Published May 8, 2019 on Scientific American.
It’s 3 P.M. on a Saturday in March, and I’m working at Silver Hill Hospital. As the on-duty doctor, my job is to admit new patients and to work with the other staff to make sure that everything goes smoothly.
I’m about to see a young patient I’ll call Adrian.* I glance in the glass-paned waiting room and notice Adrian sitting on the sofa. Their parents are also in the room (I’m using gender-neutral names and pronouns for the patients in this essay, as the author’s note at the bottom explains), standing with concerned looks on their faces.
A few minutes later, I meet with Adrian, who turns out to be a pleasant college student. They’ve been feeling anxious and depressed and, in addition to worsening paranoid thoughts, is thinking about suicide.
Each patient is uniquely complex. I have never seen two identical patients: even within the same family, even among twins, patients are unique. Each patient’s history and symptoms, brain and genes, hopes and fears differ, which is one reason why psychiatry is so difficult.
I need to figure out how to help Adrian. To do this, I need to reduce their complexity into something cognitively manageable, into something I can understand. The way I (and all clinicians) do this is to look for patterns: common symptoms and trends that help me understand what’s going on and suggest a type of treatment.
A previous clinician had diagnosed Adrian with bipolar disorder, which means that clinician had seen a particular pattern of symptoms and, accordingly, had begun them on a specific medication regimen. I sense a similar pattern as we discuss periods of mania and depression and, more recently, suicidality. We finish our conversation and return to the waiting room.
Adrian’s parents are now sitting on the couch. The mother smiles, while the father looks deep in thought, staring out the window.
I ask them if they have any questions and Adrian’s father replies quickly, “Well, I read this essay in the Atlantic—do you read the Atlantic?”
“Well, sometimes,” I said, wondering if I looked too nerdy to be an Atlantic reader.
“The essay is called something like ‘The Hubris of Psychiatry.’ This guy is saying that psychiatrists don’t know what’s going on in the brain and so have made up names for all the disorders. If psychiatrists don’t know what’s going on, why should we bring our child to the hospital? Why should Adrian take medications with side effects if no one knows how they work?”
“Psychiatry’s incurable hubris”
This article by Gary Greenberg, a practicing psychotherapist and successful writer, was in the Atlantic’s April 2019 issue. It’s meant as a review of Anne Harrington’s book Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness, but Greenberg uses it to discuss many of psychiatry’s problems. He’s a provocateur, and I like him for it.
Greenberg describes Harrington’s book as “a tale of promising roads that turned out to be dead ends, of treatments that seemed miraculous in their day but barbaric in retrospect, of public-health policies that were born in hope but destined for disaster.” Insulin comas, ice pick lobotomies, and ice baths (now-debunked treatments) are Greenberg’s bogey men: look at how misguided psychiatrists have been!
Greenberg has told this story before. His own books, Manufacturing Depression: The Secret History of a Modern Disease and, more recently, The Book of Woe: The DSM and the Unmaking of Psychiatry send more of the same into the ether. His many essays for The New Yorker and Harper’s tell similar stories.
Greenberg wants psychiatrists (and everyone?) to admit that nothing is certain. Here’s how he puts it:
“Even as psychiatrists prescribe a widening variety of treatments, none of them can say exactly why any of these biological therapies work. It follows that psychiatrists also cannot precisely predict for whom and under what conditions their treatments will work.”
Greenberg demonstrates—so elegantly!—that the root problem is that psychiatrists and neuroscientists and pharmacologists and psychotherapists (himself included, presumably?) lack an exhaustive understanding of the brain. Greenberg is (understandably) uncomfortable that, well, dammit, we aren’t wizards. Without such omniscience, he concludes, it is
“Little wonder that the history of such a field—reliant on the authority of scientific medicine even in the absence of scientific findings—is a record not only of promise and setback, but of hubris.”
Well, I’m uncomfortable with uncertainty too. It sucks. I share Greenberg’s contempt for sloppy, authority-based thinking. I’ve written about the imprecise nature of diagnosis and my quibbles with the DSM. As a clinical researcher who studies the brain, I confront and reckon with this uncertainty every day. But I’ve still got patients to treat.
To Treat or Not to Treat
“All of these medicines, but none of them are helping.” Adrian’s father continues, “Why even bother? It looks like we’re just doing a lot of guessing without any precision. And there are serious side effects.”
“Look, I’m the first to admit that our diagnoses are imprecise.” I explain that I’d recently published an essay outlining exactly why I feel my diagnoses are imprecise.
“I guess it boils down to what the goal of the diagnostic process is,” I say. “And also what you’re willing to do once you think you understand the problem.”
I tell him how, as a medical student, I’d come across the Ebers Papyrus, an ancient Egyptian medical text that explains patterns of symptoms, what they mean and how to treat that symptom pattern. If you see an arm that bends where it’s not supposed to, you diagnose a broken arm, and you should set the arm; etc.
What I liked about ancient Egyptian medicine wasn’t just what they would do, but what they wouldn’t do. For example, if you see a bump that keeps growing and growing, it’s a “tumor against the god Xenus.” This, the papyrus states, “thou shalt not treat…. Do thou nothing there against.” They realized they didn’t have an effective treatment and, in the absence of a definitive solution (based on their best understanding, that is; many treatments were literally snake oil), they simply wouldn’t do anything. Better to not act than act with hubris.
“I really like that honesty,” I confess. “But I suppose the problem is that doing nothing changes nothing, which in some cases isn’t a good option.”
“So here we are at Silver Hill Hospital.” I motion with my hands around the room. “You brought Adrian here because you’re concerned your child may try to kill themself. Based on my conversation with them, I agree it’s a serious risk and you’re right to be concerned. People commit suicide every hour of every day. Now, let’s say there’s an 85 percent risk that Adrian might kill themself,” the father nods.
“Now suppose that I told you there was a medicine that I thought might help. I wasn’t sure that it’d work, but, multiple, large studies have shown it might have, say, from a 20 percent to a 40 percent chance of working. Would you take it?”
“Of course,” Adrian’s father says with a smile. He knew where I was going.
“So right now, we’re admitting Adrian to the hospital because, like anyone, being here decreases the likelihood that they’ll kill themself. And we’re also trying medications and therapies that very well might not work. They’ve worked in many people, but our science isn’t advanced enough to predict whether they’ll work for Adrian. But we’re okay with that because Adrian’s safe in the hospital and so, if one medication doesn’t work, we can try another. We can keep trying things as long as Adrian’s alive, but if they’re dead, we’re done. We can’t help someone who’s dead.”
The Hubris of Doctoring
A few weeks later, I’m back at Silver Hill Hospital. I’m making my rounds and I see Adrian at one of the transitional living facilities, which serves as a midway point between an inpatient unit and returning home. I stop to chat, to ask how they’re doing.
“Good. I’m applying to get back in school now,” Adrian says, pointing to an application on their lap. “Things are going better.”
I mention that a few of my friends sent me Greenberg’s essay and asked me the same questions we discussed a couple weeks ago. I ask Adrian if I can write about our conversation, whether I can tell their story, changing their name to protect their privacy. They nod and smile, “Of course.” Later, I call their parents and ask them the same. Adrian’s mother is on board and before my first admission for the day arrives, I begin this essay.
My first admission is another young patient with bipolar disorder. Similar to—but not precisely like—Adrian, this patient wants to die.
We sit down in the same exam room, “My name’s Dr. Barron, I’m the admitting doctor today. Can you help me understand what’s going on?”
“Since my first manic episode two years ago, my condition has been unbearable. I feel like I’m not living life, I’m just surviving. I’m tired of waiting four to six weeks just to see if a medication works. They don’t. Nothing is yielding results. I’m unable to drive, read, work, draw—even silly pictures and I’m an artist—I can’t even watch TV. Not even TV,” they pause for the first time. I wonder if they’re out of breath or thinking or both.
“I have severe anhedonia that’s not being fixed by DBT, IPT or CBT. I think every minute about committing suicide because I can’t handle this anymore. I can’t handle this anymore,” they say, hands covering their face as they lean forward in their chair. I notice the haggard black polish at the end of half an inch of nail bed. They’re on the verge of tears.
They take a deep breath, “Every day I do nothing. I sit in my house and do nothing. Can you imagine what that feels like?”
They begin to cry. My stomach stirs and a tingle passes from my shoulders to my neck to the top of my head. My eyes begin to water as I shake my head, “No. I can’t imagine what that feels like. I’m sorry.”
I’m struck with irony. I realize I can’t promise anything with certainty. I tell them this. We sit for a moment in silence.
Then I repeat—nearly verbatim—the conversation I had with Adrian and their parents. “I’m not sure that anything will work, but are you willing to try?” I ask.
Later, as I write my admission note, I wonder what I’m doing, whether it’s hubris to do anything in the absence of certainty.
Does this patient have bipolar disorder? At this moment, I don’t know. Will the medications I’m prescribing help? I don’t know. Will anything I do help? I don’t know.
I don’t know, but it’s my job to try. Maybe it’s hubris, but then, maybe I can tip the scales in their favor.
*Author’s Note: To protect the privacy of those involved, I agreed to not used their real names. I have further omitted (but not changed) details that are too sensitive or identifying, to this end, I have chosen to use gender-neutral pronouns to disguise both patients’ genders. All of the events are true. The conversations I re-create come from my clinical notes and my clear recollections of them, though they are not written to represent word-for-word transcripts. The views expressed above are my own and not necessarily those of Silver Hill Hospital.