Sunday, June 5, 2011

Who Needs Psychiatrists?

I have seen a medicine
That's able to breathe life into a stone,
Quicken a rock, and make you dance canary
With spritely fire and motion, whose simple touch
Is powerful to araise King Pippen, nay,
To give great Charlemain a pen in's hand
And write to her a love-line.

All's Well that Ends Well

The criticisms of contemporary psychiatry are coming fast and furious now, and not just from the fringe any more. Cheryl Fuller at Jung at Heart refers to a review by Marcia Angell of three recent anti-psychiatry volumes (of which I have read Daniel Carlat's Unhinged and Robert Whitaker's Anatomy of an Epidemic, but not Irving Kirsch's The Emperor's New Drugs). And while it's not specifically about psychiatry, an American Scholar article by Harriet Washington documents the discouraging corruption of medical research and publishing by so-called Big Pharma.

The mounting charges are of the most serious kind, and warrant a full-on response from the profession (which this blog post does not aspire to be). To very briefly summarize, the basic effectiveness of antidepressant drugs (and to greater or lesser extents, all psychiatric medications) is increasingly dubious as the integrity of research purportedly showing their efficacy is called into question. Critics maintain that for decades (antidepressants came into general use in the 1960's), thousands of psychiatrists (and of course other physicians as well) and millions of patients have prescribed and taken non-therapeutic compounds based on an underestimation of the placebo effect.

As for neurobiology, critics point out, correctly, that there is no evidence for any specific "chemical imbalance" that antidepressants allegedly alleviate. However, this is not the crux of the issue, for other central nervous system agents (e.g. anticonvulsants and anesthetics) have mechanisms of action that remain somewhat mysterious. And depression is in fact correlated with specific neurobiological states, but only because every psychological state--falling in love, undergoing religious conversion--can only be based in the brain. The question is not whether any given psychological phenomenon has a biological correlate (of course it does); the question is whether said phenomenon is best understood and potentially modified in chemical as opposed to other (psychological, interpersonal, social) terms.

It is one thing to claim that antidepressants are overblown and oversold; it is quite another, of course, to claim that they are useless or even pernicious. For instance, Robert Whitaker's arguments can lead only to the conclusion that antidepressant drugs should be expunged from the earth, and that psychiatrists are either unwitting or cynical quacks for prescribing them. And of course, as psychologists and social workers have taken over much of the psychotherapy territory that used to belong to psychiatry, the profession's identity has been ever more given over to psychopharmacology. After all, Freud didn't think psychoanalysts needed to be physicians, and there is no evidence that psychiatrists make better therapists than those with other degrees, so absent real results from biological treatment, why does psychiatry exist, exactly, beyond a function as a research program?

As someone who has, regrettably, long recognized the limitations of existing drugs but who still prescribes them, what do I believe? And can what I believe be remotely legitimate inasmuch as my current livelihood (by no means opulent in doctorate-level terms, but reasonable) depends on these medications having a role? Intellectual honesty demands that if one has a pressing self-interest in believing something, one should subject that belief to fierce and insistent criticism. There is no sin greater than tendentiousness.

This discussion derives from the valorization of the randomized, placebo-controlled trial as the ultimate arbiter of medical outcome, very much at the expense of individual clinical judgment. After all, many hold that clinical judgment is subjective and idiosyncratic, and therefore open to bias and not to be trusted. If all that needs to be known about medications can be inferred from statistical trials, than anyone (such as Whitaker, a journalist) can know more about them than a physician. Indeed, on this view only the non-physician can accurately appraise medical treatments because his view is not warped by self-interest. And yet there is considerable question as to whether patients (or "patients") in rigidly controlled research studies are truly representative of real-world clinical encounters.

What, then, do I believe? I believe, with the Buddhists, that life is suffering (but not only that); the long history of humanity is one of untold miseries of anxiety and depression that were either merely endured (there being no other choice) or compensated for by relationships, religion, art, or alcohol. Like the agonies of even routine childbirth or the ravages of even typical old age, mental disorders have always been part of the human condition; only relatively recently have we tried to modify them. One can make an argument that all of these things should, again, be merely endured, but I don't think history has a rewind button. Yet the expectations regarding mood and anxiety have exceeded all bounds, as has the expectation that one has some right to reach ninety with sound mind and body.

I believe that existing drugs do not counteract specific or discrete physiological processes, but (like psychotherapy) are nonspecific mental balms. SSRI's and benzodiazepines are to mental distress as NSAID's and opiates are to physical distress, that is, they are often disappointing and attended by sometimes dismaying side effects, but millions of patients have found them of some use. I believe that in a modest way they reduce suffering, by no means always or even often, but on average. I believe this on the basis not of research studies, but of my clinical experience and that of many others. And the day I stop believing that is the day I will stop prescribing.


cbtish said...

You understate the charge against the drugs, which is not just that they do not do quite what they claim to do, but that they can greatly prolong and complicate the conditions they claim to treat.

The charge that the drugs are nonspecific is very surprising. Yes, some doctors might sometimes prescribe at random, but that is not the fault of the drugs. I find that when psychotherapy starts to reveal the detail of a patient's condition, it very often informs accurate prescribing that has excellent short-term benefits, allowing psychotherapy to make faster progress.

Psychotherapy is designed to be very specific, although again there are some practitioners who use it in a random and nonspecific way. CBT, for example, is designed to identify and change specific thought processes, not general expectations about mood. Following successful CBT, patients can expect to be just as miserable as the rest of us ;)

Novalis said...

Yes, in some quarters the charges against drugs are dire; I did not say so as explicitly as you have, although I implied it in my reference to Whitaker (according to whom, presumably, there could be no justification for prescribing an antidepressant, ever).

Perhaps it is most accurate to say that our diagnoses are relatively non-specific. When a single drug such as fluoxetine can treat major depression, dysthymia, bulimia, PTSD, social phobia, panic disorder, generalized anxiety disorder, etc. it is obvious that there is overlap. One could say that SSRI's are "specific" for a broader construct such as high neuroticism.

On a fine-grained level, psychotherapy is extremely specific--a good therapist's every facial expression, tone, and comment should be attuned to a particular patient's unique needs. However, on a theoretical level, the general endeavor to challenge dysfunctional cognitive schemas (for example) is no more specific than an SSRI inasmuch as it can be tailored to myriad diagnoses.

Anonymous said...

Good to see you back here sharing miscellany again! As to the topic at hand, medications are useful in that they alleviate suffering enough that the patient can participate meaningfully in his or her psychotherapy. Overall, matters of the soul cannot be resolved chemically or behaviorally.

Rossie // sloughing toward Jungliness