Interviewing a Psychiatrist: Dr. Stonnington

Interview

• Can you start by introducing yourself and tell us a little bit about what you do?

• My name is Cynthia Stonnington. I am a psychiatrist, and I work right now at Mayo Clinic and I have been at Mayo Clinic for almost 18 years. Before that, I was in private practice in psychiatry, and before that I worked for a clinic called Menninger Clinic, so I have done a lot of different things in psychiatry. So from a broad base..all sorts of primary psychiatric problems right now at the Mayo Clinic I am mostly focusing on working with patients with complex medical conditions which is really interesting because it makes you really have to understand that interaction with the brain and body really well. People have all sorts of psychiatric or behavioral problems as a result of medical treatments or their medical illness or they also have a comorbid psychiatric problem that sort of makes it harder to manage their medical illness or have a surgery that causes all sorts of problems. So that’s what I’m focused on right now and I have been for the past 18 years. My sort of special interest within that is neuropsychiatry….really looking at those brain based disorders that affect mood, function, emotions, and cognition.

• What made you want to go into psychiatry?

• So, I love complexity. I love complex systems, and I love trying to figure out how it all fits together. So I think that’s part of it. Psychiatry is..you can't just sort of isolate it to one thing and think you have solved the problem. You have to kind of see it in a system’s place. I love the fact that with psychiatry we get to really know our patients in our deeper sense than pretty much any other speciality which is a total privilege that people can share that emotional life with you and things that really get you to feel like you have a better understanding and can really empathize with the road that people have gone into. So, I went into psychiatry..so let me backup. When I was in medical school, it didn’t even cross my mind that I wanted to be a psychiatrist. I went in, and I was one of those medical students that liked pretty much everything that I went through all the different rotations. I didn’t think I wanted to do surgery mainly because I’m not good with spatial relations; I'm not very good with my hands; I’m not a very dexterous person, and I don’t like getting up super early in the morning...so all of those things out surgery out of it. But after that, what did I want to do? I kind of went through everything, and I gravitated initially to neurology because I do love...fascinated by the brain and I always have been. But at the time I went to medical school, I think neurology there wasn’t a whole lot you could do for patients you could diagnose them but you couldn’t really treat them well..that’s changed thankfully. But at the time I went into medicine, that was the state of the art. I thought that would be depressing, then I became interested in development and the impact of development and all the different things that happen when you grow up. I thought I wanted to be a pediatrician, and then I thought no it would get bogged down with just the...idk it didn’t bring me back to the level of the brain. Finally, it was like duh, psychiatry. I went into psychiatry, thinking I wanted to be a child psychiatrist. But I didn't actually go that step, I stayed with adults because as much as I like complexity, I thought that at the time the systems you have to interact with as a psychiatrist have to do with the family, having to do with schools, and society. In addition to what is going on in the system,s and the brain, that was too hard for me. I figured I would stay with the systems in the brain and the body.

• Can you maybe share an interesting experience that you have had with a patient?

• Wow there’s so many different things… Well, one that comes to mind is a patient who I saw when I was in my private practice -- I’ve got so many stories I can’t even figure out which one’s a good one to tell. But anyways, a patient that I saw years ago in my private practice who had a lot of early traumas, difficulties in her early life and family life and she came in with pretty significant depression and anxiety and relationship issues and stuff and she came in really disillusioned that maybe she could ever kinda break through that. I got her to really focus on what was important for her and what she wanted to achieve and we kinda set about helping her achieve what she asked for. So within a couple years she had gotten some medication that really helped her with depression and anxiety, we dealt with psychotherapy to help manage some of the issues in relationships, and she was able to get married. She said she wanted to have kids but she was on these medications but we kept her on the medications because it was too dangerous in terms of the level of her depression to go off of them and she ended up having three kids who were totally healthy despite being on those medications and she basically achieved those things and it was such a joy to work with somebody closely and have that partnership together. We figured out what she wanted and needed and we navigated how to make it happen. So that was when I was in private practice, that’s years ago, every year on Christmas day I get a card from her just showing me that she’s still got her family. 25 years later I still get these yearly cards just a reminder that she’s still living what she set out for. I think that was very satisfying.

• How do you think hearing about other people’s mental health affects your mental health?

• I think you have to really set boundaries and make sure to prioritize your own self care in order to make sure it doesn’t impact my mental health negatively. How it helps me in my mental health would be what I said earlier -- would be the capacity to empathize with people of all types and to really feel like I can focus in on what it is that their struggles are. If I were to feel like I am the only one that can help them or if I had multiple very difficult complex patients within one day then it would really wear me down. It can be very difficult because when somebody has mental health problems it trumps everything else. Their quality of life is terrible if they are not mentally able to function in a way oftentimes so you do feel that sense of responsibility and when you are in it alone or you feel like you don’t have the space to recover or center yourself then it can really negatively affect you. I have learned just over the years that I have to be able to set limits with how many very very difficult patients I might see in a day or have some grace in terms of the limits of what I can do. But also try to be really empathetic but not feel like I have to be the only person to fix the situation. And also to recognize my own feelings so that I can manage them. The hardest thing I think in psychiatry would be working with people who are not willing to partner with you and do their part to make progress. If you take on the full burden of fixing everything and the patient themselves doesn’t really do what they have to do to make gains. That’s very draining, and so recognizing that and making allowances for that is critical.

• Do you think there has been an increasing focus on mental health that may help people in general?

• Just recently I’d say. It’s been terrible the kind of stigma that people with mental health have had to deal with-- and they still do. Recently I think we’ve made progress in terms of people, and particularly the younger generation is being very open about if they are struggling to say ‘yes I need help’ and not have that sense of shame about it which is great. I think we are learning from the younger generation that way, but it very much helps when people tell their story and there are so many surprising stories that you see when they do that. When people do you think ‘oh my gosh they’ve never even had to deal with anything then all of a sudden they’re there feeling like they have a lot of struggles.’ That is a huge huge barrier not just that makes it harder for patients to do their part, to partner with you because of the sense of shame that they often feel about even being in the room or having to deal with it. So we still have a lot of work to do there but we are making progress. I think the pandemic in a way has helped because so many people have been suffering as a result of that and it’s become very clear and obviously it’s a very common struggle and it’s not like you can just say ‘oh that’s not me.’ Pretty much everybody really in one way or another has had to deal with something so that allows you to start to realize that this is a shared experience and that makes it easy.

• How do you diagnose patients?

  • The most important thing is being able to have a little bit of space to have a person tell their story. So you want to first ask them what it is that led them there? We have a system of diagnostic criteria for different illnesses that we may end up asking after you hear the story and heard what you need, you ask very specific questions that might make it clearer about symptoms that they are experiencing now or in the past and you want to put it in the context always of their entire life so you can start to build a story if they have had ongoing ups and downs with varying symptoms whether related to depression, anxiety, psychosis, or whatever the issue might be. Once you start hearing what is starting to happen then you start to list off questions that might help to better characterize whether what you’re seeing is one diagnostic category or another. You want to make sure you get a strong history also then focus on early life events and social history and some of those social determinants of health that really are important that may be driving some of the symptoms. And then you want to make sure you’re good at assessment for how their thinking is in terms of cognitive abilities depending on the situation. After you’ve gotten the sense of symptom clusters, then you wanna put it back into my “medical hat” and try to do really good work to say if this symptom cluster comes from a medical condition, like a thyroid problem or a liver problem. You want to figure out ‘do I need to do any additional labs or imaging or other things that might help us decide if the main issue is related to a medical or neurological problem, or is it more likely to be one of the psychiatric disorders.’ I think then you don’t want to just stop there you do need to always, like I say, think about it in a system sort of approach, you wanna sort of understand what are some of the biological factors, maybe somebody has a strong genetic family history, what are some of the social things that are driving symptoms, what are the psychological issues that people might be experiencing, maybe their personality structure, their tendency to have psychological responses to things. You wanna kinda put it all into that biopsychosocial formulation and then that will inform the best way to go about treating. You don’t wanna just shortcut it and just say ‘oh you have this symptom that fits in this and you have bipolar disorder and therefore we just give you that medication.’ Anyone can do that and that’s not really helpful. Unfortunately you see that happen too often. I think you have to really think about it in that systems approach. The one thing we’re missing in psychiatry, although we’re getting closer, is really having good biological diagnostic criteria to understand some of those reductionistic factors from a biology point of view that might be driving symptoms, so we do have to use them. There was a strong art in making the diagnosis, but as long as you’ve captured some evidence and good evidence-based screening tools and adequate history I think usually you can do pretty well in making an accurate diagnosis.

• I understand that the criteria for diagnosing different disorders changes very frequently, so could you tell us about how you dealt with that and your experiences regarding that?

  • I wouldn’t say super frequently but it does change over the years. I’ve been practicing psychiatry since 1986 so over the course of that time I think it’s changed. Probably about four times at most; I think these are guidelines that are helpful to create a sense of the symptoms but it’s not like the be all end all so I never thought that. The reason that those criteria have changed a little bit over time has to do with really trying to take a more rigorous evidence-based approach so over time when they first put it together they maybe didn’t have the best approach but over time they’ve started to look at whether or not these symptoms do fall together appropriately and there’s been more and more push, although we haven’t gotten there yet like I said to really have it be more from a not just a symptom cluster point of view but more of an underlying causal point of view, so looking at what are the actual drivers biologically and otherwise of the symptoms but as you can see in psychiatry it’s not so helpful so that’ll be a while before we actually get there but I think we’re moving closer to that. I take it as not to be the end all, I always have a healthy skepticism about the limitations of what every system I’m working in right now and realize it’s probably going to get better with change over time, but you try to just do the best you can in that framework. And quite frankly, the fact that we haven’t improved that much in terms of treatment suggests that there’s a-- understanding some of those intangibles are critical in developing a good doctor-patient relationship and empowering patients to do as much as they can on their own are still always going to be an important piece for psychiatry because there is so much beyond just the biologic things that are going on that can help drive or overwhelm people with those symptoms. I do think that it’s good that it’s changed over time and I’m hoping that with each iteration we’ll do better.

• Do you have any general advice for people who may be struggling with their mental health?

  • Number one: don’t suffer in silence. Ask for help, reach out to trusted family and friends for support. Number one, that's huge. Number two: remember that mental health conditions, even though we don’t fully understand everything about it, we’re still very successful in relieving symptoms, people do get better. It’s like the mirror image of what I told you about in neurology when we were very precise. You can precisely diagnose but couldn’t really help. We don’t precisely diagnose but we actually can help so that’s the good news. I think we need to recognize that even though it’s an imprecise science, the treatments work. You have to hang in there, get that support, reach out and recognize. I have multiple stories of people who came completely not functioning and are now functioning at these very high levels because they did avail themselves of treatment. It’s exciting that we can do that despite, like I said, the imprecision.