Posts Tagged depression

Cognitive Behavioral Therapy — good thinking

innerthoughtsFinally, a psychological treatment that works!  The first witch doctor probably said the same thing; so, what is different now?  A treatment method called Cognitive Behavioral Therapy (CBT), and it can be administered by an Internet application and it still works!  It’s not dependent on a therapist.  That little fact changes everything — it’s not charisma, it’s science (see reference).

The article cited above is about treatment of insomnia (something that may affect 25% of humans).  But, many other conditions, like depression, also seem to have good results with the method.  In randomized studies, the treatment works as well, sometimes better, than drug treatment (in milder cases).

Mental health problems seem to be divided in two groups: mental problems related to brain dysfunction (most effectively treated with medications) and mental problems occurring with  a normal brain.  This is like the difference between computer hardware problems and computer problems caused by pushing the wrong buttons.  Admittedly it’s sometimes hard to tell the difference and patients can really hurt themselves either way.

So what is CBT?  First consider a dog brain:


Now the human brain:

BED TIME –>  {if I don’t sleep I feel terrible, beer or a cigarette may help, I did not sleep well yesterday, if I don’t sleep for 8 hours I will die, I can’t stand this anxiety} –> NO SLEEP

That human internal conversation is the difference.  And,  the internal conversation can cause problems especially if they come to incorrect conclusions taken as truth.  CBT, with the help of a trained therapist (or sometimes a computer), teaches the patient to critically analyze the internal conversation to avoid behavior which makes the situation worse or behavior which is based on a flawed conclusion .  Unlike traditional psychotherapy this is not a long-term engagement — people learn to do CBT themselves and feel better or sleep better as a result.

CBT is clearly part of quality health care and may reduce the overuse of sedatives and anti-depression drugs.

Click the links:  overview of CBT for insomnia, computer treatment of insomnia and principles of CBT.

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Psychology of Unhappy Doctors — unmet expectations

ocdDoctors are unhappy because the medical world  is not what they expected (or dreamed about).

An essay in the Wall Street Journal today “Why Doctors Are Sick of Their Profession?” describes the feelings of many doctors.   What are those feelings?  What do they mean?

Most physicians cope very well and are quite successful in society.  Clearly, they do not have a psychiatric disorder as a group.  Yet, the WSJ article lists certain symptoms.  These are feelings of:

frustration, failed aspirations, malaise, worthless sacrifice, loss of control, conspiracy of lawmakers and insurance companies, devalued work, and recurrent intrusions of unpleasant thoughts.  Lawyers (the scum of the earth) make more money than they do.  And, oppression is keeping them from doing things the “right way”.

If a patient complains of those symptoms the diagnosis would be: depression with underlying obsessive-compulsive and narcissistic traits.  For doctors it may just be the world is not what they expected when they started 15 years of training.   The job is basically good and it’s too late to start over.

Is money an issue?   If a distraught patient says their anxiety has nothing to do with a “recent divorce” … it really has everything to do with the divorce.  If a doctor say it “has nothing to do with money” … it’s the money.

As a group doctors have a huge capacity for delayed gratification.  They go through difficult years of training by thinking it will get better later — the salary will go up, all the testing will stop, professors will go away, long hours will improve, and no one will question their decisions.  Welcome to the real world:  stagnant salaries, maintenance of certification tests, professors who set evidence based guidelines, long hours and insurance companies that question decisions.

Medical training is mostly to blame.  It’s too long, often unfocused, minimizes teamwork and shuns consistency.  The fight for doctors to follow evidence based guidelines is undermined by the constant drum beat of “cook book medicine”.  In fact, most medical treatment is by the book — a stunning revelation to most.  If physician expectations were better managed during training the dissatisfaction after training would not be an issue.

Many employees find their job the least stressful part of the day.  Stressed physicians need to focus on their job of diagnosis and treatment — it is very rewarding.  Extraneous worries can drive you crazy.

Accountable care organizations reduce physician stress by focusing physicians on the job of taking care of patients while business professionals manage the business.  Perhaps increasing the structure of medical care is the solution for physicians, not the enemy.



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