The Untreatable Patient?


There are many times I escort a patient back to my front desk Shouting things like “Never give up! Never surrender!”

I tell them how I was taught to say that when I was on active duty with the US Army Medical Corps.

“Think of whatever inspires you!” If a psychiatrist wonders if a patient is “untreatable,” then all we are really saying is that THAT patient is, at THAT moment, untreatable by THAT psychiatrist.

Sure, there is always ketamine. But before that, there is going back to the basics.

I have plenty of experience at this, since I am usually about the 4th psychiatrist that patients see.

Psychiatric symptoms, especially depression, are often caused by physical illness. Patients grow and change, so it is necessary to repeat blood tests, sometimes to do new ones. Often it is important to work on an alliance with an overworked primary care physician, who may have kicked the patient out of his or her office many times, saying “It’s all in your head; go bother your psychiatrist.”

If the patient is on over 5 drugs at once, there is almost always a drug-drug interaction, probably among psychotropics, even with foods, naturals, over-the-counters. There are several online databases; I most often use www.  There is always alternative, “natural” psychopharmacology. This is part of an armamentarium that includes searches in the National Library of Medicine database as well as telephoning or emailing colleagues who have published research.

(Believe me — they love being telephoned.)

Only then might I consider referring to a psychologist. I always, but always have a specific request — testing, or perhaps a particular kind of therapy.

I recommend strongly against open-ended referrals, as the invariable result is open-ended evaluation and therapy of a “regular” (“money-in-the-bank”) patient, in a relationship that lasts until the patient gets sick of it and leaves.

Back to the triple paradigm of Engel of U. Rochester. Biological, psychological, social. I have seen plenty of cures or near-cures from interventions that include things like:

Get yourself educated for a job you could actually enjoy.

If this is absolutely not the right live-in companion to spend your life with, why not look into moving on?

Tell your mother in law this time you will not be at home when she comes to visit. Just block that woman on your cell phone.

And so on.

Untreatable by one or even a few other psychiatrists is never, but never, the end of the line.

You might also enjoy some of the things I share and reveal on my blog.

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