Defining the competent psychiatrist

What defines a competent psychiatrist?  To staunch critics of the field, perhaps nothing.  Some believe psychiatry has done far more harm than good, or has never helped anyone, rendering moot the question of competency.  What defines a competent buffoon?  A skillful brute?  An adroit half-wit?  Having just finished Robert Whitaker's Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America (Crown, 2010), a reader might easily conclude that psychiatric competency is a fool's errand.  From directing dank 19th Century asylums, to psychoanalyzing everyone for nearly anything during much of the 20th Century, to doling out truckloads of questionably effective, often hazardous drugs for the past 35 years, perhaps psychiatry is beyond redemption. Of course, I don't think so.  For one thing, critics often disagree about what is wrong with the field.  For every charge of over-diagnosis and overmedicating, another holds that debilitating disorders are under-recognized and under-treated.  A charge that psychiatry has become too "cookbook" and commodified is answered by the complaint that it is too anecdotal and not sufficiently "evidence-based."  Claims that the field stumbles because it is subtle, complex, and understaffed by well-compensated specialists, are met with counter-claims that checklists in primary care clinics can do most of the heavy lifting at less expense.  Contradictory criticisms offer no evidence that the field is faultless.  But the confusion does suggest that psychiatry's limitations reside at a different level of analysis than that engaged by its critics.

For another thing, the undeniable shortcomings of psychiatry don't make the patients disappear.  Whether the field teems with genius humanitarians or raving witchdoctors, there are still families watching their teenage daughters starving themselves to death; beloved aunts and uncles living unwashed and mumbling to themselves on the street; people ending their lives out of temporary tunnel-vision; tormented souls imprisoned in their homes by irrational fears.  And our society still harbors a nagging ethical sense that a crime is committed only when a person knows what he's doing — and that when he doesn't, he deserves help not punishment.

We can admit that psychiatrists are (at times meddlesome) do-gooders who take on misery and heartache and uncontrolled destructive behavior despite deep controversies over how best to help.  It's the same role filled, in different times and places, by clergy, by family, by shamans, by the village as a whole.  Every society fills it by someone.  This is the modest starting point that bootstraps a meaningful definition of psychiatric competency.

Lists of "core competencies" are issued by the Accreditation Council for Graduate Medical Education (ACGME) for psychiatry residents, and by the American Board of Psychiatry and Neurology (ABPN) for board-certified psychiatrists.  Both organizations categorize psychiatric competency under the six headings established by the ACGME for all medical specialties: Patient Care, Medical Knowledge, Interpersonal and Communications Skills, Practice-Based Learning and Improvement, Professionalism, and Systems Based Practice.  (These categories are also used by the Accreditation Council for Continuing Medical Education [ACCME], so that continuing education required to maintain one's medical license addresses one or more of these competency areas.)  A review of either of these detailed lists reveals two important truths.  First, a committee can make any aspirational standard byzantine and lifeless.  And second, in the eyes of  ACGME and ABPN at least, it's not so easy to be a competent psychiatrist.

However, these official competencies are unlikely to satisfy skeptics, nor do they get to the heart of the matter.  No such list can be exhaustive: the ABPN includes knowledge of transcranial magnetic stimulation, presumably a recent addition, but fails to require knowledge of specific pharmaceuticals.  Focus areas such as addiction, forensic, and geriatric psychiatry are mentioned, but not administrative or community psychiatry.  The linguistic philosopher Ludwig Wittgenstein argues that our inability to precisely define natural categories, even simple nouns like "chair," is a feature of language itself, not of psychiatric competence specifically.  Accordingly, any catalog of psychiatric competencies, whether intended to be comprehensive or a "top ten" list, captures some, but not all, of what constitutes a competent psychiatrist.

As implied above, the starting point, although not the end point, for defining the competent psychiatrist is intent.  A psychiatrist aims to relieve suffering in an uncertain human domain.  Brought to bear are skills, knowledge, and personality factors ("professionalism" etc) which bring this goal closer.  These cannot be listed exhaustively: virtually the whole of human knowledge and experience can inform one's understanding of a patient's emotional turmoil.  The best we can say, I believe, is that a competent psychiatrist is curious, has a wide fund of knowledge and life experience, and aims to keep an open mind.  Some of this knowledge certainly should be biomedical.  But knowing about the psychology of aging, common stressors such as job loss and divorce, gender differences, and many other areas are hardly less important. The practitioner's proclivity to observe the human condition both scientifically and humanistically is ultimately a better gauge of competence than whether a specific treatment modality such as TMS has been added to a long list, or whether the practitioner is able to cough up a specific fact.

Given the controversy and uncertainty in the field, another essential of competent practice is humility.  In most cases we don't know the etiology of what we're treating.  Any treatment we offer helps some patients but not others, and nearly always carries risk.  Whitaker makes many good points along these lines.  A competent psychiatrist tempers his or her urge to intervene with the realization that the road to hell is often paved with good intentions.  Psychiatrists virtually always mean well, and (contrary to some critics) help our patients far more often than not.  Nonetheless, a competent psychiatrist is always ready to admit misjudgment or miscalculation.  Self-correction is a feature of competence in psychiatry as well as in many, perhaps all, other domains of human expertise.

For another take on the competent psychiatrist, arriving at a similar endpoint using different reasoning, see this 2011 post by Dr. Raina.

I wrote above that psychiatry's limitations may reside at a different level of analysis than that engaged by its critics.  Psychiatry is a hard job because the brain is the most complex organ, because normality is so hard to define, because human development is a subtle interplay of nature and nurture, and because we don't understand the root causes of many forms of mental distress.  But even if we did know and understand these far better than we do now, the field would still be fraught with controversy and uncertainty.  Our attitudes regarding responsibility, free will, conformity versus deviance, and how we treat each other reflect our politics and deeply held values.  Psychiatry serves as a lightning rod for strong feelings around these matters.  By its very nature, it always will.  Psychiatrists must accept that many will view us skeptically, some with hatred — and others with undeserved adoration — and not let this dissuade us.  A competent psychiatrist hears criticism from individual patients and the public, neither dismissing it unthinkingly, nor allowing it to lead to demoralization and defeat.

Image courtesy of David Castillo Dominici at FreeDigitalPhotos.net.

Do patients avoid psychiatrists for fear of legal holds?

Over on the Shrink Rap blog I got caught up in an off-topic debate.  The post was on why psychiatrists avoid insurance panels, something I've written about myself.  But the commentary wandered into exorbitant fees, inadequate mental health services for the poor, income disparity between psychiatrists and patients, a generation that expects something for nothing, and so on.  After a week, prompted by minor irritation with San Francisco's transit system the night before, I finally posted a comment.  I wrote that buses and taxicabs perform roughly the same service, but for many riders who can afford it, a cab is worth the extra money.  I acknowledged that the analogy to mental health care was flawed: bus and cab fares are both regulated, and psychiatric care is often more urgent and critical, and definitely more expensive, than an optional ride downtown.  Nonetheless, the comparison made the point that more affordable mental health services are inevitably "bus-like," and that there is a legitimate role for higher-cost "taxi-like" services for those willing and able to pay for them. It's important to realize that all analogies are flawed.  They only highlight certain similarities between two situations.  There will always be differences too, the salience of which are inevitably disputed by partisan debaters.  For this reason analogies illustrate far better than they convince.  One commenter noted that even "bus-like" mental health services are not always available.  A psychiatrist pointed out that many of us accept reduced fees or otherwise "come to some agreement" with cash-strapped patients in ways taxi drivers don't.  Then another commenter who frequently writes about forced psychiatric treatment argued that coercion never occurs with buses or cabs, rendering my analogy "shallow at best."

Going off-topic, I replied that forced treatment, e.g., being subjected to a 72-hour legal hold (the "5150" here in California), is uncommon in office psychiatry, and in any case didn't bear on the point I made.  I later added that a number of non-psychiatrists are also authorized to apply the 5150 in California, and in many instances would be far more likely to do so than a psychiatrist in a private office.  My interlocutor, and at least two others, pressed on: the mere possibility, however remote, of being placed on a legal hold is a threat that evokes fear in current and potential patients.  This fear keeps some who "truly need psychiatric intervention ... from even attempting to access 'help'."

I had already let it drop when our host asked everyone to return to the topic of insurance panels.  But it's a point that bears discussion, here if not there.  Do patients avoid office psychiatrists for fear of being placed on a legal hold?

I'm sure the answer is yes, at least sometimes.  In the first place, many patients do not know what triggers a 5150.  Movies, popular culture (such as the depicted t-shirt), and history itself prime the public to think a padded cell readily follows from a few ill-chosen words.  Often I've reassured patients that ideas or feelings, however destructive or horrific, never in themselves lead to involuntary commitment.  Patients are free to divulge fantasies of mass murder, elaborate suicide scenarios, gruesome torture, etc. without risk of being locked up.  Indeed, talking in confidence about disturbing ideas or feelings is a good way to defuse their emotional power.

But there's much more to this than simply not knowing the law.  In my experience a great many patients fail to distinguish feelings and actions.  They try unsuccessfully to control troubling feelings, and somehow equate this with uncontrolled behavior, a very different thing.  Yet the distinction is hugely important in life, and with regard to legal holds.  Feelings never justify a hold, whereas behavior, or its "probable" likelihood, does.  If this distinction is unclear, even feelings seem dangerous.

At a more subtle level, patients with hostile or self-destructive feelings often expect to be punished for them, or they unconsciously feel guilty, i.e., that they should be punished.  Indeed, people avoid psychotherapists of all types, imagining the therapist will condemn or humiliate them for the ugliness of their inner world.  Unconscious mixed feelings, i.e., simultaneously fearing and seeking a harsh response, are common as well.  A crucial part of dynamic psychotherapy is gradually trusting that the therapist won't fulfill this fantasy.  Seeing a psychiatrist evokes these usual fears of being judged and punished, heightened in some by the psychiatrist's power to diagnose and to initiate a legal hold — even if the risk of the latter is virtually zero.

I hasten to add that we psychiatrists don't make this any easier for ourselves or our patients when we are sloppy about applying legal holds.  Patients' fears of subjectivity and loose criteria are partly based in reality.  A casual "better safe than sorry" attitude may send the wrong message, trampling the treatment alliance and savaging trust.  Meticulous care in applying the 5150 is a "frame issue" as central to therapeutic success as any other treatment boundary.  As a profession we can never count on being afforded more trust than we have earned (and sadly, often less).

Of course, there are circumstances when we rightly apply a legal hold in the office.  A patient who believably voices, or behaviorally telegraphs, intent to die or to kill others should expect a trip to the psychiatric ER for further evaluation in a secure setting.  Conversely, there are presumably people intent on suicide or homicide who consciously avoid seeing psychiatrists who could thwart their plans, just as they avoid telling their family or the local police.  Such people, however, are not seeking psychiatric assistance to avoid dying or killing.  If they were, they would accept help, including inpatient treatment if needed.

I once had a patient who came to see me, he said, so I could convince him not to die.  If I failed, he would kill himself.  I quickly replied that I wouldn't play this game, although I was more than willing to talk with him about his suicidal feelings.  We met five or six times; he wasn't truly interested in overcoming suicidal feelings, and I wouldn't engage in the no-win challenge he set up.  He left — no hold applied — and months later I learned he was still very much alive.

Similarly, those who rail against the completely predictable response of psychiatrists to voiced threats of harm are enacting a "death by cop" scenario.  The paradigm is someone who brandishes a weapon in front of police, who then react the only way they can — and usually with great regret.  Fantasies of punitive authority, forcing the hand of those in power, and/or getting one's just desserts, are made real.  Patients who force their psychiatrists to take control of their behavior likewise sacrifice adult autonomy in order to enact a primitive unconscious fantasy.  Unlike most patients who are relieved to be protected from their own frightening impulses, these few harbor antagonisms that may feel more vital to them than life itself.

Loss of privacy and the new psychic numbing

I grew up in the era of the nuclear arms standoff.  Thousands of warheads on land, at sea, and in planes stood ready to obliterate most of the human race if the Soviets, Americans, or a rogue third nation launched a nuclear "first strike."  Authors of that era wrote of the psychological effects of living under such a threat (not that it is gone now, but it certainly felt different back then).  Some said it rendered life fundamentally meaningless.  Why indulge personal hopes or dreams when we, our community, our entire culture could be gone in an instant?  Psychiatrist Robert Jay Lifton coined the term "psychic numbing" for the denial we employed, individually and collectively, to allow us to live our lives while faced with the real and ever-present risk that our world might end that very day. Psychic numbing was curious yet undeniable.  We all knew the danger was real.  But because the unimaginable horror of World War Three was coupled with an apparent inability to do anything about it, we told ourselves the likelihood was low and somehow pushed it aside.  Instead of being the top priority it arguably should have been, nuclear annihilation lurked like an ominous cloud at the periphery of consciousness.  We and our comedians made nervous jokes about it.  A few idealists joined peace and disarmament groups.  Meanwhile, the rest of us watched warily out of the corner of our eye, weighed down by a pervading fatalism and learned helplessness.

The dynamic of psychic numbing is repeating itself today.  This time it is not the existential risk of nuclear war, but the reality of losing our privacy.  Revelations that our own government monitors our private telephone conversations and tracks our vehicles, allegations that a few years ago would have been waved off as paranoid rantings, are now headline news.  We now know that our email is scrutinized for keywords (and possibly collected and stored in its entirety), and our cellphones are used to track our locations.  Like the nuclear threat of the 1970s, it feels as if we can't do anything about it.  Our discomfort lurks like an ominous cloud at the periphery of consciousness.  We and our comedians make nervous jokes about the NSA.  A few idealists join activist groups to oppose the scrutiny of innocent citizens.  Meanwhile, the rest of us watch warily out of the corner of our eye, weighed down by a pervading fatalism and learned helplessness.

The theft of privacy has been opportunistic and widespread.  The 9/11 terrorist attack justified not only "security theater" at airports, but also a trading away of everyday privacy in the name of national security.  Video cameras monitor public areas in major cities; license plates of highway traffic are scanned en masse and recorded by local and state police; the FBI can activate your laptop's webcam remotely and secretly (with a court order).  Meanwhile, quite apart from national security or law enforcement considerations, internet privacy has become an oxymoron.  The social web, an aspect of Web 2.0, promoted living one's life in full view of "friends" and others.  Facebook and Twitter distribute micro-doses of fame to monetize the formerly private lives of their users.  Younger people post photos of themselves in compromising situations while failing to appreciate the permanence of these images.  Older people use online health and mental health support sites, not realizing their "private" conversations are archived and publicly searchable.  A great many advertisers and others track web activity for commercial purposes, amassing huge databases without users' knowledge or consent.  Whether on actual highways or the quaintly-named information superhighway, the distinction between public and private is quickly eroding away.

Is privacy passé, a luxury we can no longer afford?  Psychic numbing tells us to shrug and bear the new reality.  As many thought 30 or 40 years ago about the nuclear arms race, loss of privacy appears to be the price of living in our modern world.

Don't believe it.  The forces that now seek to strip us of individuality and dignity have always been here.  New technologies present novel challenges, but human nature hasn't changed.  It took decades to realize we weren't forced to live with Mutual Assured Destruction hanging over our heads.  When we overcome our psychic numbing this time, we will re-discover that nervous humor, wary sidelong glances, and helpless fatalism are not effective ways to deal with a real problem.  We will re-discover the value and honor in self-respect.

How to promote nonviolence — (2) Necessary elements

In my last post, I outlined the fundamental problem facing advocates of nonviolence: Despite nearly universal conceptual agreement with this goal, human psychology conspires to make peace elusive and strife apparently unavoidable.  Our emotions trump our rationality, biasing assessments of real-world evidence and leading to post-hoc justification of whatever our "gut" feels.  Unfortunately, and rightly or wrongly, our gut feels scared or mistreated much of the time.  Violence is often the result, whether construed as self-defense or justified retribution.  This occurs with individuals, groups, and nations, and behaviorally ranges from brief verbal expressions of contempt to weapons of mass destruction and genocide. Gut reactions cannot be overcome by rational argument alone.  "Fight or flight" responses to threat, and urges to inflict retribution or punishment, start at the emotional level.  Since it is unrealistic to hope for a world without emotional triggers — without perceived threats that "demand" violent self-defense, or injustice that "demands" violent retribution — those who advocate nonviolence must accept the reality of emotional provocation.  Another reality is that even those who endorse a nonviolent philosophy are saddled with the same emotional reactivity as everyone else.   Given these constraints, how can nonviolence be promoted an emotional level?

Safety

It has often been said that our physiologic response to stress serves us well in situations for which it was originally designed, e.g., an attack by a wild animal, but that it is misplaced in our modern world of "attacks" by time deadlines, career pressures, and miscommunication by loved ones.  Autonomic stress responses — increased pulse and blood pressure, outpouring of stress hormones, faster reaction time —  may save our lives in dire situations, but only hurt and exhaust us when activated chronically and without purpose.  Many effective ways of managing unhealthy stress do so by enhancing feelings of safety and relaxation, emotions that are incompatible with the stress response.

In many respects, violence is similar.  With rare exceptions, it is a reaction to a perceived threat.  It may be said that violence serves us in situations "for which it was originally designed": self-defense against a warring enemy or a criminal intent on killing us.  Yet it only hurts and exhausts us individually and as a species when activated chronically.  Enhancing feelings of safety and relaxation helps us be less violent and more peaceful; conversely, a heightened sense of danger and tension promotes violence.  While dangerous threats exist in the real world, they trigger violence emotionally, not rationally.  Being cut off in traffic may constitute a real physical threat, but our urge to respond with verbal or physical violence arises from a complex stew of imagined contempt by the other, anonymity in our vehicle, an assessment of the likelihood of further escalation, how much we feel they "deserve" it, and similar factors.  Emotional safety is complex and not easily assured.  Yet it is a necessary element in our closest relationships, in our work, in our communities, and on the world stage.  When it is lacking, violence often results.

Humanization of the Other

This is perhaps better stated in the negative: It takes dehumanization to commit violence.  From schoolyard putdowns to racial epithets to "the enemy" in wartime, our thoughts and language serve to make emotionally driven violence acceptable.  It is hard to treat another person as expendable or deserving to suffer while imagining his or her grieving parents or children — so we take pains not to.  Seeing each other as cherished, capable of suffering, and harboring a unique view of the world — in a word, human — is another necessary element for promoting nonviolence.  Without it, people are means to an end, not ends in themselves.

Role Models

Depicted with the prior post was Mahatma Gandhi, the first to apply nonviolent principles to politics on a large scale.  Gandhi's nonviolent philosophy, which he termed satyagraha, would likely have had little influence without his personal actions and role-modeling that led to political change in India and elsewhere.  Gandhi modeled nonviolence working.  Role models such as Gandhi, Martin Luther King, Jr., and Jesus of Nazareth show others a peaceful path by modeling not only behavior, but also emotion: the courage to act according to ideals, without succumbing to fear that might otherwise justify violence.

A similar role model is depicted with this post.  Morihei Ueshiba (often called O Sensei, or Great Teacher) founded the Japanese martial art of aikido.  Based on earlier violent styles, aikido aims to neutralize violent attack while leaving the attacker unharmed.  Aikido's core principle of harmonizing one's physical and spiritual energy with the attacker's would be little more than esoteric philosophy if not for its practical application.  As Gandhi did in politics, Ueshiba modeled nonviolence working, in this case against literal physical attack, and in a manner that can be learned and practiced by others.

Early Learning

Patterns of emotional reactivity are established in early childhood.  While a propensity to violence may be inborn, nonviolent alternatives can be introduced quite early as well.  A society dedicated to nonviolence would teach this in preschool, introducing more sophisticated and challenging scenarios in grade school and beyond.  Such a curriculum would not pretend that the world is a peaceful place.  Maintaining a nonviolent stance in a world that seems to demand the opposite is a lifelong challenge.  All the more reason to start confronting this challenge as soon as possible, ideally before personality is codified and harder to influence.

Practice

It's one thing to aspire to an ideal, quite another to behave accordingly.  There is no substitute for practice, "walking the walk" as well as "talking the talk."  Emotion may trump rationality, but intentional action (and well-chosen cognitions) can shape emotion.  Practicing peaceful conflict resolution may occur in daily life, of course.  But in addition, dedicated training or exercises may be necessary elements.  For example, disciplined participation in nonviolent political action, or in aikido training, may instill peaceful "reflexes" in a way that merely hearing or reading about these practices cannot.

In this post I outlined ways of promoting nonviolence, taking into account emotional and worldly realities.  This list is very general and far from exhaustive, and is offered in the spirit of collaboration and discussion.  Instead of dividing ourselves by tactics — more guns laws or fewer? death penalty or not? — common ground seems a better place to start.  Most of us seek peace, yet most of us share emotions that feed violence.  This makes a peaceful world an elusive yet worthy goal we can work toward together.

Polypharmacy — Sloppy thinking in psychiatry 2

My second post in this series on sloppy thinking in psychiatry is devoted to polypharmacy, the medical term for prescribing multiple medications at once, especially for the same problem.  Polypharmacy is at best a risk thoughtfully taken because nothing simpler and safer will do.  At worst it's a dangerous error, exposing patients to unnecessary hazards purely as a result of laziness and sloppy thinking by their doctors.  Unfortunately, the latter is all too common in psychiatry.  Let's look at why. It has been said that the less we know about an illness, the more treatments we have for it.  Instead of one definitive cure that attacks the root of the problem, various remedies ease symptoms — not the cause — often via different mechanisms.  A good example of a definitive cure is a specific antibiotic to treat a bladder infection.  We know how bacterial infections work, and we have antibiotics to attack the root of the problem.  Ancillary treatments for fever or pain are sometimes used, but they are clearly secondary, and often optional.  In contrast, the pathogenesis of psychiatric disorders is not known, thus we have no treatments to attack the roots of these problems.  For example, antidepressants affect neurotransmitters that appear implicated in depression, but the exact way these neurotransmitters relate to the syndrome of depression is unknown.  Thanks to our ignorance, we have medications that affect serotonin, and others that affect norepinephrine and/or dopamine.  In recent years atypical neuroleptics (antipsychotics) have been approved as add-ons for treating depression, a worrisome development given their risks.

Since we don't have a definitive cure for depression, many patients report partial (or minimal) improvement from any one medication.  The prescriber may then add another on the theory that it may help via a different chemical mechanism — a theory that is difficult to confirm or refute, as we don't know the mechanism in the first place.  The original medication is not stopped: If the patient improves, why disrupt a winning combination?  And if the patient doesn't improve, we wouldn't want to withhold an antidepressant from a depressed person, would we?  Sloppy thinking all around, yet sadly common.

Similar arguments can be made for the treatment of bipolar disorder and schizophrenia.  Lacking a true understanding of pathogenesis, we treat empirically.  And empiric treatment, while often compassionate and necessary and helpful, invites the shaky logic of adding more medications hoping for more empiric benefit.

Compounding and worsening this situation is psychiatry's abandonment of parsimony in diagnosis and clinical assessment over the past 30 years.  Prior to the publication of DSM-III in 1980, psychiatric evaluation was an attempt to explain a patient's seemingly unrelated complaints using a single theory (often psychoanalytic, but possibly biological or even behavioral).  The introduction of phenomenological diagnosis in DSM-III encouraged multiple diagnoses in the same patient, say Major Depression and PTSD on Axis I, and a personality disorder on Axis II.  There was no longer any attempt to tie it all together.  This has encouraged a piecemeal approach to treatment: a medication for depression, a different one for PTSD, maybe something for sleep, and something else again for agitation due to the personality disorder.  That's four different psychiatric medications already, and we've hardly even started.  Patients with personality disorders often complain of "mood swings," so let's add a mood stabilizer like lithium or Depakote.  And they're anxious, so we could add a benzodiazepine tranquilizer like Ativan, or a beta-blocker like propranolol, or an atypical neuroleptic.  Or what the hell, all three!  We're up to seven or eight medications now, and we haven't even considered a stimulant for their ADHD — because, after all, the patient is having trouble concentrating... funny how it was never diagnosed before.  And we haven't augmented the antidepressant with thyroid supplementation, nor have we added a second antidepressant...

While 10+ psychiatric medications is clearly over top, I've evaluated a number of patients who arrive on six, often an (1) antidepressant, (2) mood stabilizer, (3) tranquilizer, (4) sleep aid, (5) stimulant, and (6) another antidepressant or mood stabilizer.  Almost without exception, I've been able to cut this list in half, and in some cases down to zero, or more often, one medication.  It's less a matter of expert medication choice, and more an aversion to sloppy thinking.  According to one study, antipsychotic polypharmacy can be simplified without harm 2/3 of the time.

Psychiatric polypharmacy is often intellectually lazy.  Needless to say, there are far more drug combinations than there are studies assessing the risks and benefits of these combinations.  Polypharmacy is nearly always an educated guess, not "evidence based medicine."  It's not even good single-case research, where one would ideally change a single variable at a time.  All too often, medications are added to treat the side-effects of other medications, as with "ADHD" in the case above, a tail-chasing exercise that only gets worse over time.  With every added medication there are added side-effects, and sometimes adverse interactions that can be more harmful than the original problem.  In my experience, generic side-effects such as weight gain and cloudy thinking are more the rule than the exception in patients taking multiple psychiatric medications.  It should happen a lot less than it does.

Once again, photo courtesy of Petr Kratochvil.