Psychology Today Blog

Subscribe via RSS

I Haven't Seen the Evidence for Evidence-Based Psychiatry
Patient! Are you a person or a collection of symptoms?
Published on April 15, 2011 by Paul R. Linde, M.D. in The Everyman Psychiatrist

"Patients don't read the textbook" is a perennial truism in medical education, especially in teaching students, interns, and residents how to treat patients. And for good reason. Real patients present with multiple problems simultaneously and, furthermore, some of these issues are not suitable to being medicalized. There are existential, spiritual, social, and moral problems not amenable to facile categorization.

When you go see your doctor, would you rather be seen as a collection of sortable symptoms or as a real-live complex human being? One problem with evidence-based clinical research in psychiatry is that it looks at data collected from the grouping of multiple patients. This data may or may not pertain to you as an individual patient.

Read More

San Francisco's Homeless Mentally Ill: Still Neglected
Psychiatry's Sickest of the Sick: Abandoned by Public Health Officials
Published on September 16, 2010

The homeless mentally ill in the city of San Francisco have been so visible for so long they've become almost part of the landscape to us city dwellers--essentially invisible people who, for all intents and purposes, have disappeared.

But for visitors, who flock to neighborhoods such as North Beach, the Embarcadero, South of Market, and the Haight in search of a little urban adventure, they can't help but notice both the numbers of mentally ill and the intensity of psychiatric illness on display.

I still see these people. Time and again when I am out and about in San Francisco, I observe many of the "frequent flyers," many of whom I know by name, that I've assessed in the psychiatric ER of San Francisco General Hospital, where I've worked as a physician and psychiatrist for more than 20 years. I've had to discharge many of them back out to the streets because there is no will on the part of the city or the state of California to provide appropriate care to these patients.

In my opinion, this is tantamount to discrimination.
Read More

Save the Appendix! A View of DSM-5 from the Trenches>

June 01, 2010

When I look at the creation of DSM-5 from the perspective of an ER Psychiatrist, I feel as if I've been left behind, disqualified, overrun by hobby horses.

Epidemiologists ride some; ivory tower denizens can be found astride others; bench scientists at NIMH a few lengths behind but threatening to make a late push; several from each group carrying the insurance industry and Big Pharma's agendas in their side saddles.

However you deconstruct this derby, though, we humble clinicians can be found trampled, face-down in the muck of the stable floor

Say what you will about DSM-III and its offspring through DSM-IV-TR, they've been constructed in a practical and user-friendly way for clinicians. It's not at all evident that DSM-5 will be guided by the principles of clarity or user-friendliness.
Read More

Whose Leg Is It Anyway?: Medical Decision-Making Part 2
Medical Paternalism vs. Patient Autonomy
Published on May 20, 2010

While working in the psych emergency room at San Francisco General Hospital, I take a call from my medical colleague, Dr. Jones, toiling away in the "regular" Emergency Department.

"Paul, I'm gonna need your help on this one," she says.

"Okay," I say.

"It's an 80-year-old woman with a pretty severe left leg cellulitis bordering on phlebitis who isn't even letting us draw blood on her when in fact she needs IV antibiotics and a surgical evaluation."
Read More

Whose Leg Is It Anyway?: Medical Decision-Making in the ER
Medical Ethics: Should Paternalism Be Such a Dirty Word?
Published on May 11, 2010

Determining if a medical problem represents an "imminent loss of life or limb" for a patient seems as if it should constitute a straightforward, yes-or-no, situation for an ER doctor to figure out. It is at the heart of what defines a "medical emergency."

For example, nearly everyone would agree that if a person's heart has suddenly stopped beating, the lungs have ceased ventilating, and the patient is comatose, then paramedics and an ER doctor should do all they can to save the patient's life.

(Of course, unless, the patient has a strict standing order of do-not-resuscitate/do-not-intubate (DNR/DNI) as is sometimes the case with very elderly/terminally ill patients.)
Read More

This Is Your Brain on Drugs: A View from the Psych ER
For the ER Psychiatrist, Drugs and Alcohol = Full Employment
Published on May 4, 2010

If it weren't for drugs and alcohol, I might be out of a job.

I work as an emergency psychiatrist at San Francisco General Hospital.

Two out of three patients arriving in psych emergency suffer from a wicked drug or alcohol problem. In order of mayhem induced, the list reads like this: methamphetamines, PCP, cocaine, alcohol, hallucinogens, Ecstasy, heroin, cigarettes, and, last but not least, marijuana.
Read More

ER Psychiatrists: The Couch Potatoes of Adrenaline Junkies
Emergency psychiatry: the antidote to perfectionism.
Published on April 30, 2010

Why did I choose to work in psych emergency?

Since seven years of psychotherapy hadn't provided me with the answer, perhaps I needed the three years it took me to write DANGER TO SELF: ON THE FRONT LINE WITH AN ER PSYCHIATRIST to answer that rhetorical question.

I discovered this: My decision had much to do with a gut feeling that my style of thinking and relating on an interpersonal level with both patients and staff were tailor-made for the place.

Read More