New York Times
by Richard A. Friedman
Contributing Op-Ed Writer
July 17, 2015
AMERICAN psychiatry is facing a quandary: Despite a vast investment in basic neuroscience research and its rich intellectual promise, we have little to show for it on the treatment front. With few exceptions, every major class of current psychotropic drugs — antidepressants, antipsychotics, anti-anxiety medications — basically targets the same receptors and neurotransmitters in the brain as did their precursors, which were developed in the 1950s and 1960s. Sure, the newer drugs are generally safer and more tolerable than the older ones, but they are no more effective…
At the same time, judging from research funding priorities, it seems that leaders in my field are turning their backs on psychotherapy and psychotherapy research. In 2015, 10 percent of the overall National Institute of Mental Health research funding has been allocated to clinical trials research, of which slightly more than half — a mere 5.4 percent of the whole research allotment — goes to psychotherapy clinical trials research.
As a psychiatrist and psychopharmacologist who loves neuroscience, I find this trend very disturbing. First, psychotherapy has been shown in scores of well-controlled clinical trials to be as effective as psychotropic medication for very common psychiatric illnesses like major depression and anxiety disorders; second, a majority of Americans clearly prefer psychotherapy to taking medication…
Finally, many of our patients have histories of trauma, sexual abuse, the stress of poverty or deprivation. There is obviously no quick biological fix for these complex problems. Still, there has been a steady decline in the number of Americans receiving psychotherapy along with a concomitant increase in the use of psychotropic medication in those who are treated in the outpatient setting. These trends are most likely driven by many factors, including cost and the limited availability that most Americans have to mental health practitioners. It is clearly cheaper and faster to give a pill than deliver psychotherapy…
More fundamentally, the fact that all feelings, thoughts and behavior require brain activity to happen does not mean that the only or best way to change — or understand — them is with medicine. We know, for instance, that not all psychiatric disorders can be adequately treated with biological therapy. Personality disorders, like borderline and narcissistic personality disorders, which are common and can cause impairment and suffering comparable to that of severe depression, are generally poorly responsive to psychotropic drugs, but are very treatable with various types of psychotherapy…
A couple of months ago, I had me something of a rant. It was long overdue for me:
Robert Whitaker got it started in an interview with Bruce Levine:
by Bruce Levine
March 5, 2014
Bruce Levine’s Question: Is it really possible for psychiatry to reform in any meaningful way given their complete embrace of the "medical model of mental illness," their idea that emotional and behavioral problems are caused by a bio-chemical defect of some type? Can they really reform when their profession as a financial enterprise rests on drug prescribing, electroshock and other bio-chemical-electrical treatments? Can psychiatry do anything but pay lip service to a more holistic/integrative view that includes psychological, spiritual, social, cultural and political realities?
Robert Whitaker’s Answer: I think we have to appreciate this fact: any medical specialty has guild interests, meaning that it needs to protect the market value of its treatments. If it is going to abandon one form of treatment, it needs to be able to replace it with another. It can’t change if there is no replacement in the offing. When the APA published DSM-III, it basically ceded talk therapy to psychologists, counselors, social workers and so forth…
It’s not Bob’s fault. He didn’t mean to set me off. He didn’t know that there were a lot of psychiatrists who didn’t sign the mythic Talk Therapy Cession Decree of 1980
, who didn’t sign up for the ‘complete embrace of the "medical model of mental illness," their idea that emotional and behavioral problems are caused by a bio-chemical defect of some type’,
and who had reluctantly left our academic positions, and just continued doing the psychotherapy we had learned to do. And he didn’t know we didn’t need any advice about how to repurpose ourselves [because we didn’t repurpose ourselves back in 1980]. Said Robert Whitaker
… So I don’t believe it will be possible for psychiatry to change unless it identifies a new function that would be marketable, so to speak. Psychiatry needs to identify a change that would be consistent with its interests as a guild. The one faint possibility I see – and this may seem counterintuitive – is for psychiatry to become the profession that provides a critical view of psychiatric drugs. Family doctors do most of the prescribing of psychiatric drugs today, without any real sense of their risks and benefits, and so psychiatrists could stake out a role as being the experts who know how to use the drugs in a very selective, cautious manner, and the experts who know how to incorporate such drug treatment into a holistic, integrated form of care. If the public sees the drugs as quite problematic, as medications that can serve a purpose – but only if prescribed in a very nuanced way – then it will want to turn to physicians who understand well the problems with the drugs and their limitations. That is what I think must happen for psychiatry to change. Psychiatry must see a financial benefit from a proposed change, one consistent with guild interests.
No thanks. Life without a guild is preferable. Of course there wasn’t really any Talk Therapy Cession Decree of 1980. I was just being sarcastic. But that dichotomy actually did arise in those days – the psychotherapy versus the medical model thinking Levine is talking about. Pick one or the other [how about both? or maybe the right one for the patient at hand?]. Jeffrey Lieberman just wrote a book about the horrors of the pre-1980 psychiatry he saved you from – caricaturizing psychiatrists as Freud Clones who had left real medicine for a fairy tale world, charlatans all. And a million times I’ve heard that an interest in psychotherapy doesn’t require a medical education – a wasted four years. But actually, I can’t personally imagine any better preparation than spending one’s life amid and among the suffering people that physicians attend daily. That’s what got me interested in the first place and where I learned much of what I know. And I certainly didn’t shed my medical identity, or for that matter my psychiatric identity. I prescribe medications when I think they are appropriate and might help.
But I’ll stop my rant. This blog isn’t about that old story. This blog is about honesty in science. But I guess it has been so long since someone acknowledged that psychiatrists are physicians who care for the sick, bringing to bear whatever might help – whether biologic, psychologic, sociologic, humanistic, cybernetic, etc. And that for many of our patients, psychotherapy of the kind I learned, practiced, and still practice is exactly what the doctor ordered. As for Whitaker’s thoughts about searching for a marketable skill or some new function. I guess I already have one, so I don’t need to ponder a Collaborative Care environment where I’m asked to be an expert consultant medicating patients I’ve never seen [which to me smells like malpractice].
What I came to say is that I appreciate Dr. Friedman noticing that we’re still around and that what we do fills an important need in the cosmos of care of the sick…