Questions people have asked me

By Dr. Alan Koenigsberg

Some friends have asked a few questions (edited for space).

1. “Grandparents miss the hugs from their teenage grandchildren that they regularly received when they were younger. What happened?”

Most likely, this is a normal psychological growth pattern during the teen years. Teens are working to develop a sense of self and autonomy, and shy away from behaviors that seem uncool or childlike, so hugging parents or grandparents makes them  uncomfortable. Chances are, when they are older, they will be more self-confident, and once again resume hugging.

2. “I have a hair-trigger temper over small things, not big things. What’s going on?”

It could be physiological, such as people with ADHD have, when they cannot block out repetitive stimuli, and are constantly bombarded with minor stimulations which build up and shorten their fuses. This is a core symptom of ADHD, and is usually effectively remedied with proper treatment.

It could be psychological, as when someone is overwhelmed at home and/or at work or both, and has little reserves. This could be worsened if there are also other stressors, such as sleep deprivation, too much caffeine and so on.

Most often, it’s a blend of both, so some things can be remedied on one’s own, while some benefit from external help.

3. “I’ve read that antidepressants are no more effective than placebos. If that’s true, why are so many antidepressants prescribed?”

No, it’s not true, but it also depends. Here’s the situation: Antidepressants may work well, if prescribed optimally and if used in conjunction with adjunctive treatments, both medications and healthy habits.

Most prescriptions for these medications are written by non-psychiatrist physicians or nurses, and they are not usually using the optimal doses nor using the optimal adjunct treatments. They also have little time to spend with each person.

When it is done optimally, an expert in this field, usually a psychiatrist who takes time with each person, knows what doses to use for each person, maximizes those doses and knows how to use adjunct medications to obtain the best results. In those hands, the remission rates can be closer to 80-90%.

4. “Why do so few, if any, psychiatrists accept insurance or Medicare?”

Excellent question, and here’s my answer. Insurance companies have traditionally reimbursed physicians for performing procedures — such as surgery, colonoscopy, X-rays — not for cognitive care. Given that psychiatry is almost completely a cognitive specialty, reimbursement rates have been notoriously low.

With Medicare, not only does that involve the older population, which means that many of them have multiple medical conditions and require even more care for best treatments; Medicare has cut payments over the years, not increased them.

Alan Koenigsberg, M.D., is a practicing psychiatrist and clinical professor of psychiatry at UTSW Medical School in Dallas.

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