What's killing psychiatry?

Managed-care companies say they're improving the way psychiatrists do business. And psychiatric drugs have never been more effective. Meanwhile, psychiatry itself is becoming extinct.

by Lisa Birk

* Names marked with an asterisk have been changed

Your mother died nine months ago, and you're sad. Really sad. You sleep 14 hours a day, wake up tired. Drink a couple beers before work. It takes three times as long to do the office billing. Your colleagues make comments. You go home, call your managed care company for a referral.

A high school graduate answers, asks your zip code and your problem. You stutter -- this is private stuff, and she's typing it into a computer. You mention your mother died. You don't mention the beer.

"Depression. Eight appointments," she says, and tells you three names to call in your zip code.

The first appointment runs long, 20 minutes. The psychiatrist asks a dozen questions. Eating regularly? Sleeping well? Concentrating? Drug allergies? He doesn't ask about drinking, so you don't mention it. Hey, you can stop anytime you want.

Fifteen minutes later you walk out with a prescription for Prozac. Call if you have diarrhea.

At the next appointment, the doctor asks what "outcomes" you'd like. Better concentration, less sleeping, you say. Together, you decide that meeting those goals will mean success, and that's when you'll stop therapy.

The next six appointments go pretty much the same, except you feel a little better. The doctor asks the same questions; you answer. You never talk about your mom. Or the drinking. There isn't time, and anyway, you don't really know the guy. Are you gonna tell him your most intimate secrets? Besides, he keeps looking at the clock.

The Prozac kicks in after a month or so. Your sleep pattern normalizes, you're quicker at work, and life doesn't seem so bleak. Success, right?

After the last appointment, you feel odd, empty maybe. You can't quite figure out why. Sure, you are quantifiably better (except for the drinking), but you don't feel quite satisfied, quite . . . human. Pills did something to your synapses -- allowed them to absorb more joy, alleviated some symptoms -- but no one has listened. No one has heard about you. Was that therapy? You shrug it off, pick up your last prescription and head home. Maybe have a couple of beers, watch Jeopardy.

Another success for modern psychiatry.

On to part 2

Lisa Birk is a freelance writer living in Cambridge.