one of those people…

Posted on Monday 26 December 2011

Psychiatry: Where are we going?
NIMH: Director’s Blog
by Thomas Insel
June 03, 2011

At the recent annual meeting of the American Psychiatric Association [APA], a talk by Dr. Laura Roberts caught my attention. In her presentation on “living up to our commitments,” Dr. Roberts, the new chair of Psychiatry at Stanford, described a dire situation for psychiatry in 2011. While some of the most disabling and deadly medical problems, neuropsychiatric illnesses, have become the leading source of medical disability in this country, the discipline of psychiatry is often still struggling with issues of stigma, scandal, and self-doubt.

Consider these numbers. While 37.6% of practicing physicians are age 55 or older, in psychiatry nearly 55% are in this age range, ranking as the second oldest group of physicians, surpassed only by preventive medicine. Part of this aging cohort effect is the low rate of medical school graduates choosing psychiatry. Only 4% of US medical school seniors [n = 698] applied for one of the 1097 post-graduate year one training positions in psychiatry. As Dr. Roberts noted, it is troubling that the area of medicine addressing the leading source of medical disability is also facing a shortage of new talent. Indeed, over the past decade the number of psychiatry training programs has fallen [from 186 to 181] and the number of graduates has dropped from 1,142 in 2000 to 985 in 2008. In spite of the national shortage of psychiatrists, especially child psychiatrists, 16 residency training programs did not fill with either U.S. or foreign medical graduates in 2011.

Beyond these numbers, the profession is struggling with its identity, a theme echoed in other plenary talks at the APA meeting. Traditionally, psychiatry has been the medical discipline that cultivates a rich relationship with patients, countering suffering with empathy and understanding. But a recent article in the New York Times reported that only 11% of psychiatrists perform psychotherapy and described a psychiatrist who ran his office “like a bus station,” seeing so many patients for 5 -10 minute medication checks that he had to train himself not to listen to his patient’s problems…

The scientific foundation of psychiatry has shifted from psychoanalysis and is moving to cognitive science and neuroscience. The new generation of academic leaders recognizes the need to integrate these new perspectives with traditional psychodynamic theories, creating new training programs. Some residents in this generation are bringing an extraordinary set of tools and talents to the profession. Imagine a new discipline, clinical neuroscience that brings the best science of brain and behavior to the compassionate care of those with serious mental illnesses. Who would not want to be part of this revolution? What better way to live up to our commitments?
The story can be told in two ways – either as an evolution or as a revolution. There had traditionally been two psychiatrys: psychiatrists who were involved with the instututionalized mentally ill and psychiatrists who saw mentally ill people who lived in the community. Training in a place like Grady hospital in Atlanta where patient’s charts started with the birth records and moved forward throughout life, you could see the history of institutional psychiatry by looking at the edge of the chart. Somewhere near the front of the chart, there was a blue line [blue was the color of the emergency room forms]. There would be  a flurry of emergency room pages in late adolescence for somatic concerns that went nowhere. Then there would be a note that read something like, "Brought by the family. Agitated. Delusional. Hallucinating. Transfer to CSH in AM" [CSH meant Central State Hospital, a facility in Middle Georgia that housed 20,000+ patients at its peak, mainly people with Schizophrenia]. There would then be a gap in time in the record until some time in the 1960s. You can tell this story in two ways: State Hospitals as humane treatment [as opposed to prison], or State Hospitals as snake pits housing society’s undesirables. Whichever way you saw it, it was a huge expense for the State. With the introduction of the antipsychotic medications in 1950s, psychosis became treatable. There had been other treatments: ECT, Insulin Coma therapy, psychosurgery – dramatic treatments that may have ameliorated symptoms but didn’t empty the hospitals. With the antipsychotics, it became possible to get people better enough to leave the hospital – another story that can be told in two ways – a miracle or abandonment. So beginning in the 1960s, the watchwords were The Community Mental Health Movement and Deinstitutionalization. There was a massive Federal Initiative created to manage the formerly institutionalized patients. Since the medications don’t cure anything, the idea was to provide the adjunct services to make community life possible. It was a noble effort, moderately successful, also expensive. I came in at the end of things. The megalithic State Hospitals were essentially closed. The Community Mental Health money was drying up. And so working in a psychiatric emergency room in a charity hospital was a bit like being on the front lines of a war – psychotic people who could only be hospitalized for a short time for stabilization with medications and then back to the streets where there were decreasing resources. By then, the patients were beginning to live as homeless people – migrating to the cities where there were more services and more tolerance. I saw some miracles, but I also saw a lot of abandonment. Then there was the problem of toxicity. Antipsychotic medication is anything but benign, particularly when taken chronically.

The other psychiatry dealt with patients who were less impaired. Some were hospitalized for episodes – suicidal episodes, depressive episodes, manic episodes, episodes of showstopping mental discomfort [anxiety, depression], behavioral episodes. Most were treated as out patients – medications, psychotherapy, etc. When Dr. Insel says, "The scientific foundation of psychiatry has shifted from psychoanalysis …," he’s not being entirely fair. It’s a piece of rhetoric from the earlier era as simplified as that of the people who speak of Deinstitutionalization as a triumph over darkness. Psychoanalysis is something specific, and there aren’t that many psychoanalysts. Never were. What is more accurate is that the dominant form of psychotherapy in American psychiatry [Dynamic Psychotherapy] was heavily influenced by some of the principles of psychoanalysis. It actually arose from the teachings of Adolf Meyer and people like Harry Stack Sullivan who were themselves not analysts. It was a form of psychotherapy that borrowed many psychoanalytic ideas, but actually was a thing unto itself. How do I know that? I did [do] both is how I know [mostly Dynamic Psychotherapy]. What is correct about what Dr. Insel says is that many of the teachers of Dynamic Psychotherapy and leaders in psychiatry were psychoanalysts [although many of the best Dynamic Psychotherapists I’ve known were not psychoanalysts, and no small number weren’t psychiatrists either]. Another part of this story is that in a lot of instances, outpatient psychotherapy is in the range of optional. The joke, "How many psychiatrists does it take to change a light-bulb? One. But the light-bulb has to want to change.", is not totally a joke. The point is that this kind of psychiatry was expensive too – hospitalizations, long therapies. Something did need to be done about that.

Meanwhile, back at the revolution. When I came into psychiatry in the mid-1970s, I knew none of this. I was a science type who had been put into the position of being a practicing doctor and discovered that I not only liked it, it also felt like it was what I was supposed to be doing. I’d become more interested in sick people than the things that made them sick – which was unexpected. I was older than my peers, and the chronicity and the personal nature of mental illness didn’t bother me. I was used to it. It was, in fact, what I was interested in. And I had become a "one person at a time doctor" with little interest in matters of medical policy. By the mid-1980s, I was directing a residency training program, teaching the medical student psychiatry course, about to finish psychoanalytic training, and awaiting the arrival of a new department chairman. But I guess he fit the mold of the "new generation of academic leaders" in "and is moving to cognitive science and neuroscience. The new generation of academic leaders recognizes the need to integrate these new perspectives with traditional psychodynamic theories, creating new training programs." I wasn’t so impressed with the "integrate" part. It felt more like "replace" to me. Later that year, after confusing months I threw in the towel and went into practice – not knowing what was going on. I only knew what I needed to do. I didn’t know I was in the midst of a revolution, but I was. They move quickly, these revolutions. The antipsychotics weren’t the only new drugs to come in the 1950s. There were antianxiety drugs [benzodiazepines] and antidepressants [tricyclics]. I guess what came with the DSM-III was the notion that with a bit of research and discovery, drugs like these could do for the rest of psychiatric illness what the antipsychotics had done for the the psychoses [or what they had wanted them to do]. This new revolution was different from Deinstitutionalization. Deinstitutionalization was based on drugs that actually existed. This revolution was based on wished for future discoveries and  medications, still virtual – so what was talked about was drug research, drug research, and then there was drug research. I could make no sense of it all except that they didn’t want me or what I valued, so by mutual but unspoken agreement, I moved on. When Prozac appeared in 1987 soon followed by its cousins, I guess they thought the longed for drugs had arrived at last – likewise when the Atypicals followed in a few years. My new chairman at Emory became dean shortly after I left and replaced himself with Charlie Nemeroff in 1991. About the same year, Martin Keller became chairman at Brown. Alan Schatzberg took over at Stanford. The same thing happened all over the country – a new breed. And drug research [and promotion] took the spot-light, funding psychiatric departments for two decades in return. The "new generation of academic leaders" had arrived, but you already know that part of the story. So in his June post, Dr. Insel is simple parroting the long-standing dream and battle cry of the revolution that followed the DSM-III and the rise of the pharmaceuticals – "Imagine a new discipline, clinical neuroscience that brings the best science of brain and behavior to the compassionate care of those with serious mental illnesses. Who would not want to be part of this revolution? What better way to live up to our commitments?"

I don’t think Dr. Insel exactly heard the point Dr. Laura Roberts was making in her APA address. She gave the answer to his question "Who would not want to be part of this revolution?" fairly clearly – the medical students who would be the next generation of psychiatrists. That’s who doesn’t want to be a part of his revolution [among others]. She was trying to point out that the now aging "new generation of academic leaders" had tanked psychiatry by making unethical and ill-advised decisions – by trying to create a psychiatry in their own image without the science to back it up. To demand a bigger seat at the table would’ve been fine, but they took the whole table – and that wasn’t a very good idea. Probably, Dr. Insel had trouble hearing Dr. Roberts’ message because he has, himself, been a charter member of that very "[not so] new generation of academic leaders."

That was last summer. In recent speeches and blog posts, he seems to be trying to change his tune a bit…
Antidepressants: A complicated picture
NIMH: Director’s Blog
by Thomas Insel
December 06, 2011

… it is important to remember that optimal treatment for depression does not begin or end with medication. Treating depression is an art that requires many tools. We will not save lives by dismissing any of the tools we currently have available, even as we endeavor to develop better ones. A quality treatment plan for depression includes a thorough assessment, a comprehensive treatment plan that includes choices tailored to and guided by the individual—whether that be medication, psychotherapy or both—and careful, frequent follow-up.
… harkening back to a kind of psychiatry that he helped destroy. But I expect that it’s too late for Tom Insel to be a part of the future directions in psychiatry. Like I said, "They move quickly, these revolutions."

As for me, do I lament deciding to leave internal medicine for psychiatry? Not much. It was a good personal choice for me and I was lucky enough to be able to practice it as I envisioned it. And what about my being on the wrong side of a revolution and leaving a career in academic medicine? No laments there at all. Given the times, I didn’t want to be a part of that version of academic medicine, even then. It was only after I retired and began to look into what had transpired in the background that I began to feel my lamentations. The field of psychiatry I entered apparently had to change to adapt to the world of modern medicine. I didn’t know too much about that back then, half my life ago, but I can see now that it needed to change by evolution – a series of incremental adaptations threading the shoals of the many challenges of the times as they appeared. That’s not at all what happened. It changed by a revolution – masterminded by a particular group of psychiatrists, mediated by the DSM-III revision, ultimately bankrolled by the pharmaceutical industry, and steered by a "new generation of academic leaders" who were surprisingly corrupt – all occurring in stealth. What I feel about what happened? shame. What I feel towards the people that lead us here? betrayed.

Tom Insel is one of those people…
    December 26, 2011 | 8:35 AM

    Outstanding post. And I see that group of “leaders” much as Nero fiddling while Rome burned. There is still so much “mental discomfort” and suffering and so little that truly “works”.

    December 26, 2011 | 9:06 AM

    Always start my morning with Pharmagossip and 1 Boring Old Man. This article jumped out at me, as hubby (a diabetic) and I long ago discussed how ‘lowering’ guidelines would soon place everyone into a pre-disease mode–in need of treatment by the latest, greatest. ( I’d never consciously thought how this applied to the field of psychiatry . . . but when I read your articles about TMAP, etc. where we are medicating earlier and more aggressively, I’d suggest that psychiatry, like other fields, has determined that pre-anydisease is good for pharma, and thus ultimately good for its medical spokespeople. These revolutionaries obviously have seen pre-psychosis, pre-depression, pre-anxiety, pre-*** in every child . Get ’em while they’re young???

    (Hubby was in the ag field, and of your generation, Mickey. He saw similary ‘revolutionary’ activity in academia/BigAg. Like you, he chose another path–and now, looking back, people like me recognize the loss to academia because money supplanted science, truth and integrity.)


    Joel Hassman, MD
    December 27, 2011 | 3:41 PM

    Gee, you think that so few American graduates show an interest in psychiatry and that our colleagues over 55 year old are a new majority group? As a psychiatrist who happens to be interested in clinical care and trying to engage peers to be invested and active in biopsychosocial interpretations, you think this post is trying to kindly say that psychiatry is on life support, and PPACA will pull the plug on the profession by 2016 or so?! And who do we have to thank mostly for this turn of events? Our beloved KOLs, but it doesn’t stand for Key Opinion Leaders for me!

    By the way, I have to ask this question of the author here, is it me, or, were psychiatrists trained before the 1980s took a course in paternalistic attitude that created a mindset that most psychiatrists weren’t just doctors, but mini community leaders that had a near zero tolerance for any type of dissention in the office?

    What is it with much of my older colleagues who treat patients like employees or servants? I do not exaggerate this interpretation at all in writing this.

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