Issue 6 Stories
Physicians Perspective

The Challenge, Wonder and Promise of Psychiatry

When people ask me about my experience as a psychiatrist, I have a favorite response: “It’s not always pleasant, but it’s always interesting.” Indeed, I am very pleased that I chose to practice psychiatry—a field that is fascinating, challenging and rewarding all at the same time.

Psychiatric disorders are more common than most people think. At some point in their lives, nearly half of all Americans will meet the criteria for a psychiatric disorder—either a mood, anxiety, impulse-control or substance-use disorder—and one-quarter of Americans likely will meet those criteria within the next 12 months. One-fifth of all psychiatric cases are classified as serious, and a quarter of the population may have multiple diagnoses.

These disorders frequently affect people at early ages, too, with nearly 75 percent of cases occurring before age 25. The economic cost in terms of lost productivity and financial burden is enormous. In fact, depression alone is estimated to cost the U.S. economy more than $200 billion each year, and depression remains the leading cause of disability worldwide.

This high prevalence means that mental health issues are all around us—in our families, within our circles of friends and among our colleagues. Yet despite being so commonplace, a great deal of stigma is still attached to psychiatric disorders. Many people still don’t like to talk about these problems, and many hesitate before seeking professional care, often clinging to an underlying belief that doing so is an admission of weakness or vulnerability.

Addressing the Vulnerability Issue

This often-unconscious fear of vulnerability can lead to a kind of denial, both individually and collectively, about mental health problems. When I encounter this hesitancy or denial in my patients, I usually ask them: “Would you blame yourself for having a fever?”

Invariably, the answer is “no.” Yet people often think that feeling depressed or anxious is their fault, perhaps because their sense of identity gets entangled with the neurobiological phenomena underlying their problem.

Fortunately, given our increasing awareness of the biological underpinnings of mental health problems, this attitude toward these kinds of disorders is changing. Nevertheless, we still need to send the messages—loud and clear—that people don’t have to suffer in silence, that help is available, and that the decision to seek professional help actually represents courage and strength on the part of the patient.

Psychiatric Disorders as “Less Real” than Other Diseases

Another worrying assumption sometimes seen among the general population—and, unfortunately, even among some healthcare professionals—is the dismissal of psychiatric diagnoses as being somehow less credible than other medical diagnoses, and the assumption that psychiatric or mental health problems are somehow “less real” than organic diseases, and don’t need to be treated in an analogous manner.

Nevertheless, it is true that psychiatrists don’t always conduct an elaborate physical examination or order a battery of lab tests to assess their patients. The practice of psychiatry requires honing a complex set of interpersonal, communication and self-reflective skills that allow the psychiatrist to understand and reach a so-called “difficult patient.” While these abilities are also valuable assets for other types of physicians to have, they often can function more as optional “add-ons.” Having a wider perspective on life and the ability to decode the intricacies of verbal and nonverbal communication in real time, on the other hand, is a professional necessity for a psychiatrist.

The Effectiveness of Psychiatric Treatment

Despite the challenges in our current understanding and treatment of psychiatric disorders, psychiatrists do make significant contributions to their patients’ lives. Studies show that more than two-thirds of patients with anxiety or depression respond to initial treatment, and an even greater percentage improves after receiving augmented treatment. Given how common these types of problems are, that translates into a huge amount of relief for a lot of people.

Every day, I hear about how treatment has improved quality of life for many of my patients. I recall one patient describing how each second during an acute 20-minute panic attack can seem like an eternity, and how one of these attacks might have driven him to end his life, if not for treatment. I have seen patients with melancholic and catatonic depression come to life after several therapy treatments, and their precious smiles will remain etched in my memory forever.

A number of my patients with attention deficit hyperactive disorder have been able to achieve their academic goals after their condition was uncovered and treated. I also know quite a few patients who struggled greatly with addiction but improved dramatically after a few months of sobriety. And it’s hard to express the degree of relief a patient with paranoid schizophrenia feels when medication helps alleviate the hallucinations and delusions that can so severely disrupt that person’s quality of life.

The fact is that every day people are getting better because of psychiatric treatment. As an added benefit, for having experienced these conditions and having dealt with them successfully, they often become more skillful, more understanding and more compassionate people.

New and Ongoing Developments in Psychiatry

Much like other medical specialties, psychiatry is evolving rapidly. Even so, there is still much more we need to understand to improve our treatment strategies.

The search for the “ultimate” antipsychotic medication continues. Currently, our most effective antipsychotic, clozapine, requires monitoring due to its potentially dangerous side effects, including blurred vision, irregular heart rhythm, fainting and shakiness, as well as less common side effects such as convulsions, difficulty breathing and unsteady gait. Clozapine also requires rigorous monitoring due to a rare but life-threatening side effect known agranulocytosis, or lowered white blood cell count. The Holy Grail of psychopharmacology would be to find a medication similar to clozapine without those side effects, and a huge amount of research currently is being conducted to achieve that goal.

A significant development in psychiatry occurred just recently in November 2017, when the U.S. Food and Drug Administration approved Abilify MyCite, a type of pill containing a sensor that can be used to digitally track whether patients have ingested their medication. This technology should help with medication compliance, the degree to which patients follow their doctors’ instructions for taking their medications.

Ketamine, an intravenous anesthetic, has shown a lot of promise as a first antidepressant, with rapid onset of action. My research mentor at Cleveland Clinic, Dr. Amit Anand, has received a grant of $13 million from the Patient-Centered Outcomes Research Institute to conduct a comparative study of ketamine and electroconvulsive therapy (ECT). A chemical similar to ketamine, esketamine, is also undergoing clinical trials and may soon be available as an intranasal antidepressant with rapid action—a development that is quite exciting to clinicians.

Of course, ECT has come a long way from the days of negative publicity brought about by its use in the film “One Flew Over the Cuckoo’s Nest.” Today, ECT is a very safe and effective procedure, and it remains the gold standard for depression that resists other forms of treatment. A patient’s improvement following ECT can be dramatic and at times almost miraculous. Public education about this treatment option is needed to allay any concerns for prospective patients about its safety and efficacy, and we also need to make ECT more readily available to patients. 

Other procedures such as transcranial magnetic stimulation (TMS) and deep brain stimulation (DBS) are also being explored to help with depression and anxiety disorders. TMS is a noninvasive procedure that uses magnetic fields to stimulate certain brain areas to improve symptoms of depression, while DBS is a more invasive neurosurgical procedure that involves the implanting of neurostimulator electrodes to target certain brain areas. DBS has been established for many treatment-resistant disorders such as Parkinsonism and obsessive-compulsive disorder, but recently we have seen a surge in interest in treating depression that resists other forms of treatment by using DBS to target various brain areas.

A Great Team

Syed S. Rizvi, MD

Working as a psychiatrist has been a great joy. It’s fascinating to see the similarities and differences among patients with similar diagnoses, and it’s truly humbling to see how significantly psychiatry can help so many people suffering with these conditions.

I count it a great honor to be part of the team of mental health professionals at Sentara RMH. We are all dedicated to providing compassionate, high-quality care to the people who turn to us for help, and we truly strive to carry out our mission as Sentara caregivers to improve health every day.

Syed S. Rizvi, MD, is a psychiatrist in practice with Sentara Behavioral Health Specialists in Harrisonburg. He joined the Sentara RMH team in 2017.

Behavioral Health Conditions Treated at Sentara RMH:

Anxiety

Bipolar Disorder

Dementia

Depression and Mood Disorders

Grief and Loss

Schizophrenia

Seasonal Affective Disorder

For more information on what these conditions are, their signs and symptoms, and various available treatment options, visit Sentara.com/Harrisonburg and search for “Behavioral Health.”

Take Action!

If you would like to connect with a Sentara RMH Behavioral Health provider, please call 540-564-5100.

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