assessments of those with depression and bipolar is to have a clear sense of several things: how people's symptoms have changed over time, the transitional process from one mood state to another, how quickly those transitions take place, and if there were any patterns that can be recognized. Information regarding any influence treatment has had on the course of symptoms is also noted. This very careful and thoughtful analysis not only takes time, but also requires a fair amount of help from the patient.
Another part of the psychiatric evaluation is the mental status examination. This is a structured way of evaluating the important dimensions of mental functioning: mood, attention, memory, patterns of thinking, et cetera. The psychiatrist compares what he finds through the mental status examination with information that he has about typical patterns of thought and emotions found in different conditions. The psychiatrist may request psychological tests to more precisely define the nature of the psychological processes. The psychiatrist may well order some screening laboratory studies, and perhaps neuroimaging, electrocardiogram, or electroencephalogram (EEG).
All of this information is used to identify a diagnosis from which the psychiatrist is able to make suggestions for treatment. The recommendations are based on scientific literature which looks at how others with similar problems respond to treatment.
The focus leans toward symptoms and diagnosis, more so than functioning, although both are important. It's a frequent criticism of psychiatric assessment that psychiatrists focus more on problems than on creative adaptation. People are not just a sum of their problems, they also have come up with creative solutions to these problems. For instance, one person with a severe depression may be unable to leave their bed, whereas another person may have found a way to continue to function normally.
One thing that is important is to find a way of keeping track of mood states and transitions. This is especially true because of a phenomenon called State Dependent Learning. This phenomenon is based on how the brain stores memory. The hippocampus, which is part of the limbic or emotional part of the brain, is where memory is stored. The result is that memory is inevitably stored along with emotions surrounding that memory. In fact, emotions serve as kind of a way of classifying and finding memories. In other words, when you're in a certain mood, it may be very difficult to recall times when you were in a different mood, thus making it very important to keep track of mood changes over time. Otherwise, decisions may get made based on what your mood is at the moment, rather than a more comprehensive sense of how things have been over a period of time.
Goal Setting
Psychiatrists tend to focus on the reduction of symptoms. One prominent psychiatrist, Dr. Gary Sachs, has proposed that, "The ultimate goal of bipolar management should be complete and sustained remission (meaning the absence of significant symptoms), whenever possible..." Dr. Sachs goes on to say, though, that for most people this goal may not be achievable.2 I would argue that the question of whether this is even a good goal or not needs to be raised, as this book does.
Dr. Sachs points out later in the same article, "Over aggressive management might entail pushing medication doses to intolerable levels...." I suspect a better goal is to medicate in a way that helps reduce mood changes to a point where they are manageable and don't interfere with a successful life.
Treatment
Psychiatrists tend to be interested in using many different approaches to treatment. These treatments may include medications, psychotherapy, behavioral therapy, health interventions, referrals for appropriate non-psychiatric medical assessments, and advising patients on healthy living habits. Even such treatments as Transcranial Magnetic Stimulation (TMS) or Vagal Nerve Stimulation (VNS) could be included. Depending on the nature of the disorder, the severity of symptoms, and level of impairment, a treatment can take place in a number of settings. Options include out-patient treatment, the more intensive partial hospitalization program, or even residential treatment options.
Psychiatrists vary in the extent to which they practice all of these different modalities. Most psychiatrists are comfortable using and monitoring medications, and will usually refer people for psychotherapy. Other types of psychiatric treatment may require consultation with another psychiatrist (such as with TMS).
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