Why Psychiatry Needs Stratification

I had this moment where I felt psychiatry was fake. I started trying to understand why insurance denies so many behavioral health claims and why hospital policies feel so rigid. I am not anti-science; I believe in science. But after 62 days of working as a mental health worker, our current diagnostics and treatment of mental illness just did not seem credible. I watched patients get diagnosed and saw the fact that medications often do not work, forcing a constant cycle of changing them or increasing the dosage.

I was becoming heartbroken. I had come to this field full of optimism that I could use my computational skills to help. Now I was questioning the entire field.

Then, a few weeks ago, I interviewed for an unlicensed psychiatric technician position at a non-profit hospital, and it changed my perspective. Based on the discussion, it seems they are already doing stratification perfectly. Their patients are primarily those considered gravely disabled and those with substance abuse issues. They try not to admit people with developmental disabilities or those who are a danger to self and others. This is not because they would turn them away, but because their focus is specific. They even have a residential facility to discharge some patients to while they look for placement in the community. Their psych beds are bought by the county and the state, but they are not a county hospital.

I was impressed when they described their restraints. They do not do prone positions and mostly use chairs, taking the chair to wherever the patient is having an episode. It just felt more humane. This interview was a refreshing validation. It proved that the hypothesis I was forming in my notebook was not just a theory; it was a practical, working model.

My hypothesis is that we need to do a lot of stratification: social stratification of mental illnesses, chemical abuse stratification of mental illnesses, and then biological stratification of mental illnesses.

My path to this idea was unconventional. I have always been interested in a lot of topics. In high school, I was an art and humanities student against my placement in the science class because I wanted to study law and political economy. I love debating and was deeply analytical. I looked into the Philosophy, Politics, and Economy (PPE) courses at Oxford. I never got to study that; I came to the U.S. to study computer science instead.

This background is why I think I see the floor differently. When I started working the night shift, I found I was always asking questions and trying to find answers as I observed the patients. I started writing on puzzle scratch papers. I realized I was dabbling in both philosophy and psychology, and I bought a small book to write my thoughts in. I was not just observing; I was analyzing the system.

I know I am not a doctor or a nurse practitioner, but I can also argue that I spend more time with the patients than either of them, thanks to the 15-minute rounds and one-to-ones. My job is literally to observe and record behavior. From that vantage point, I see a disconnect.

This is why the current system feels so broken. I have read the Diagnostic and Statistical Manual of Mental Disorders book used for diagnoses, and when I compare the meaning of those labels to the actual behaviors of the patients on the floor, they just do not check out in most cases. The patient's attitude, their culture, and their entire context seem to give different information. The DSM feels like opinions rather than hard research.

So I looked into the history of psychiatry and the DSM, and what I found backed up my hypothesis. The history of psychiatry is barbaric. The development of the DSM itself is problematic and not very scientific. It helps explain why there have not been many breakthroughs in psychiatry for a long time. It is a system built on a flawed foundation.

I also see that mental illness is highly cultural. I see people admitted for behaviors that, back home, would just get them tagged as "stubborn" and never placed in psychiatric care. The baseline for mental illness seems to vary by culture. More than that, I hold a very strong belief that mental illness is in large part based on a lack of strong social support and the state of our socioeconomic system.

This is why "medical" psychiatry feels so limited. The only things close to medical are the medications, the taking of vital signs, and the urine and blood draws, which seem to be mostly for ruling out pregnancy or other physical illnesses before and during admission.

My observations are not just abstract. I cannot disclose every conversation, but a few patients gave me a lot to think about. A patient was having an episode, and staff were trying to call code grey. I decided to try to de-escalate. I just asked them why they thought they were having an episode, and they said this always happens before their menstrual cycle. I told the charge nurse, but they said it was not correct. But I could not say anything back to the nurse, because it is outside my scope of practice.

But I know from being terminally online that it is common for some to make fun of women who say that they think their period is what is making them irritable or do other things that they typically would not do on +234 social spaces. To those banger guys, it was just an excuse. But it is actually a category in the ICD-11 and even the DSM-5. I know this because I have read them from cover to cover, and I know of an organization that is actually dedicated to this fully. In this case, I could not help the patient even though I understood what they were saying. IAPMD has a free tool to help people who have Premenstrual Dysphoric Disorder self-screen. You can check it out here and I will be building a simple tool to allow patients track the symptoms based on the IAPMD resources.

Another patient always cries when they are disoriented. I really want to see what is going on in their brain beyond just saying they have 'delirium' while crying, and I wonder if the tears can be used to diagnose, too, since it seems the patient's response to being disoriented is tears.

I believe neuroscience is our most objective way to address these diagnostic issues, alongside the biopsychosocial element, since we cannot reduce everything with mental illness to just the brain. This is where my unique path comes together. Being a psychiatric technician will give me more stories and allow me to observe patients, but it doesn't pay enough to be a career. I could become a psychiatric nurse practitioner, but the educational training for doctors and nurses is completely different. I think I am sort of doing my residency now as a technician, just without the legal power to diagnose, treat, and prescribe medications. But I lack a lot of medical knowledge, especially neuroanatomy.

I definitely need to go to medical school for that education. I do not just want to be a clinician. I want to contribute to scientific research and build psychiatric technology tools.

That non-profit hospital showed me that better systems are possible. My first step in building them is to use my computational skills. I am building a Python script to scrape a list of psych-approved hospitals in California and see what the patients' reviews are. I cannot possibly go and interview or get a job in every hospital, so this is a good starting point to gather data. I am no longer just questioning the field; I am actively researching how to fix it.