Shrink Rap

I think of psychiatry as an art. The art is in determining what a patient's problem is, what will make that patient better, what drug to prescribe, how much to prescribe and what to do if it doesn't work. What I like best about this job is seeing people get better.

Most of what I do is what's called medical psychotherapy. A patient comes in, we talk about what problems he's having, I'll give him a prescription, and he's out in 15 to 20 minutes. That's what most psychiatrists do nowadays. Rarely will you see the old-fashioned analytical treatment, with the psychiatrist nodding, "Uh-huh, mmm-hmm."

There are several reasons for this. Among medical specialties, psychiatry is still treated as second-class. Psychiatry gets only about 50 percent of the Medicare rate, whereas everybody else gets 80 percent. So it's not economically feasible to sit with the patient for an hour. Some medical schools aren't even teaching psychotherapy; they're teaching psycho-pharmacology.

Psychiatry is healthy, though. It's growing with new technologies and new drugs. Drugs are therapy. You can't get people to talk about their conflicts when their minds are racing or if they're hearing voices. When I started as a student in medical school, they had Thorazine and that was all. And they used electroshock therapy because it was the only treatment available.

People think psychiatrists are rich. We're not.

We're one of the lowest-paid specialties in medicine. Some think psychiatrists are all crazy and that's why they went into psychiatry. Most of us are pretty normal. There are a few nuts in every bowl.

Some people don't want us around because they're afraid we can read their minds. And, of course, when a very ill-informed movie star says psychiatry kills, that doesn't help.

I recognize that you can't see someone forever. I get to the diagnosis as quickly as possible. I'm direct. Some psychiatrists will say, "Well, what do you think you ought to do about that?" I'm more likely to say, "You're going to AA or I won't see you."

I've had a private practice in Naples since 1987. In addition to being a general psychiatrist, I'm an addictions specialist and a pain management specialist. As head of psychiatry at Naples Community Hospital, I'm on call 24-7.

The patients I see at the hospital usually come into the emergency room with a psychiatric diagnosis, or they say, "I'm suicidal. Help me." About a quarter to a third of my patients are indigent.

There's no big influx of patients during the season. Most live here. I don't get many wealthy patients. If you're wealthy and crazy, you're just eccentric. If you're middle class or poor and act crazy, you are crazy.

We see a lot of geriatric patients. People come down here to retire. They get to the point sometimes where they're demented or can't care for themselves. Often they're by themselves and are exceedingly lonely. That's heart-rending. Some people die alone at home-they just dehydrate on the floor where they've fallen.

Suicide rates go up as people get older. Women attempt suicide by a ratio of eight-to-one over men. But men succeed at suicide by a ratio of eight-to-one over women.

One of my peers had a patient whose wife was brought in suicidal. Several times at about four in the afternoon she'd take a bunch of pills and lie down in the foyer with the pill bottles around her. The husband would come home and call an ambulance.

The last time she did this, her husband had a flat tire. When he arrived, it was too late. I'm sure she didn't want to die. It definitely was a cry for help.

I knew Nelson Faerber [former Collier County School Board member who killed himself last year while facing charges of child molestation] for many years.

I knew some things about that case that most people don't know. I believe Nelson was innocent. He was depressed, but he was looking forward to proving his case.

Then the newspaper ran a story that tried and convicted him, and I believe that's what pushed him over. He wrote four separate suicide notes and not any of them admitted guilt. Usually suicide notes are the deathbed confession.

We had talked about suicide. But he came to realize that as a good Catholic, it was a mortal sin to kill yourself. I think that's what kept him from doing it earlier. In some people's minds, suicide implied guilt. But not to those who knew him. It wasn't his guilt that drove him; it was embarrassment and degradation.

There are clues, but there is no real predictor of suicide. If someone wants to kill themselves, they will.

I have some patients who become despondent because as they get older they get a lot of pain. I have a chronic pain group. Some of them thought they were the only people in the world going through this. But they came into this group and many have said, "You saved my life."

I feel very close to my patients. Particularly our pain group. It's like a family.