Asking for professional help

By Alan Koenigsberg, M.D.

I have had many questions about how and when to seek professional help for depression or anxiety conditions.

My short answer is that if the symptoms are acute and severe, seek an evaluation. On the other hand, if the symptoms are not as severe, but over time, clearly cause some form of dysfunction, seek an evaluation.

The second question I get a lot is whom to seek treatment from. My answer to that question depends substantially on what the symptoms are. More often than not, people ask me if they should seek treatment from a psychologist, social worker, therapist, psychiatrist or clergy.

As a physician, my answer to that is almost always to get a thorough evaluation before asking about what kind of treatment is appropriate.

One way to think about this is similar to having any type of physical ailment, such as headaches, for instance. Asking what kind of treatment is appropriate before getting an evaluation and diagnosis just doesn’t make sense to me. They could have tension headaches, migraines, temporal arteritis, allergies, medication side effects and so on.

If a woman of childbearing age experiences a sudden onset of lower belly pain, asking what treatment is appropriate, before knowing the origin of the pain, could be dangerous. It could be caused by a ruptured appendix, twisted ovarian cyst, ectopic pregnancy, kidney stone, diverticulitis, irritable bowel syndrome and on and on.

The same concepts apply for anxiety and depressive disorders. One could be experiencing an anniversary reaction to a lost pregnancy, divorce, death or the onset of a clinical depression.

Anxiety attacks could be the onset of generalized anxiety disorder or too much caffeine or prescription medication as well as withdrawal from prescription medications.

Psychotherapy might be appropriate for some of the above situations, while not so much for others.

In general, I recommend much the same for these conditions as I do for general medical symptoms: Make an appointment with your internist or family physician for an evaluation.

The benefit in having a primary care physician who knows you well and for years becomes apparent in this situation. They know you, your family history and medical history and can generally help rule out the more common general medical conditions that mimic psychiatric symptoms.

They are generally good at diagnosing the common anxiety and depressive disorders, as well as initiating treatment. They will refer to a psychiatrist if the first or second treatments don’t fully work or if there are other complicating issues.

Once the precipitating factors are identified and a clear diagnosis is proposed, various treatment options can be recommended. They might refer one to a psychotherapist, a psychiatrist or both. Older psychiatrists tend to have been trained in both medication treatment and psychotherapy; the younger ones generally focus more on medication treatment and work in collaboration with psychotherapists.

One reason I emphasize a medical evaluation to start is that there are so many biological factors that influence our thinking and behavior that go unrecognized without that evaluation.

I have seen many patients over the years who have low thyroid, drug withdrawals, cancer treatment that dehydrates them, autoimmune diseases with high steroids and so on, which precipitate various psychiatric symptoms. Chronic pain syndromes often precipitate depressive illness, as does diabetes.

I have also worked with patients with poor kidney function who need very low doses of medications, as well as patients with cancer treatment who need high doses of medications in order for the medicine to be absorbed.

There is often a substantial amount of exploration needed to provide optimal care for those conditions which affect our brains.

Alan Koenigsberg, M.D., is a practicing psychiatrist and clinical professor of psychiatry at UTSW Medical School in Dallas. He can be reached at akoenigsberg@mac.com.

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