The Magic Flute – on the difficulty of getting diagnosis and treatment right

[Posted on 27 June, 2017 by Anne-Katrin Kantzer]

A few weeks ago I had the privilege of going to see Mozart’s ”The Magic Flute” at the Göteborg Opera in a fascinating production directed by Rikard Bergqvist. My youngest son was a bit disappointed that it failed to deliver on his expectation that the protagonist, prince Tamino, would end up fighting against a huge beast. However, he quickly let it go as he was captivated by the mesmerising dreamscape and the incredibly beautiful music.

The beast was instead represented by a cone-shaped cage of green light that Tamino was imprisoned in. The green light then acted as a recurring symbol, whenever the prince was trapped and astray in thoughts and expectations that he needed to sort out and come to grips with on his own.

For me, the green light evoked thoughts about how easy it is to end up in a state of complete inaction, being trapped in expectations and thoughts, not being able to see the forest for the trees. Working in child and adolescent psychiatric services, children and adolescents come in every day, sometimes by appointment, sometimes urgently, presenting with complex difficulties and a variety of symptoms. The child’s background and living conditions are always factored into our assessment. Schools and/or social services are often involved in one way or another as well: truancy, learning difficulties, concentration problems, challenging behaviours. And there we are, sitting in the cage of green light, not knowing how to figure our way out of all the information that we’ve got.

The child is the one who ends up suffering: health care services commission a comprehensive and thorough investigation, leaving the child waiting for months or even years, all the while getting no help with their difficulties. Either that, or, just as bad, treatment begins without any psychiatric diagnosis or any underlying understanding of what is causing the child’s difficulties. Unfortunately, both schools and social services often simply sit back and wait for child and adolescent psychiatric services to present an evaluation, before considering any further efforts.

Certainly, these are complex problems we’re dealing with. Problems that concern both body and mind, as well as the surrounding environment and cultural aspects. We still don’t have many biological markers to help us find our way in this difficult terrain. But still – must our approaches to care diverge so greatly in psychiatric services from those applied when we treat physical conditions?

Anyone treating physical conditions would ever dream of settling for simply squeezing the child’s belly if they were complaining about a stomach ache. Getting a thorough basic medical history is a matter of course, as is a complete examination of the child. By the same token, those of us who work in child and adolescent psychiatric services cannot be content to simply look for ADHD, or dive straight into treating the eating disorder, without getting a comprehensive overview of the patient. We certainly can’t today, when we have such extensive knowledge about the concept of ESSENCE and how common overlapping and concurrent symptoms are. A broad basic medical history is a prerequisite for providing the patient with effective care. Only then can we interpret the symptoms against the correct background. Only then can we know what it is that we want to concentrate on in a targeted investigation, or what it is we want to treat and how. This saves time, frees up treatment capacity, and cuts down on wait times for examination, by making sure that the issue at hand is clear from the outset.

Back to the treatment of physical conditions: naturally, a patient suffering from acute pain should get pain-relieving medication, even when the cause of the pain is yet to be determined. The headache is treated, and any relevant blood tests or EEG scans can be ordered in the meantime. The same goes for psychiatric patients. Urgent needs can be handled immediately. Some symptoms are clear and should be addressed without much delay. Health care services might for example, in case of an ongoing ADHD investigation, offer parental support and provide educational approaches for handling behavioural difficulties. Patients prone to depression or anxiety should be treated for their depression, while remembering that underlying factors must also be examined eventually. Schools should make adjustments according to the student’s needs (which in most cases have been observed in school and may be what caused the individual to be referred to child and adolescent psychiatric services) even before the child is diagnosed with e.g. autism.

Even physical care might struggle to hit the mark perfectly. If you have a well-founded suspicion that a certain condition is present, you try implementing treatment based on evidence and proven experience. The treatment is then evaluated within a reasonable timeframe, and if it proves ineffective, you have to re-evaluate either the treatment method or the diagnosis itself. The same goes for psychiatry!

It does not have to be any harder than that. Our magic flute to get us out of the green cage is a good, broad basic medical history, with quick intervention efforts for obvious symptoms. Then we will be able to find the way for our patients. Or, as Tamino sings in Bergqvist’s translation: “My magic flute helps me see through all the things that blind me”.

[This is a blog. The purpose of the blog is to provide information and raise awareness concerning important issues. All views and opinions expressed are those of the writer and not necessarily shared by the GNC.]