Checking Up On Mental Health

February 06, 2008
By Dr. Mark Dillen Stitham

Dr. Mark Dillen Stitham

Dr. Mark Dillen Stitham
Adult, Child and Forensic Psychiatrist
Interviewed by Melissa Moniz

What made you decide to sub-specialize in adult, child and forensic psychiatry?

Part of it was interest, of course, but part of it was economics. The thing is, there are about 180 psychiatrists on Oahu. Only about 10 percent of psychiatrists are child psychiatrists, and we have a shortage in the country. Unfortunately, people don’t always bring the kid in, so the need is there but not the demand. And, in fact, I think psychiatrists in general are under-employed of all the specialties because of the stigma of mental illness. But it is changing a little bit now because people are becoming more comfortable with different mood disorders, like depression.

The forensic part I find fascinating. I don’t mind going into court, but a lot of doctors don’t like it at all. Because I did 10 years in radio and 10 years in television, I don’t mind. You have to present the case and tell the story, much as you would do a newscast, and I enjoy that. But I would say 95 percent of the time I’m writing reports, only about 5 percent is actually in the courtroom.

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Is the bulk of your practice forensic work for civil cases?

Yes. But I do have an outpatient practice. I see kids and adults, but I gave up the hospitals back in the ‘80s because I would spend more time on the phone trying to get permission for the patient to stay another 24 hours than I did treating the patient! I was the first doctor at Kahi Mohala, the private psychiatric hospital, in September of 1983. I also used to work for the community mental health centers. So I’ve had a career now here in Hawaii for 28 years, and I’ve done a variety of different aspects. But I enjoy doing clinical work; I don’t like just doing forensic because psychiatry can really help a lot of people. We still don’t know a lot of what’s going on in the brain. It’s been called the most complicated two pounds of matter known in the universe. The thing is that there are a lot of things we can help: Depression can be relieved, schizophrenia can be controlled, panic disorder can be treated. So very rarely does someone come into my office and I can’t help them at all.

How many court cases have you worked on?

I’ve done about 3,000 reports over the last 20 years, and I’ve been in court about 50 times. So the vast majority of the time the courts rely on the reports; it’s more efficient.

For what reasons would you have to appear in court for a case?

The case is usually more complicated and the judge wants to hear the testimony. Most of my work is done in the disability field. So usually, when I do appear, it’s for the Department of Labor. It’s costly and it takes up time, so it’s only the more complicated cases that require me to actually go in.

You mentioned there’s a need for psychiatrists, but the demand isn’t there. Can you explain why that is?

There’s denial, but there’s also poor insurance coverage. In health insurance, psychiatry was the “last hired, first fired.” A lot of people don’t have as good coverage for mental health as for physical. I also think it’s the stigma and the feeling that that’s just the way life is. My competitors are bartenders and hairdressers! Think about it. How many people are spilling their guts to their hair-dressers and bartenders every day, when they should be seeing a psychiatrist? We get a physical checkup a year; I think we should have a mental health checkup. The ancients thought it was the gods that cursed you. I’m not saying everyone should go to see a psychiatrist. I’m just saying there are many who should, who often don’t. It often has to do with socio-economic status, the higher, the more likely they are to go. Or it could be even because of culture. Asian cultures can see seeking mental help as “losing face,” so they don’t come in. Like any disease, the earlier you catch it, the easier it is to treat.

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Are there areas of your field that you don’t like?

Marital therapy: That’s something I don’t like to do mostly because by the time people come it’s often just divorce therapy, and they often have one hand on their packed bag! Couples should come in as soon as they’re having trouble. But it is scary to go and talk to a total stranger. You have to remember that the person is trained and it’s confidential. I’m not plugging psychiatry; I’m plugging people getting help if they need it. If you realize that you’re miserable, there may be something going on and help is out there.

What’s the process in evaluating a patient?

Either they are referred by their family doctor, or directly from the phone book. When they come in, first you spend about an hour and do a complete history, which includes: Why are they there? What symptoms do they have now? Are they on any medications? What is their past treatment? What’s their medical history and then finally their social history? Then you come up with a formulation, a working diagnosis. Sometimes psychological testing is used, but not always. Then you discuss with the patient and tell them: “I think you’re suffering from X,Y, Z and here is my treatment approach I’d recommend.” For many problems, I use a combination of psychotherapy and medication. Not everyone needs medication, but studies have shown that if you use both together, when indicated, you usually get a better response.

What’s interesting is that people seem to think that you come in and lay on the couch, but that’s psychoanalysis. That image is so powerful because that image is still used in movies, television and even cartoons. People see the person lying on the couch. Even though I do have a couch, it’s really for families - no one actually lies down on my couch.

What’s the most common problem for which people see a psychiatrist?

The “common cold” of psychiatry is depression. Depression will affect about 1 in 8 men and 1 in 5 women in their lifetime, so that’s almost an epidemic. People often try to treat themselves by turning to alcohol or drugs. Second most-common would be all the anxiety disorders: phobias (unnatural fears), obsessive-compulsive disorders and others. Less common, but still affecting about 1 percent of the population, is schizophrenia. That’s 3 million Americans. We’ve had a lot of advances and there’s a lot we can do, if only people will seek out the care for it. Most of these conditions can be helped and controlled, and that’s the “take-away” good-news message.