1 Boring Old Man

The American Psychiatric Association Preliminary Scientific Program for the Annual Meeting is on-line, and I was perusing it looking for something specific. I remain awed that the Harvard Master Class Psychopharmacology Course still has veterans from Chuck Grassley’s Senate Investigation [see april fools day – 2016…]. So I was curious to see if they were still prominent on the APA Program as well [that list included Charles Nemeroff, Alan Schatzberg, Joseph Biederman, Timothy Wilens, Thomas Spencer,  Jeffrey Bostic, Martin Keller, John Rush, Karen Dineen Wagner, Melissa Delbello, and Fredrick Goodwin].  At the 2016 APA, Charlie Nemeroff has a session on Personalized Medicine: Depression; Alan Schatzberg has one on the HPA Axis Genetic Variation, Psychosis, and Cognition in Depression and directs the Essential Psychopharmacology Course; and Karen Dineen Wagner leads a session on the Management of Depression in Children and Adolescents. Compared to former years, that’s not much.

But as long as I had the program open and was using find to search the .pdf, I put in some other words. There were two prominent names that were not in the program at all: INSEL and LIEBERMAN. But then I did some how often? word-counting: RDoC 5; DSM-5 13; Borderline 13; Psychodynamic 13; Psychotherapy 14; CBT 21. That’s hardly a scientific study, but it did confirm an impression I had just leafing through the program. At the least, the word psychotherapy appears to be back in the discourse after a prolonged sabbatical. For a very long time, the word psychotherapy primarily appeared in the phrase evidence-based-psychotherapy – which was mostly a synonym for cognitive behavior therapy [CBT] and some of its derivatives – referring to the time-limited, structured psychotherapy originated by Aaron Beck. In the 1970/1980s, there were a number of clinical trials of CBT in depressed patients. The usual design had four groups: placebo, antidepressant, CBT, and CBT+antidepressant. And the usual outcome was that either CBT alone or antidepressant alone beat placebo, but CBT+antidepressant beat all three of the other groups. Psychoanalysis or the the dominant psychiatric psychotherapy of that time, psychodynamic psychotherapy, had no such evidence base and was not considered an evidence-based psychotherapy.

The arrival of the DSM-III in 1980 was not a simple matter. It represented the confluence of more forces than one can even catalog. It solved a lot of problems even as it was compounding others and creating some new ones of its own. That would be expected of something that was such a drastic change, something to work out  in practice by iteration, trial and error, etc. Unfortunately, that’s not what happened, at least not as I saw it then or for that matter, as I see it in retrospect. The affected parties quickly adapted it to their own needs and the landscape underwent rapid fundamental changes. We’re now decades beyond those adaptations, and in another crisis state much like the one that lead to those 1980 changes in the first place. With Dr. Insel, the prophet of Clinical Neuroscience, gone; the failure of the DSM-5 Revision process in bas relief; the slowing of the flow of new drugs from the psychopharmacologic pipeline to a dribble; and the fading prominence of the KOL Psychiatrists; psychiatry appears to be trying to find itself once again – and that process is reflected in the American Psychiatric Association Preliminary Scientific Program – sometimes in extremes. I mentioned the return of psychotherapy, getting psychiatrists back to talking with patients. But to go back to my unscientific-word-counting ways for a minute, Collaborative Care comes in with a word count of 9 – a proposal where psychiatrists don’t even see the patients at all.

from the President

Should Psychotherapy Remain Part of Psychiatry?

PSYCHIATRICNEWS

by Renée Binder,M.D.

January 29, 2016

As we are making huge advances in neuroscience and genomics, the day may come when we can better understand the etiology of mental disorders and devise biologic treatments that target the underlying mechanisms. In one of his blogs, Tom Insel, M.D., immediate past director of the National Institute of Mental Health, wrote about changing the field of psychiatry into the field of clinical neuroscience. I would argue that psychiatrists need to keep the practice of psychotherapy as one of their essential skills, even as the toolbox that psychiatrists use to diagnose and treat our patients will continue to deepen and expand. In the future, as we add modalities for diagnosis and treatment, we also need to improve on existing modalities…

So what is the future of psychotherapy as part of the practice of psychiatry? The 2014 APA resource document titled “Psychotherapy as an Essential Skill of Psychiatrists” states, “Of all mental health practitioners, only psychiatrists are privileged—and able—to provide all therapeutic modalities … and integrated comprehensive treatment.” The position statement on psychotherapy, passed by the Board of Trustees in December 2015, states that APA should advocate for psychiatrists “to be reimbursed by payers in a manner that integrates care and does not provide financial incentives for isolating biological treatments from psychosocial interventions”…

In my opinion, it would be a huge mistake for psychiatrists to give up psychotherapy as one of our essential skills. Other disciplines would gladly provide this treatment instead of us. But we would lose the ability to provide one of our core treatments that are incredibly helpful to our patients. We also would lose the ability to provide one of the most rewarding modalities of psychiatric practice for those of us who chose psychiatry as a specialty because of the ability to develop relationships with patients and understand and treat them as whole human beings. There is a growing but false dichotomy between neuroscientific and psychosocial interventions. We need to advocate for keeping psychotherapy in our toolbox, expanding research on the common elements of psychotherapy, and furthering its use in novel ways in different types of psychiatric conditions.