Not All Mental Health Issues Need a Medical Doctor

Though I am thrilled with the attention mental health has received in recent years and with the pandemic, the pendulum is swinging far in the direction of labeling everything a mental illness.  In my practice, I am seeing more and more situational stressors that manifest, very reasonably, with anxiety and mood changes.  In most of these cases, therapy or other lifestyle modifications would be recommended first before a medication because these interventions would be safer and more effective.  However, there has been a cultural shift that is emphasizing the involvement of a doctor for all mental health problems, to secure a diagnosis and to start a medication.

Here is a case example to illustrate my point:  A patient was referred to me for increased anxiety related to return to work after a stress leave.  The family doctor wanted to know if this patient had an anxiety disorder.  What came up in the assessment was that this patient was refusing insurance-provided psychotherapy saying that this made him even more anxious.  When I probed further, it turns out this patient did not want to return to work.  He found the work environment toxic and he felt singled out by colleagues.  He did not enjoy the work itself either.  He was already on a medication for his anxiety and he found it somewhat helpful, but still voiced being unable to return to work.  My clinical opinion in the end was more common sense than medical expertise: that if his work and work place were not going to change, how he felt about returning to work was also not likely to change.  In order to feel better, he would need to find something else to do and with other people.  I suspected the reason why he refused the therapy being offered (which came free of charge) was because a primary goal for therapy was to get him functioning again to return to work and he did not want this.

The above example is not a mental illness.  It is not an issue that should involve a physician.  But workplaces need notes from doctors to justify or explain employee absences.

Can someone who does not want to go to work, or who has broken up with a romantic partner, or has lost a loved one experience a mental illness as a result of this stress?  Absolutely.  Can we expect family doctors to know when this line is crossed?  I don't think so.  Not with the increasing number of patients and complexity, not to mention the ever dwindling resources and the pressure for family physicians to diagnose within a 15 minute time slot.  It is a common challenge for all physicians, psychiatrists included, to struggle with determining when a patient presentation is a "normal" reaction to a stressor and when it becomes pathology requiring medical intervention.

The consequence of more mental health issues flooding physicians' offices are many.  One consequence is a population that is overmedicated and yet feeling no better.  Another is a population that is disempowered from understanding themselves and their emotional needs such that they do not know how to make the changes necessary to improve things.  A third consequence is a patient population that develops the unrealistic expectation and entitlement that a doctor or a pill is needed to do the work for them.

There are significant implications of this trend for the health care system also.  These unsuitable requests take a lot more clinician time and resources.  In part because even though it is not a doctor's job to emotionally support you when there is no illness at play, many physicians will not turn you away.  It is poor bedside manner and uncompassionate, especially when a longer term physician-patient relationship is at stake.  The family doctor needs to maintain trust with their patients to better manage any medical concerns that arise. 

Most doctors are not meant to provide therapy when it is the main treatment indicated.  Most of us do not have the training.  In addition, physicians have their own emotional resources to look after and need to stay in within their scope of practice.  For a physician to provide support and empathy in times of illness is an important part of the care we provide. It not only improves patient outcomes but also makes the job more rewarding.  So every doctor must find a balance for themselves lest they burn out. 

What is important to point out is that there are others in the community whose job IS to actually provide this psychological support.  The next essay will discuss how each of us can better triage our own mental health or emotional difficulties to more efficiently and effectively use our medical system.  We need to do our part to protect and support our increasingly strained universal health care system, a pillar of the Canadian Identity.