Good Psychiatry: Treatment Recommendations
This is the final installment of a series where I describe what a patient can expect when seeing a psychiatrist for the initial consultation.
The case formulation (where the psychiatrist explains his clinical impression and the rationale) dovetails perfectly into the conversation a psychiatrist will have with the patient about the possible treatment approaches for the specific symptoms and diagnoses discussed so far in the assessment.
With regards to mental health treatment, there are 2 main categories:
1) Non- Medication options
a. Self-care and self-help
b. Talk therapy
c. Connection to other community supports and resources
2) Medication options
Non-medication options for improved mental health and recovery are diverse and numerous. An example for the self-motivated patient, is to begin with setting up a regular sleep schedule and exercise regimen, or to cut down on their alcohol, and recreational drug use. Patient's can also take it upon themselves to learn more about their own mental health by going through workbooks and listening to mental health podcasts. Guided mindfulness and self-compassion exercises are freely available in books and online and start the journey of helping people relate to themselves, their feelings, and their thoughts in different, healthier ways. Journaling and practicing gratitude are other examples of self-help.
Many mental health issues however can not be worked through and resolved on their own, and this is when talk therapy with a mental health professional can be very helpful. It should be mentioned that hybrid models of therapy (using texting and emailing) are becoming more available to meet the rising demand for therapy. Different apps can also help people track their moods and habits. Being so new to the scene, it is not yet known how they compare in the long term to the more traditional provision of therapy. Earlier, I wrote an article as an introduction to different face-to-face talk therapies. It can be found here: https://sarah-chan.ghost.io/looking-for-a-therapist-a-primer-on-psychotherapy/.
Community resources that help support patients struggling with mental health difficulties are also varied and useful. This could mean anything from peer support groups to religious and cultural communities, from Crisis distress phone lines to social supports for housing and financial problems. Fortunately, in Ottawa, you do not need a psychiatrist to access some of these supports. Anyone can start by visiting the website: www.accessmha.ca
Non-Medication interventions are by far some of the least expensive but most effective treatments for many mental health concerns.
Most psychiatrists will focus on medications because this is their unique area of expertise and where many feel they have the most clinical experience. However, psychiatrists who offer both non-medication and medication support, provide more holistic care and have better patient outcomes.
When it comes to medication, few mental health illnesses rely on medications for recovery. Two examples of such illnesses however are psychotic disorders and bipolar disorder. When discussing medications, the psychiatrist will review the reasons for the medication suggested and the possible side effects. Medication can be used to target an illness specifically, like depression; or they can be used to target a symptom, like insomnia. The aim is to use as few medications and at the lowest doses possible. When more than one medication is proposed, the psychiatrist needs to make clear the different reasons for each medication to avoid redundancy. Generally speaking, more medications usually means more side effects and interactions with other drugs.
Three of the most common classes of medications used by psychiatrists are antidepressants (which incidentally are also very good for anxiety disorders), antipsychotics (used in many different conditions, not only psychosis) and mood stabilizers (for moods that are more labile and can go up as well as down). These medications can be used safely in combination and evidence shows how they can also complement one another. Some times, a psychiatrist will choose a medication to avoid certain side effects (like sexual dysfunction), at other times, a psychiatrist may choose a medication for a side effect that may be desired (like appetite stimulation).
After a treatment plan is in a place, follow-up should be offered, either by a family physician or the psychiatrist. This allows the patient time to implement some of the non-medication suggestions proposed while giving time for medication to start working, which can take up to 4-6 weeks. In follow-up appointments, the doctor monitors any improvements or deterioration, makes any necessary changes to medications and answers any other questions. Some psychiatrists may also offer some therapy in these appointments where appropriate. It is quite common for diagnoses to change over time as more symptoms emerge and evolve. For example, patients with bipolar illness can present first with depression and only over time and response to treatment for unipolar depression will a bipolar diagnosis declare itself. Follow-up therefore allows for a more precise diagnosis leading to better-tailored treatment.