Março de 2020 – Vol. 25 – Nº 3
Walmor J. Piccinini
Pensei e escrevo sobre uma publicação de Allen Frances no Psychiatric Times de 14 de outubro de 2019. Não é novidade o assunto, escrever para jovens. No nosso meio existem várias publicações dirigidas aos jovens, psicólogos, advogados, psiquiatras e terapeutas. Um dos mais conhecidos é o livro do Contardo Caligaris “Cartas a um jovem terapeuta: Reflexões para psicoterapeutas, aspirantes e curiosos”. Um ligeira busca no Google vai mostrar inúmeras publicações semelhantes.
Allen Frances é médico psiquiatra, professor Emérito e ex-chefe do Departamento de Psiquiatria da Universidade Duke e ex-chefe da equipe que redigiu o DSM-4. Ele resolveu publicar seus conselhos sob forma de Twitter o que está bem de acordo com o momento que vivemos. O título é bem interessante “As 50 coisas mais importantes que aprendi em 50 anos estudando psiquiatria”.
Segundo o Wikipedia “Allen Frances, nascido em 1942, é um psiquiatra americano que começou sua carreira na Universidade de Cornell onde se tornou professor. Em 1991 tornou-se chefe do Departamento de Psiquiatria da Universidade de Duke e editor de duas revistas psiquiátricas bem conhecidas; The Journal of Personality Disorder e o Journal os Psychiatric Practice.
Frances presidiu a força-tarefa que produziu a quarta revisão do Manual Diagnóstico e Estatístico de Transtornos Mentais (DSM-IV) e tornou-se crítica à versão atual, DSM-5. Ele alertou que a expansão da psiquiatria está causando uma inflação diagnóstica que está engolindo a normalidade e que o excesso de tratamento do “bem preocupado” está distraindo a atenção da missão central de tratar os doentes mais graves. Em 2013, Frances disse que “o diagnóstico psiquiátrico ainda depende exclusivamente de julgamentos subjetivos falíveis em vez de testes biológicos objetivos”.
Na minha maneira de ver as situações, ele foi criando uma série de atritos com seus colegas e nos últimos tempos se tornou “basagliano”. Sem entrar no mérito das suas posições políticas, vamos examinar seus Twiteres.
Como temos a mesma idade, acho que vivenciamos a psiquiatria e suas transformações nos últimos 60 anos. A propósito de conselhos lembro minhas conversas com meus filhos adolescentes, há mais de 20 anos atrás. Eu terminava dizendo:
“Tem gente que paga para me ouvir e vocês nem de graça”. Parecia que não me ouviam, mas ouviam e agora que seus filhos chegando na adolescência eles se mostram gratos ao que lhes ensinava.
Muitos dos ensinamentos do Allen Frances podem ser encontrados nos “Aforismos de Hipócrates”. Por exemplo:
“A Arte é longa, a vida é breve.”
“Há, verdadeiramente, duas coisas diferentes. Saber e crer que se sabe. A Ciência consiste em saber, em crer que se sabe, está a ignorância”.
“Tudo acontece conforme a natureza”.
“Cura está relacionada ao tempo, às vezes às circunstâncias”.
Voltando ao Allen Frances;”Eis aqui as 50 questões mais importantes que eu aprendi nos meus 50 anos estudando psiquiatria”:
- Your patients will be your best teachers. (Saber ouvir o paciente).
- No meeting with any patient is ever routine for them; so it should never be routine for you.
- Focus on establishing a strong therapeutic alliance and healing relationship—the most important goal of any first session is the patient’s returning for a second. (3ª. Aliança terapêutica é base de todo tratamento)
- Helping serious mental illness is very much harder, but also much more gratifying, than treating mild illness or the worried well.
- Validate that your patients are currently trying to do their best, but also set a tone of future expectations they will find ways to change themselves, and their world, for the better.
- Always inspire realistic hope and always reverse unrealistic demoralization.
- Follow your patient, not your preconceived notions, a supervisor, or a manual.
- There are no bad or boring patients; but there are some bad and boring doctors.
- Be as empathic, as caring, as involved, and as alert for the tenth patient each day as for the first.
10.Never lose sight of the practical struggles the patient faces in the real world and try to help them find practical solutions.
- Don’t be shy about giving advice when advice is needed.
- Don’t give advice when the patient can find their own way.
- Include family, friends, other informants, and potential co-therapists whenever possible.
- Be open ended enough in your questions to let patients tell their life stories; structured enough in your questions to get the specific information you need.
- Try to create rare magic moments—things you say to patients that they will remember always and use in changing their lives.
- Take your time and be careful—small mistakes can have major consequences.
- Know the patient, not just the diagnosis.
- Diagnosis should almost always be written in pencil—especially in the young and the old. Always err on the side of underdiagnosis—it is easy to later up-diagnose; almost impossible to erase a diagnostic error that can haunt the patient for life.
- Use DSM, but don’t worship it. I equally distrust clinicians who do not know DSM and those who only know DSM.
- Educate patients about their symptoms, diagnosis, course, the risks and benefits of plausible treatments.
- Negotiate, don’t dictate, the treatment plan: allow the patient to pick whichever plausible treatment most suits them—with awareness that no one size fits all.
- Do not join the bandwagon of diagnostic fads. Whenever everyone seems to suddenly have a diagnosis, it is surely being way overdone (eg ADHD, autism, bipolar disorder).
- Watchful waiting is the best treatment whenever there is doubt or the symptoms are mild.
- Placebo is best medicine ever invented and responsible for most of what appears to be “drug effect” when milder symptoms improve.
- Severe illness is usually easy to diagnose reliably and always requires urgent intervention.
- Don’t be a careless “pill-pusher,” but do understand the great value of medications used wisely for proper indications.
- Know the risks, not just the benefits, of medications
- Educate your patients on adverse effects, complications, and withdrawal symptoms.
- Be alert to, and try to avoid, drug-drug interactions and include in your consideration all the many non-psychiatric medications the patient is likely to be taking.
- Start low and go slow especially with young and old patients.
- De-prescribing requires much more skill than prescribing—learn it well and apply it often to reduce the harms caused by over-medication.
- Avoid the current tendency toward irrational poly-polypharmacy
- Learn and use three treatments that are very effective, but relatively harder to use and thus very underutilized: lithium, clozapine, and ECT.
- Never meet with drug sales people; ignore all drug company marketing; do not believe any study that was funded by a drug company; and educate patients to be skeptical of direct-to-consumer drug ads that misleadingly promote disease mongering.
- Read the scientific literature with great skepticism and awareness that most studies do not replicate, positive results are always exaggerated, and negative results are usually buried. Do not be wowed by genetic findings—so far, they have flopped in finding causes and have no place in planning treatments.
- Uncertainty sure beats false certainty. Accept its inevitability;’ dont jump to conclusions; and help your patients deal with the anxiety it provokes.
- Learn statistics, especially as it applies to medical decision making, and think probabalistically, not in rigid yes/no categories.
- Have a rich, varied, and satisfying personal life.
- Embark on a personal psychotherapy to help understand yourself better, solve any problems you may have, correct biases based on your personality and experiences, and discover what it is like to be a patient.
- Learn from your supervisors, but don’t follow them slavishly.
- Read widely, especially the great classic novels, and see psychologically astute movies and plays.
- Read history and try to deduce its recurring patterns.
- Travel the world to understand the wide diversity of human experience.
- Do not impose your cultural biases, your religious beliefs (or non-beliefs., or your personal values on your patients).
- For every complex question, there is a simple, reductionistic answer—and it’s wrong. Don’t expect or believe simple answers to complex questions, such as “What causes mental illness and how best to treat it?”
- Instead, do have a well-rounded, four-dimensional bio/psycho/social/spiritual approach to understanding mental disorders and selecting treatments for them.
- Be a vocal advocate for our patients. We must do all in our power to reverse the shameless neglect of the severely ill that has relegated 600,000 of them to jail or homelessness.
- Be yourself—and grow into an even better version of yourself as you enjoy the special privilege of helping others also better themselves.
- FIRST, DO NO HARM!