Psychiatry’s Identity Crisis

Psychiatry’s Identity Crisis – The New York Times

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.

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.

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.

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.

The doubling down on basic neuroscience research seems to reflect the premise that if we can unravel the function of the brain, we will have a definitive understanding of the mind and the causes of major psychiatric disorders.

a complete understanding of neurobiology is unlikely to elucidate the complex interactions between genes and the environment that lie at the heart of many mental disorders.

Anyone who thinks otherwise should remember the Decade of the Brain, which ended 15 years ago without yielding a significant clue about the underlying causes of psychiatric illnesses

we now have astounding new techniques for studying the brain, like optogenetics, in which neurons can be controlled by light, allowing researchers to understand how neurons work alone and in networks. But no one thinks breakthrough biological treatments are just around the corner.

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.

There is often no substitute for the self-understanding that comes with therapy. Sure, as a psychiatrist, I can quell a patient’s anxiety, improve mood and clear psychosis with the right medication. But there is no pill — and probably never will be — for any number of painful and disruptive emotional problems we are heir to, like narcissistic rage and paralyzing ambivalence, to name just two.

Anyone who doubts the need for psychotherapy research should consider the case of post-traumatic stress disorder, for which the mainstay of treatment has been exposure therapy.

But we know that many patients with PTSD do not respond to exposure, and many of them find the process emotionally upsetting or intolerable.

Dr. John C. Markowitz, a professor of clinical psychiatry at Columbia University, recently showed for the first time that PTSD is treatable with a psychotherapy that does not involve exposure. Dr. Markowitz and his colleagues randomly assigned a group of patients with PTSD to one of three treatments: prolonged exposure, relaxation therapy and interpersonal psychotherapy, which focuses on patients’ emotional responses to interpersonal relationships and helps them to solve problems and improve these relationships. His federally funded study, published in May’s American Journal of Psychiatry, reported that the response rate to interpersonal therapy (63 percent) was comparable to that of exposure therapy (47 percent).

PTSD is a serious public mental health problem, particularly given the rates of PTSD in our veterans returning from war. This study now gives clinicians a powerful new therapy for this difficult-to-treat disorder. Imagine how many more studies like Dr. Markowitz’s might be possible if the federal funding of psychotherapy research were not so stingy.

 

5 thoughts on “Psychiatry’s Identity Crisis

  1. Pingback: Psychiatry’s Identity Crisis | All Things Chronic

  2. Dave

    During the “decade of the brain”- Dr Lewis Judd, in the American Psychologist in the early 1990’s said ” by the year 2000, we will largely conquer mental illness”. It seems like he was just slightly mistaken. I believ ein the 1990’s psychiatrists were successful in reaffirming their identity as doctors- to do so meant focusing on a biomedical approach to mental illness- in other words they chose to use medications more and psychotherapies more. They did this not for the public good, but to improve their status in the house of medicine. Low and behold, during the past 20 years depression alone has risen rapiudly as a leading source of disability worldwide. The legitimizing myths and system justification of professionals is often a thin veil for ulterior motives- usually involviong greed or status or ego. And that is why i promote populism as a counterforce to the excesses and deficiencies of professions whose mission is to serve themselves and call that the public good.

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    1. Zyp Czyk Post author

      I agree. Most of what goes on in the field of medicine (more like “medical industry”) seems to be financially motivated, even while many individual doctors are not.

      But this is the systemic problem of capitalism, and it’s not going to change anytime soon. We’ll have to find some way of working within this system to enact change, and I do have hope for that.

      Because pain is so common and still has no cure (may never), there is a huge financial incentive to find and develop treatments to help. So far, it seems they are barking up the wrong trees, but the lure of phenomenal profits will keep them working on it.

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  3. Dave

    I agree that we can expect new treatments for pain- but the problem is the “new” treatments reflect the same moral and mental laziness and arent really new, at all. In fact a few yearsago in an offical text book of the American Academy of Pain Medicine they indicated there wouldnt be new drug entitities for pain in the foreseeable future. Nonetheless there are some “new” drug entities being worked on for pain. But these are mostly monotherapies that lack sophistication in terms of multi-objective optimization. So they may target some aspect of pain better then current treatments- but there seems to be no interest in multiobjective optimization in pain care.
    New and improved opioids or gcrp blockers, ligands, ion inhibitors, receptor modulators- thats conceptually the same as we have now. So you see medicine cant get out of their reductionistic simple minded quandary- they’re happy to not break their head open for they can make more than enough money just with the same old dated approach to pain they have been using for decades.Its up to people outside of medicine to call for reforms- but too many ngo’s or advocacy organizations get captured by the medical model-and easily coopted by the biomedical industry- not to mention the biomedical industry pays front groups handsomely for promoting the biomedical industrys views. At a sociopolitical level most people with serious pain conditions are screwed by psychiatry or medicine- but i think individuals in pain can find some help outside of the established medical system.

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    1. Zyp Czyk Post author

      I believe that there are probably various substances that can act as anti-dotes to pain out there in the “natural world”. They’ve co-evolved with humans for millennia and can both cause and cure various ills as they evolved interacting with us. (like venoms, opioids, and marijuana)

      Lately, I have more hope for these substances than I do for manufactured solutions coming out of research labs. And then, there’s the overarching holistic environment that makes it all work together. But in real terms, here and now, I agree the system is looking in the wrong places in the wrong way.

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