Of all the medical specialties, Psychiatry may be the most unique. For the most part, the science base of other medical specialties has been well established for decades. Sure, there are ongoing advances and sophistication in diagnostic and therapeutic capabilities in these specialties but the core science has remained essentially unchanged. For example, if I was a practicing endocrinologist, the clinical history and physical examination that I would pursue is rather straightforward and easily quantifiable. To add further scientific credence to my diagnostic acumen as an endocrinologist, I could rely on a wide variety of biological laboratory tests, testing that has been based on thousands of previous patient assays that created a reliable set of values differentiating normal from abnormal. A person presenting with complaints of fatigue, weight gain, slow pulse and cold intolerance would raise suspicions of a sluggish thyroid gland. There certainly are signs on the physical examination suggestive of hypothyroidism, but at the end of the day when this person’s thyroid blood tests objectively support a malfunctioning thyroid gland the diagnosis becomes clear. Treatment of the hypothyroidism also allows for a quantifiable course because the dosage of thyroid hormone replacement can be adjusted based on serial thyroid blood tests.

Psychiatry’s story is quite different. Because of a limited science base at the turn of the twentieth century, Freud and his followers were guided by a pure psychological explanation for the emotional problems presented by their patients. We certainly knew of the existence of the brain but did not have the ability to directly evaluate brain function. So for decades psychiatrists expanded and clarified the Freudian concepts and the implementation of the primary treatment modality psychotherapy. By the 1950’s and 1960’s significant technological advances allowed for the measurement of brain chemicals (called neurotransmitters), brain electrical activity (via the electroencephalogram) as well as providing a more specific diagnosis by the development of the Diagnostic and Statistical Manual (DSM) in Psychiatry. Such advances were paralleled by the development of medicines that altered brain chemistry and allowed for a true pharmacologic approach to psychiatric care.

However, unlike our sister medical specialties, Psychiatry has not been able to successfully develop reliable and accurate biological testing to clarify diagnosis. There was a time when we hoped to be able to measure brain neurotransmitters (or their breakdown products) in cerebrospinal fluid, blood or urine, but this never proved to have diagnostic credence. Brain imaging has come a long way with the advent of the CAT scan, MRI and PET scan, but so far the use of these techniques for diagnostic purposes remains experimental. There will come a day when like in the show Star Trek a person will recline on a scanner and it will produce an accurate readout of a person’s brain/bodily biological dysfunction. But that day will be off in the future.

An economic innovation then occurred, the comprehensive involvement of insurance company payments for psychiatric services. Due to the logarithmic growth of expenditures for psychiatric care the insurance companies instituted the management of care (known colloquially as “managed care”) that relied on utilization review and fixed payment for the type of care provided. Psychotherapeutic services provided by non MD (master’s level and doctoral level) mental health professionals became the preferred level of reimbursement based on insurance company business models’ cost of care calculations while the psychiatrist’s practice became more and more the realm of medication prescribing.  For a time, the mental health field was skewed with one camp supporting only the provision of psychotherapy while the biological camp tended to overplay the sole importance of pharmacotherapy. Currently, a careful combination of both therapeutic modalities can be the most effective depending upon the nature of the disorder.

So how does the psychiatrist effectively determine the proper medication approach? An accurate diagnosis is first required. Because the psychiatrist cannot rely on laboratory testing to rule in a psychiatric disorder, laboratory testing may still be important to rule-out an underlying non-psychiatric medical disorder that may mimic and/or complicate the presenting psychiatric problem.  Once it is determined that there is no significant non-psychiatric medical problem present, the primary psychiatric disorder diagnosis requires careful investigation.  This detective work entails a careful history (discussed in previous articles on this website) and psychiatric examination. The psychiatrist must be a “stickler” for the words our patients use in describing their problem. What one person means by the word “anxiety” or the word “depression” may be quite different from another. So it is essential that words our clarified as carefully as possible to get an accurate picture of what it is like to experience the symptoms described.  Unlike the symptoms of a sluggish thyroid, the symptoms of depressive disorders can vary from patient to patient. The DSM tries to provide some meaning and accuracy to the diagnostic process but it still leaves a lot to be desired. The “art” of this process can often be as important as the “science”.

Therefore, treatment planning requires a true merger of the art and science of our unique field. As discussed in previous articles on this website, developing a treatment plan that identifies the specific goals of psychotherapy and pharmacotherapy becomes essential. In a joint treatment team that involves a psychiatrist and non-MD therapist, coordination between the psychotherapist and psychiatrist may be critical. Our patients need to understand the treatment plan and the specific goals that it addresses while remaining an active participant in treatment planning throughout their course of care.

If you have any questions about this article or need help for mood disorders contact psychiatrist David A Gross in Delray Beach at 561-496-1281 or visit his website athttp://www.davidagrossmd.com