Shalom Feinberg, MD

But they are both MD’s…

Moshe hasn’t been feeling well for months. He has a growing list of medical complaints and worries. His family doctor examines him and finds no illness to explain his symptoms. Moshe is no longer able to help his wife Leah with their children as he withdraws into bed whenever he is at home. With the help of a credible referral agency, Leah finds a competent psychiatrist nearby and calls to schedule a consultation for her suffering husband. Moshe refuses to attend the appointment, and instead, calls his family doctor yet again, asking for some medicine to help him. The doctor prescribes an anti-anxiety pill, Xanax, but things with Moshe do not improve

Through a series of case examples, I hope to explain the benefits of consulting with a psychiatrist when dealing with mental health issues.

We can understand why Moshe may resist going to see a psychiatrist. The thought of seeing a “shrink” can be intimidating on many levels. And anyway, what are the differences between a psychiatrist and a general physician?

Briefly, psychiatrists are specialized medical doctors, who receive extensive and wide-ranging training in clinically relevant aspects of the nervous system and the brain. In Moshe’s case, a psychiatrist would perform a differential diagnosis, and would be able to decide whether his symptoms are due to stress, an anxiety disorder or clinical depression, as well as the severity of each. If not diagnosed correctly, the treatment will not be effective and the wrong treatment may prolong or potentially exacerbate the symptoms. Moshe’s internist gave him an anti-anxiety medication, however, Moshe was in actuality suffering from a depression. His symptoms continued until he finally relented and consulted with a psychiatrist. When placed on an antidepressant, Moshe’s symptoms gradually improved. His psychiatrist was also able to suggest that he would benefit from seeing a therapist and the specific type of evidence-based psychotherapy that would be effective.

Once on the correct dose of medication, Moshe met with the psychiatrist periodically so that his symptoms could be monitored, dose of medicine adjusted and side effects, if any, managed.

Moshe’s situation is not uncommon. He suffered longer than necessary until he finally agreed to see a psychiatrist with the expertise necessary to develop an appropriate treatment plan.

Rabbi, Askan or Psychiatrist?

Yehuda is an 18-year-old young man, the fifth of twelve children. Over the past few weeks, his parents and Rebbe have noticed that he is increasingly preoccupied and confused. He appears unhappy and has started to talk to himself, mumbling about how upset he is with certain life circumstances. The family, while certainly concerned about Yehudah, is fearful of negatively impacting on a future shidduch for Yehudah or his siblings if they seek professional assistance. Instead, they request advice from a local Rov and then from an Askan, who suggests that Zoloft would be helpful in treating Yehuda’s “depression.” He gives Yehuda’s father a handful of Zoloft (an antidepressant) pills, as well as the name of a general medical doctor who can write a prescription for more Zoloft when Yehudah runs out of this initial supply. Over the next few days, Yehudah continues to deteriorate as he becomes increasingly agitated, repeatedly running out of his house and into the street, yelling and screaming, putting his safety at risk. This necessitated a call to Hatzolah, who, with all the neighbors watching, took him to the emergency room of a local hospital. He was subsequently admitted to a psychiatric unit.

This unfortunate situation is also not uncommon. All psychiatric medications are not equal! It takes a psychiatrist’s expertise to arrive at an accurate diagnosis and prescribe the appropriate medication. In speaking with Yehuda and his family, a competent psychiatrist, after an in-depth evaluation, would have recognized that Yehuda has many symptoms beyond the confusion, agitation and unhappiness most obvious to his family. He would have concluded that these symptoms are more consistent with a psychotic illness than a depressive disorder. While Zoloft is a commonly used and effective antidepressant, it does not treat psychosis, even one that includes symptoms of unhappiness.

Would a psychiatrist have saved Yehuda from a psychiatric hospitalization? No one can answer with certainty. But in general, the sooner one addresses a developing psychiatric concern, the greater is the likelihood to successfully treat it and prevent further deterioration. Unfortunately, I have seen many “Yehudah”s after the fact, and also have had the privilege of catching many more before they become “Yehuda”s.

When the therapist says “Wait!”

Despite having been in psychotherapy for 6 months, Rachel’s anxiety symptoms and panic attacks are increasing in frequency and intensity. Her dysphoria is similarly intensifying. She is barely able to care for her children. However, her therapist insists that therapy will help her over time and a medication consultation is not yet warranted. Finally, with the support of her spouse, Rachel decides to seek a psychiatric evaluation despite the objection of her therapist. Based on the psychiatrist’s assessment of Rachel and his discussion with her therapist, Rachel is immediately started on a combination of two medications, a short-term anti-anxiety medicine and an antidepressant. She starts to find some initial relief after taking a few doses of the anti-anxiety medicine. After a number of weeks, the anti-depressant, in conjunction with the ongoing psychotherapy, generates a more complete and lasting response to Rachel’s anxiety and dysphoria. She returns to being a caring, involved and loving spouse and mother.

The question of how much time to allow a trial of psychotherapy to work before sending a client for a psychiatric consultation certainly varies from person to person and situation to situation. This therapist’s view that therapy alone would suffice over time is not always correct. It was the insistence of the therapist to hold off on seeking additional help that was problematic. A professional can offer their educated opinion to a client, but ultimately it is the client’s decision when to seek out either a second opinion from the same type of professional (social worker or psychologist) or one of another discipline (in this case a psychiatrist). In Rachel’s example, the significant, unchanging anxiety and suffering, which persisted for a number of months, was appropriate cause to seek a psychiatric consultation.

Ongoing care: Which MD?

Yosef was suffering from a severe depression that included suicidal ideation. However, this resolved over the course of a few months with the help of antidepressant pharmacotherapy provided by a psychiatrist, and psychotherapy provided by a licensed mental health professional. Yosef asks the psychiatrist how much longer he needs to stay on this medicine, and whether his local family doctor could more conveniently (and economically) write the prescriptions for this remaining time.

Boruch Hashem; Yosef is doing well. Generally, after resolution of a single depressive episode, antidepressants are continued for a minimum of 6-12 months. However, this is not a straightforward decision and a number of factors enter into play. If medication is terminated too quickly, the potential for relapse is significant. A professional experienced specifically in these matters should be guiding Yosef in making this determination.

The second question Yosef asks of his psychiatrist is whether his family doctor can take over writing his prescriptions, and in essence, his care. In Yosef’s case, a psychiatrist should be involved due to the severity of the episode. However, generally speaking, I feel the answer to this question is “it depends.” Clearly as I have written throughout this article, a psychiatrist is best qualified to manage psychiatric issues and, ideally, he should follow a patient for the length of their treatment. But there are instances in which a non -psychiatric physician could handle this task. An example might be a responsible patient (i.e. compliant with their medicine and able to call for additional help if symptoms start to return), who is in clear remission on a straight forward medication regimen and who requires maintenance medication for many years to come (and has tolerable or no side effects.) Of course, the general medical doctor has to be comfortable and willing to take on this role. A frank collaborative discussion between psychiatrist and patient is necessary to reach an appropriate decision on this type of issue.

Pediatrician or Pediatric Psychiatrist

Aryeh is a rambunctious eight-year-old boy whose Rebbe noted that despite the Rebbe’s best efforts, his schoolwork was well below expectation. Aryeh’s ability to focus and concentrate was poor, and he was notably restless, fidgeting with items in his desk and roaming around the classroom. Aryeh would often call out and enjoyed acting as class clown. The Rebbe tried to give him more attention and seat him in front of the class, to no avail. In speaking with the menahel, the Rebbe heard that past Rebbeim had noted the same type of issues with Aryeh. Attempts to suggest that his parents seek a professional assessment for Aryeh were not successful in the past. The Rebbe spoke with Aryeh’s parents and discovered that his behavior at home was similarly problematic. This time, the parents agreed to seek help for Aryeh. Although the school gave them a list of child psychiatrists and neurologists who had been successful with other students, Aryeh’s parents took him to his pediatrician. After a brief conversation with Aryeh and his parents, and without consulting with the Rebbe or school or requesting any behavioral checklists from the school, the pediatrician prescribes Ritalin 5 mg three times per day. Six weeks after the family said they would seek help for Aryeh, the Rebbe, seeing little change, calls Aryeh’s parents to find out what became of the assessment. They explain that Aryeh also appears no different at home and they want to stop his medication trial. They have had no subsequent discussion with the pediatrician since he wrote the initial prescription for Aryeh.

In this case, Aryeh needed a more thorough evaluation. A child psychiatrist would have spent the time to diagnostically determine the cause of his symptoms. For instance, were they due to Attention Deficit Hyperactivity Disorder (ADHD), a learning disability or an anxiety disorder? A child psychiatrist would have sought information, not just from Aryeh and his parents, but from his Rebbe and school. If still uncertain of the diagnosis, a psychiatrist may have recommended a psycho-educational evaluation. If he was believed to have ADHD, a psychiatrist would have continued to closely follow Aryeh after initially prescribing medication and adjust the dose as needed. To do this most accurately, the psychiatrist would have asked the Rebbe and other teachers to complete school behavioral checklists to help assess Aryeh’s progress periodically as the medication trial continued. A psychiatrist would also provide education about ADHD, address parental concerns about medication, and work collaboratively with them to help maximize Aryeh’s potential.

When medication is the wrong treatment

Mrs. Schwartz is an 85-year-old widowed female who was taken to a psychiatrist by her nephew because of continued depressive symptoms displayed over a number of months. One month earlier, he had brought his aunt to her general doctor, who had placed her on Zoloft. However, according to Mrs. Schwartz’s nephew, the medication wasn’t working, and Mrs. Schwartz continued to appear depressed, was doing little during the day, and was verbalizing statements of hopelessness. On consultation, the psychiatrist found Mrs. Schwartz to be a rather friendly, pleasant and verbal woman who was able to ambulate with the help of a cane. She described how she was living alone for many years in a nearby apartment building, and how most of her friends and contemporaries had either moved away or passed away over the last few years. Her 2 children lived many miles away and were able to visit only rarely. The nephew who brought her to the consultation was also only an occasional visitor. She felt rather lonely and stuck in her apartment. The psychiatrist and Mrs. Schwartz discussed an assortment of possible ideas to change her isolated life situation. Fortunately, financial resources were not an issue. As they talked, Mrs. Schwartz became more activated and hopeful. Together, Mrs. Schwartz and the psychiatrist arrived at a tentative plan which involved moving closer to one of her children and possibly into an assisted living setting. A phone conversation with her child confirmed that this was a viable option. Diagnostically, the psychiatrist did not feel that the reported depressive symptoms warranted an antidepressant trial, and discussed discontinuing the Zoloft with Mrs. Schwartz and her family.

This vignette speaks to another aspect of the unique role a psychiatrist can play in the treatment of psychological issues. In this case, it involved helping to stop an unnecessarymedication. Family physicians may not necessarily have the expertise or the time to get at the heart of an emotional issue. Thus in the face of reported “depression” by patient or a family member, they are likely to quickly and simply prescribe medication.

In closing, it is important to be aware of when to consult with a mental health professional when confronted with emotional issues, and in specific, with a psychiatrist when medication may be part of the therapeutic equation.

Dr. Shalom Feinberg is Associate Clinical Professor of Psychiatry at Albert Einstein College of Medicine, and a Board Member of NEFESH International. His practice is presently not accepting new patients.

* Identifying names and features in all vignettes having been altered.