Psychiatry is a Challenge

Let's dig into why

Just a heads up.. this post may be better suited for potential or current PMHNP students. Practicing PMHNPs undoubtedly already understand that effectively practicing psychiatry is challenging and may not find this to be all that interesting. But, on the other hand, it may be convenient to send to a significant other or friend when they don’t believe or understand why your work is so draining or stressful!

With that said, what makes psychiatry so challenging?

The answer to why is a combination of reasons. In order to effectively practice psychiatry one must obtain a sufficient level of mastery over a variety of concepts as well as the ability to skillfully apply said concepts in practice. Furthermore, each of the concepts can be further deconstructed in various subconcepts.

As an example… one must be able to accurately assess and diagnose. This requires mastery of the DSM 5 and it’s content (The book is 947 pages!!). Without such mastery, you are unable to speak and understand the language of psychiatry*. While it is easy to understand the difference between depression and mania on a superficial level, in practice it can be much more difficult (pt has hx of depression—>uses methamphetamine—> induces psychotic symptoms/decreased need for sleep/engagement in risky behavior—>drug induced mania ≠ bipolar dx). Understanding the nuance (and potential overlap) between childhood diagnoses such as ADHD, ODD, DMDD, and Conduct d/o can be much more difficult, especially as children and adolescents tend to minimize symptoms.

Now let us imagine, that an individual has developed a sufficient level of mastery over the content within the DSM 5 and is able to effectively speak the language of psychiatry. While they may be equipped to effectively assess & diagnose they are no where near prepared to effectively treat.

To be able to effectively treat requires an understanding of a multitude of interventions, both pharmacologic and nonpharmacologic. It requires an understanding of potential medication interactions and contraindications, in case one may be relevant to the patient in front of you at any given moment. It also requires an understanding of various principles which fundamentally guide treatment.

A few examples of these principles are:

• Start low and go slow

  • aka use the smallest dose of a medication in order to alleviate potential side effects, increase slowly over time and use lowest effective dose

• Use the least bad, good option

  • all antidepressants are roughly equal in terms of efficacy, so try an SSRI first due to more tolerable side effects, fewer medication & food interactions as well as greater safety in overdose relative to other antidepressant options

• The medication my patient can maintain long term is better than the medication that they cannot

  • relevant to anxiety medications such as benzos which are extremely effective but likely to lead to dependence and rebound anxiety as well as increased risk for dementia

  • relevant to zyprexa that is extremely effective at treating psychosis or mania, but likely to cause severe weight gain and contribute to development of metabolic syndrome

  • similar to zyprexa it is relevant to seroquel which may be an effective sleep aid, but brings its own risk of weight gain as well as a risk for movement disorders.

Ironically perhaps, treating effectively also requires the experience to be able to recognize the few instances when the above framework doesn’t apply.

An “X factor” in good psychiatric care is being well acquainted with the available resources (and laws) in your area. Knowing the available therapists, level 1 hospitals, and detox facilities means that you can most appropriately match your patient to the care they may or may not need. Knowing the laws means you are able to protect your license and your practice which will enable you to continue to serve community for many years.

I’m curious, as readers do you agree or disagree?

Do you have any other reasons which explain why psychiatry is so difficult to effectively practice? Leave a comment below and let us know what you think.

DISCLAIMER

This is not Medical Advice and while the reader believes what he has shared, substack dot com does not equate to strong evidence. Please do not treat patients based on what is read in this post, these are opinions of an internet stranger. Instead use these posts as a starting point for furthering your own study & education.

*By this I mean, the individual is able to hop on a consult, share the patient’s diagnosis and clearly explain by which criteria the patient meets said diagnosis.