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Comment by thebean11 | Hacker News Reader

> Psychiatrists are mostly doing medication management because that’s where they’re most effective.

I think it's money: insurance will shell a lot more $/hour if they do 15 minute medication appointments instead of hour therapy + medication appointments.

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Going to dissent here—we need psychiatrists doing medication management because there are so many medications today, and so many previously untreatable conditions which are treatable with modern medications.

If we switched to one-stop therapy + meds, the psychiatrist shortage would be worse.

the problem with this approach is there's not an obvious person to consult with to decide whether to start with therapy, medication, or both. I find that therapists tend to consider themselves unqualified to even suggest that their clients look into medication (or perhaps they are explicitly prohibited from doing so, idk). psychiatrists can either give you drugs or say no, but they tend to offer you something if there's at least a chance it could help.

The problems with this approach are probably even bigger than that, but given they're already stretched this thin and there are years long waiting lists for new patients it will probably be some time before we can really address the more nuanced issues of phychiatry.

This comes back to what I mentioned earlier in the thread that it “requires a shocking amount of initiative on the part of the patient.”

There are also easy and hard paths through the system. If you are motivated to get a diagnosis, you can talk to a psychologist or psychiatrist and get a diagnosis. You can look for a therapist who specializes in those issues. You can take this diagnosis to a psychiatrist and say “I have diagnosis X and symptoms Y.”

If you go into the hospital with a broken leg, you can just check into the hospital and you will come out with a cast and an appointment to have it removed. If you have mental health issues, unless they are severe enough to require hospitalization, you are in charge of your own treatment.

Integrating counselling and medical doctoring is a strange idea, and it's somewhat weird that it's even as much of a thing as it is. Drug-focused psychiatrists are certainly going to be a thing so long as med school is so costly and med schools conspire to keep the supply of doctors low.

Increased secularization is also probably a factor. I presume going to your clergy for assistance was previously more common. I'm sure that kind of care had mixed effectiveness, but suspect it less available and norms are bit different for initiating that kind of conversation.

> Integrating counselling and medical doctoring is a strange idea

Why? It doesn't seem any different to me than surgery + physical therapy for a non-brain-oriented medical problem.

Right, and a surgeon doesn't serve as your physical therapist just like the psychiatrist doesn't serve as your talk therapist. They're different roles, even though they're both addressing the same part of your health.

Under the US system, the surgeon has to press the patient to learn what operation they're going to perform, because the physical therapist / primary care doc / specialist doc isn't paid to communicate with the surgeon, but they're willing to guess the operation if the patient doesn't take great notes.

It's weird even when the medical doctor is trying to alleviate the same symptoms as the counselor? I think the way you put it simply sounds weird because a psychiatrist isn't the first doctor you think of. The concept isn't strange at all, especially considering the huge overlap in training.

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