David Goldbloom talks the risks and rewards of psychiatry

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It's estimated that one in five Canadians will experience some form of mental illness each year. Dr. David Goldbloom, senior medical adviser at Toronto's Centre for Addiction and Mental Health, is among the nearly 4,800 licensed psychiatrists in the country devoted to treating such illnesses.

In a new book written with a fellow psychiatrist, Dr. Pier Bryden, Goldbloom offers a frank and engrossing account of what it's like to walk in his shoes. How Can I Help?: A Week in My Life as a Psychiatrist takes readers behind the doors of the country's largest mental-health hospital and chronicles the daily challenges and victories Goldbloom faces when treating patients struggling with psychiatric illness.

As Goldbloom explains to The Globe and Mail, psychiatry isn't so different from other areas of health care.

You mention that psychiatrists are often seen as outliers, even among other health-care professionals. How so?

When I went through medical school, as soon as you declare your interest in becoming a psychiatrist, you deal with disappointment and dismay, be it from your fellow students or teachers, who say, "Why would you do that?" or "Why would you waste your time with that?" And I have to tell you, in the more than 30 years I've been practising, I've never had the feeling I'm wasting my time with patients.

People are judgmental and they look at psychiatry as being not as rooted in the science that permeates the rest of medicine. And the science in psychiatry is in some ways junior, but I think the differences are at times overblown.

We are still hampered in our diagnostic system by not having any biological markers. So mine is a profession without meaningful laboratory tests or X-rays. That being said, the most masterful physicians I was exposed to as a student – in medicine, in pediatrics, in surgery – they got their best clinical information from listening to and examining patients. It was not the laboratory tests that made them master clinicians. It was their ability to listen, to discern the information, to apply their knowledge of disease to the unique circumstances of the individual.

How has psychiatry changed since you began practising?

We have learned better how to use the very powerful drugs we have at our disposal. People have learned to leverage technology better, whether it's televideo outreach to people who live nowhere near a mental-health professional or technology that holds promise now for allowing us to personalize treatment, looking at genetic markers that may help predict who will benefit from what treatment.

But at the core of psychiatry is the relationship between the physician and the patient. And while lots of things change in and around that, the relationship remains a cornerstone of the journey through various treatments and efforts to help a person feel better, and also function better.

You mention that you always try to find something you like about your patients, although you say that's easier with some than others. How might a patient's likeability be affected by his mental illness?

There are times mental illness can bring out the worst in people, in terms of irritability, social withdrawal or behaviour change, or even outright hostility. It can be extremely challenging, not just for physicians, but for family and friends sometimes.

The first thing is recognizing the importance of hanging in to help and support someone. It's also about becoming informed and educated about what is known about their illness so you're in a good position to understand and contextualize what they may be going through.

You note that many families report being turned away by psychiatrists who can't admit patients for treatment until they actually threaten to hurt themselves or others. What is it like turning people away?

It's extraordinarily difficult. None of us who went into medical school or any of the other helping professions went into it with the idea of saying "no" to people seeking help. It's not a comfortable position for anyone to be in. But I don't think it's any different from a surgeon telling a person who can no longer walk on bad knees that it'll be many, many months before those knees can be replaced.

How could that be solved?

I don't think it's any one single thing. Our health-care system originally was designed around the idea of care being centred in hospitals. The reality is most people living with any variety of illnesses are not in hospitals. They're living in the community. But we have not successfully made the transition to community-based options for care that complement the role of hospitals. It's not that I believe we should do away with hospitals. Far from it, but the services that are provided in the hospital should be made maximally available to the people who most need them. Sometimes people end up being in the hospital because there's no realistic alternative for them and their families in the community.

You describe the current fascination with neuroscience as a double-edged sword for psychiatry. Why?

Neuroscience is the final frontier. The brain is our single-most complex organ, so there's huge and understandable excitement. The risk is that the answers that it will generate won't come tomorrow for people who are struggling. Asking them simply to cling to the hope that neuroscience will lead to major advances isn't good enough.

The reality is if we look at drugs that were initially developed in the late 1940s to the early 1960s, for the major mental illnesses, we haven't seen the generation of new drugs that work markedly better than the old ones. They may be better tolerated or have different side effects, but they don't work radically better. And radically better treatments are what we need.

How do you cope when you lose patients to suicide?

I'm hardly unique among psychiatrists, and hardly unique among physicians in that we all take care of people who die of their illnesses. For example, if you had cancer and your oncologist said, "By the way, I should tell you I've never lost a patient to cancer in my career," you'd immediately leave and find another oncologist because that just wouldn't be plausible. And it's similarly impossible in mental health.

What that means is you have colleagues who've been there who can support you. It's a matter of turning to colleagues, family and friends, doing things to honour the memory of the person who died, asking yourself questions about what you did and what you didn't do to understand whether you could have done things differently, and thinking of that in terms of the next person you're going to try to help.

What steps do you take to maintain your own mental health?

Having a close, supportive family has been good for my mental health. Playing squash regularly has been a marvellous, legitimate outlet for aggression. Playing piano regularly is a soothing and transporting event. It certainly transports people right out of my house! And there's humour. Humour, for me, has been an important part of how you cope with life.

This interview has been condensed and edited.