As second year winds down and I approach the ultimate exam of medical school, Step 1 of the USMLE, I have spent a lot of time in reflection, and on one stark dichotomy in particular. The vast majority of medicine that we studied has been physical; we study the art of physical diagnosis in order to best assess our patients’ pains and murmurs and abrasions, leading to verifiable diagnoses. In addition, we have objective blood work showing a TSH level or a number for total cholesterol, and a scan to show a cyst or mass. All of these means give us the ability to diagnose patients with confidence and ease, allowing for objective, physical proof. Indeed, we are able to monitor blood levels of an overwhelming array of molecules within the human body, and able to see the composition of injured tissues, bones and blood flow from a variety of types of scans.
At stark contrast to this very real and physical world of medicine lies the abstract realm of psychiatry, where little to none of these objective blood measurements exist. Mental health and mental illnesses are real, yet very rarely do we have a test that can show our patients the authenticity of what they are experiencing. There are seldom findings on physical exam when one is suffering from depression. There is no scan that can show a change in neurotransmitter levels explaining one’s bipolar disorder. There are few blood tests available to show changes in the body in anxiety, or paranoia, or obsessive-compulsive disorder. In psychiatry, expertly trained physicians are able to assess a patient’s mental health through a comprehensive evaluation of physical and mental well-being. This is pivotal to the correct diagnosis of mental health disorders and essential to providing the correct medication to alleviate the feelings and complaints the patient experiences. Even though the process leading to a mental health diagnosis is thorough and medically advanced, why does it remain that mental health illnesses are viewed differently from physical health illnesses?
The dichotomy rests in the simple fact that we as humans, with complex consciousness and insight into our conditions, struggle to come to terms with a diagnosis that has little objective evidence. Without seeing the scan, the blood test, or tests with the results showing abnormal findings, we have great difficulty accepting our diagnosis and accepting those of others. This phenomenon has led to the significant criticism and judgment that exists towards mental health and illness. Even before the Sandy Hook Elementary School tragedy a year and a half ago, mental health illnesses were often poorly understood by much of society, leading to incorrect beliefs about the cause, process, and treatment of mental health. With the release of the new DSM-5, the definitive source of all that is psychiatry and mental disorders, heavy discussion has ensued over the extent of mental health disorders, the criteria which serve to make the diagnosis, and their treatment. It is evident that the boundaries of mental health are still hazy and consequently, the reaction of those with mental health diagnoses remain just as ambiguous as they strive to come to terms with their condition.
Placing the Blame
I have noticed that it is much easier for a person to talk about their physical illnesses than their mental health. We don’t blink an eye to admit “I had a gallstone and had my gallbladder removed” or “I tore my ACL and my mom has rheumatoid arthritis” because these are physical complaints with physical solutions. However, we much less often hear “I have severe anxiety every day and panic attacks” or “I have depression.” These mental health diagnoses are harder to admit due to an inner battle we all have in ourselves. As hard as it is to admit weakness or problems with our body and physical strength, it is even harder to admit a problem with our feelings or mind. We tend to think it must be our fault, that we did something to cause it. That we’re too mentally weak to bear the emotions, or stress. That we are embarrassed of our diagnosis. We think that others judge our inadequacy or mental-emotional plight. These feelings are often unspoken, yet the impact that they create on mental health causes widespread and significant effects.
When a physician who comes in to lecture tells your class “I know you all want to get out of here early so you can go back to studying ‘real medicine’ for your boards” or later says “I know I’m not a ‘real’ doctor, but what can we find on physical exam in a patient with this condition,” you start to really wonder about how this barrier to mental health and psychiatry evolved and what we can do to address it. Psychiatry is real medicine and mental health disorders are real conditions. Yet, both the field of medicine and as a society, we pay little attention. In fact, many people feel discouraged to admit they struggle with depression or anxiety or mood disorders due to the fear of facing criticism and judgment from our friends, families and jobs. I believe that this is a disservice to ourselves; it only leads to more suffering by being afraid to seek help.
The Labeling Problem
Part of the problem that is more than evident is the practicing of ‘labeling’ patients. This happens more frequently in mental health diagnoses than physical diagnoses, directly leading to some of the stigma associated with mental health and awareness. We hear “he is a schizophrenic” or “she’s an alcoholic” rather than “he has schizophrenia” or “she has alcoholism.” In physical medicine, emphasis has been placed recently on changing this practice, especially in reference to a patient who has diabetes. Too often we hear “he’s a diabetic.” Labeling patients with their diseases creates a feeling of being defined by one’s condition, thereby hindering efforts of healing and attaining better health. This premise underlies the unspoken sentiment that affects mental health disorders, creating a barrier to proper care for patients who seek help and treatment for mental and emotional disorders.
The Totality of Health
The aspect that strikes me most about the irony behind the hush-hush nature of mental health is the fact that almost every single physical diagnosis comes with a significant aspect of mental health side effects. From a hysterectomy for endometriosis, to cancer treatment with surgery, chemotherapy and radiation, all physical diagnoses affect the patient mentally through fear, worry, anxiety, depression and feelings of failure or embarrassment. These emotions take a toll on the body physically; they can and do alter the outcome of treatment in many cases. We realize that an open heart coronary artery bypass graft surgery is a grueling operation with an arduous physical recovery, but we tend to ignore the fact that an overwhelming percentage of patients experience severe depression after the surgery. Current data assesses that up to 40% of patients become depressed after CABG surgery. Depression can be a significant challenge to endure in any condition, but especially so after the grueling physical ordeal of open-heart surgery. It is disheartening to realize that western medicine still focuses on repairing the body of ills, fixing the tangible complaints, but often fails to acknowledge that a person is much more than their physical body. Health truly is the interaction between physical, mental and social health, and no one can feel completely healthy with only one or two of those parts in excellent condition.
Despite the negativity, I think the future of medicine is bright and the abilities we have to treat each individual patient is resounding with hope and success. However, to attain the most complete and effective health care system for each patient, open communication and honest reflection on the impact of mental health are indispensable tools for dissolution of the barriers to psychiatric care.