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Antidepressants

Antidepressants: The Psychiatrist

Psychiatrists usually work with people who have severe or recurrent mental health problems that require medical treatment. GPs may refer to a patient to a psychiatrist if they have taken several courses of antidepressants and have not adequately responded to treatment or if their problems are complex. Psychiatrists sometimes see patients in an out-patient clinic, but more often, they work as part of a mental health team with colleagues from other professions such as nursing, social work, psychology and occupational therapy. Some people pay to see a psychiatrist privately.
 
A referral to a psychiatrist often, but not always, involves the prescription of medication. We talked to some people who were under the care of a psychiatrist, or had been in the past. The amount of contact they had with their psychiatrist varied. Once they began seeing a psychiatrist he or she took responsibility for prescribing, reviewing and altering their medicines. Sonia recalled that once she had been referred to the mental health team that ‘the consultant psychiatrist was the one deciding what medication I took’. Rachel said seeing a psychiatrist wasn’t as it was portrayed in films and TV programmes. ‘Despite what they might show on the television you don’t lie on a couch and have them say, you know, let’s talk about your... the psychiatrist will ask about your symptoms and he’ll then look in his book and see what tablets he can send you away with.’ Although some people said their psychiatrist was concerned with wider issues than prescribing medicines, often people said that appointments were short and largely focused on medication.
 
Sometimes the psychiatrist will prescribe an additional antidepressant such as mirtazapine, or other medicines such as antipsychotics, medicines for anxiety, or a mood stabiliser.
 
(See ‘Other medicines prescribed with an antidepressant).
 

Flora found it helpful seeing a psychiatrist. ‘The best support...

Flora found it helpful seeing a psychiatrist. ‘The best support...

Age at interview: 43
Sex: Female
Age at diagnosis: 21
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In terms of psychiatrists and medical professionals they’ve all been wonderfully kind, supportive, helpful I really, you know, can’t thank them enough because they have, they've been very good. The things that I feel that, where there have been shortfalls is that I feel that GP’s I don’t think know enough about how to support someone with mental health even those with the best of their intentions and so I think that appropriate referrals maybe in the past for me were not made quickly enough and in terms of medication again I think, I don’t know what the answers are for this but the GP’s just get their generic training on what they’re told the latest things are. But I actually feel that the best support that I’ve had and I’ve got has been when I have been referred to a psychiatrist and that’s when we can have in-depth conversations, that’s when I really can find out more about things.
Several people had seen a number of different psychiatrists over time, and had mixed experiences. Like Flora, Hannah had a very difficult time when she was hospitalised, and although she was resistant to taking the medicines her psychiatrist prescribed, she still felt he had been sympathetic and sensitive. ‘I found him really supportive and helpful... I always feel grateful that he was willing to listen to my views’. When she was a teenager Lucy was referred to see a psychiatrist because after taking Prozac (fluoxetine) that had been prescribed by her GP, she had felt progressively worse. The psychiatrist recommended that she should stop taking an antidepressant. ‘At that point I was doing quite badly... I was thinking... you’re leaving me with nothing... I would have thought they’d have more suggestion of what to take’. Now she is older she says she feels more comfortable questioning doctors and more clear about her own needs. Gerry would have liked the psychiatrist he saw to have provided more information about the medicine that he was prescribed. ‘If there was any sort of thing that I would change, I did feel a bit like the specialist just packed me off and said’ right here’s your course’, he didn’t give me any warnings about like you might feel a bit spaced out or you might, he was just like persevere with them I’ll see you again in two weeks’. Others also felt their psychiatrist didn’t listen to them, or had not involved them in decisions about treatment. Several said that when you are experiencing emotional or mental distress it can be difficult to question the authority of a psychiatrist. Some felt that psychiatrists took a paternalistic attitude towards patients and that they were distant or impersonal.
 

Rachel felt the psychiatrist was too focused on diagnosis and...

Rachel felt the psychiatrist was too focused on diagnosis and...

Age at interview: 51
Sex: Female
Age at diagnosis: 11
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The psychiatrist will ask about your symptoms and he’ll then look in his book and see what tablets he can send you away with. I mean I’ve even had where it’s got to quite heated discussions with them, you know, and them trying to do a deal with me like well can we at least put down that if, you will go to the GP and have these, if you feel worse.
 
Do you feel that that’s the sort of, there’s a joint decision making process going on between you and, when you see a psychiatrist or is it more like it’s being done to you?
 
It’s more like being done to me particularly with the psychiatrist because it’s a bit like that thing with consultants in a hospital or whatever, you know, he or she, I’ve always had ‘he’ psychiatrists that you know they’re the sort of the God on high, the head of the tier of the hierarchy and you know just the whole atmosphere. I mean it might, I may be a little biased because I have yet to have a psychiatrist tell me anything that I have found particularly useful in getting better. And that might sound rather arrogant but it’s not, it’s ….I respond much better to people who let me tell them ‘this is how I feel’ it might not go into a little box, some things do I mean obviously there’s but some things are just about how, how you feel and it’s really.
 
It’s very individual isn’t it?
 
Yes and it’s very presumptuous of somebody else, you can have all the training in the world but you’ve got to be able to, instead of trying to fit everybody into a neat little box and, you know and there’s time restrains and everything else they’ve got so many people to see in a certain time and, you know, I get that but there’s not always the time to give people the individual attention that perhaps they’d need.
Janet felt she was not in a position to disagree with the psychiatrist and said she didn’t like ‘to rock the boat’. Michael had always felt ‘the doctor knows best’ and rarely questioned things. Sonia had mixed experiences talking with psychiatrists about her treatment. ‘Out of three psychiatrists that I’ve had only one I felt has actually involved me in kind of any real decisions’.
 

Michael has had good and bad experiences with psychiatrists

Michael has had good and bad experiences with psychiatrists

Age at interview: 72
Sex: Male
Age at diagnosis: 26
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Well, you see, it’s just the luck of the draw which psychiatrist you get for a start and some people have got bad ones and some have got good ones and there’s also, until you get a consultant you get the oh what do you all them the, the junior psychiatrists before they become consultants and they change every six months and I think they were thinking of changing them to every three months, so every time you go you have to tell your whole story all over again and I’d like to see them kept on longer for perhaps a year seeing people.
 
More continuity then?
 
Because every time you see a new one you have to establish a relationship with them, you have to tell your whole story again which is painful because they don't seem to read their notes, you have to tell your whole story every time. And by the time you’ve told your story your sessions almost finished and by the time you’ve got friends with them, where you feel you can trust them or you’ve sussed them out whether you don’t trust them, they’ve gone and you’ve got somebody else. So either people ought to have a longer time to get to consultants earlier and perhaps the other one sitting in but I think there ought to be longer term seeing people, you need time to open up to them, it’s not easy talking about things to people.
 
So one of the things that you would recommend would be its good for people to see the same person?
 
Yes.
 
Continuously.
 
Yeah, yeah once you get a consultant you do that until they’re better or something which I think it’s a lot better but again they, some, as I was saying some psychiatrists just say how are you, I’m feeling alright, you sure you’re alright, still taking those tablets, tablets alright, sleeping, okay, yes, appetite’s alright, okay. I mean you could say okay whether you are or not and they say right see you next week that’s five minutes and you’re gone. And others will say, and some of them won’t even look at you or they’re looking at their watch or just looking at the thing on the screen without even looking at you. Some have got terrible personal skills, interpersonal skills but some are great, some will sit and talk to you and when they say how are you they talk about it and tell me how you feel and how is this. And the ones that remember, you know, how’s your cat getting on or something like that, or has your wife done this or how is your, they’re, they’re the winners ain’t they. But it’s just the luck of the draw.
 
And would you say that over the years then you’ve felt better or worse depending on which kind you’ve seen?
 
Yeah. I mean I had a bad one that lasted for 12 years. Yeah I couldn’t tell him anything, if I said I was ill, he’d up my pills, if I said I was suicidal he’d have put me in hospital, so I just said alright, fine, okay and he said right see you. Or if I said, also he used to say, although sometimes I’d say yes alright, I’m fine and then he’d sometimes say well I think you ought to stay off work, go and see your GP and get a certificate to stay off work, and I’d say alright, no you ought to stay off and so I would but it was hopeless really, he never listened to me never, no conversation all short sharp.
A few people had come into conflict with their psychiatrist. Olivia X had been taken aback by the way the psychiatrist she saw made a diagnosis after seeing her for 10 minutes. She said it was difficult to get her point of view across ‘you’re in an emotionally vulnerable position you’re fragile’. Her refusal to agree to the psychiatrist’s recommendation for treatment caused events that led to her being sectioned.
 

Olivia X disagreed with the diagnosis given by the psychiatrist...

Olivia X disagreed with the diagnosis given by the psychiatrist...

Age at interview: 45
Sex: Female
Age at diagnosis: 40
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I would have liked a proper psychiatric consultation because it was literally within ten minutes he told me I was bipolar. And in fact to say that is a little bit like taking the rug from under your feet because you’re basically saying I think you’re loopy, you know. And I think that’s appalling I think you couldn’t just suddenly say to someone you’re got cancer, you couldn’t suddenly just say, you know, and he didn’t have a check list or anything that he was going through in a methodical manner, it was just purely on my behaviour. Now if he said look I’m going to be judging your behaviour I would have gone in and I could have been as nice as pie and then he would have had no behaviour to judge whatsoever, I just went in very relaxed and myself and a bit over the top probably.
 
And he couldn’t make anything of it so?
 
And he just thought you’re wild… wild equals bipolar, bipolar equal’s olanzapine and lithium.
 
So really within ten minutes or so of speaking to him he was offering you lithium?
 
Yes.
 
Without any other tests or diagnosis?
 
Yes, yes.
For some, referral to the mental health team had occurred at a point of crisis, when they needed urgent care. If someone is considered to be very ill, or a danger to themselves or others, the Mental Health Act 1983 is the law in England and Wales that allows doctors to admit the person to hospital, to be detained and treated without their consent. People can be admitted under different sections of the Mental Health Act, depending on the circumstances, which is why the term ‘sectioned’ is used to describe a compulsory admission to hospital. A psychiatrist is almost always involved in the decision to admit someone to hospital against their will, but cannot do it on his/her own. An approved mental health worker (AMHP) always has to agree that this needs to be done and, in nearly all cases, another independent doctor also needs to agree. Sometimes people said they were wary about telling their psychiatrist how they were really feeling, or if they had stopped taking their medicines, because they worried about the power the psychiatrist had to enforce treatment on them.
 
Although the psychiatrist may decide which antidepressant or other treatment to prescribe, or changes the patient’s dose, he or she notifies the GP to issue the prescription. Some said the system worked well and that they usually received copies of letters that were passed between the GP and psychiatrist, but others worried about a lack of continuity. When Sonia needed to see a doctor urgently because she was feeling very unwell, she couldn’t get an appointment to see the psychiatrist so went to the GP, but he was unwilling to make any decisions or changes to her medicines because he had not prescribed them.
 
Often people who were prescribed antidepressants by a psychiatrist also accessed other services provided by the mental health team, for example time with a psychologist, therapeutic interventions such as CBT, or help from a CPN (Community Psychiatric Nurse).
 
(See also ‘Being prescribed an antidepressant’,Treatment in hospital’, ‘Taking other medicines with antidepressants’, ‘Talking therapies and antidepressants’ and ‘Community Mental health Team’).

Last reviewed June 2016.
​Last updated June 2016.
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