Dr Robert London

‘All or Nothing’ Thinking and Psychiatry

‘All or Nothing’ Thinking and Psychiatry - October 2011

It seems that more and more books and articles in the popular press are being written that are critical of psychiatry. Some critics argue that the medications we prescribe barely work and cause serious side effects. Others characterize the entire profession based on the failure of a few to disclose ties to “Big Pharma.”

One of the most strident voices is that of Dr. Marcia Angell, former editor of the New England Journal of Medicine. In a recent piece, she writes that the pharmaceutical industry formed an alliance with psychiatrists by showering psychiatrists with gifts and free samples, hiring them as consultants, buying them meals, and helping to pay them to attend conferences (The New York Review of Books, July 14, 2011). She also quotes Dr. Daniel J. Carlat, who asks in his recent book: “Why do psychiatrists consistently lead the pack of specialties when it comes to making money from drug companies? Our diagnoses are subjective and expandable, and we have few rational reasons for choosing one treatment over another” (Unhinged: The Trouble With Psychiatry – A Doctor’s Revelations About a Profession in Crisis, New York: Free Press, 2010).

If only our problems were so straightforward. A bit of cognitive-behavioral therapy (CBT) thinking might be in order here. Let’s drop the “all or nothing” set of ideas about psychiatrists and the current state of psychiatric care.

Psychiatry is indeed in a quandary, (as are other areas of medical care) but not solely for the reasons cited by our critics. Besides the issues tied to the pharmaceutical industry, I believe the problems include the move of primary care doctors into the world of prescribing psychiatric medications without proper training; the complexity of one-dimensional medication management within our great and complicated specialty and the failure of psychiatrists to recognize, learn, and use effective cognitive and behavioral treatments.

Psychotropics and Primary Care

We’ve known for years that physicians who are not psychiatrists have been prescribing antidepressants at a high rate. A recent study shows just how extensive this prescribing has been. According to the study, recently published in Health Affairs, between 1996 and 2007, the percentage of doctor visits during which antidepressants were prescribed but no psychiatric diagnosis was noted rose from 59.5% to 72.7% (Health Aff. 2011;30:1434-42).

Disturbingly, many of these primary care physicians have entered the world of mental health treatment without training and are now trying to figure out how to incorporate mental health visits into primary care settings (Fam. Sys. Health 2011;29:144-5). According to this article, the median medical visit is 15.7 minutes, but when you add a psychiatric comorbid mental health problem, the visit increases 3 to 4 minutes. The article further suggests that mental health services, including conditions such as schizophrenia, depression, and anxiety disorders, must be considered part of primary care.

Are they really suggesting an extra 3 to 4 minutes for assessment and additional payment for these disorders rather than a referral to specialist trained for at least 4 years in the branch of medicine that treats mental illness – psychiatry? What they mean is they need an extra 3 to 4 minutes, in a very busy general medical practice, to prescribe, using multiple psychiatric medications. Often times, their only guide is the Patient Health Questionnaire 9 [PHQ 9], Pfizer’s 9-point assessment scale used by nonpsychiatric doctors and their assistants to measure for depression. Do these primary care physicians also do laser surgery for glaucoma – thinking what they need is the mechanical equipment with instructions or arthroplasty for certain arthritis patients? In emergency departments, when a mentally ill or disturbed person is seen, it’s customary to send for the psychiatrist, not the primary care physician – whose extensive years of training and expertise focus on a myriad of physical illnesses.

Complexity of Medication Management

Before the 1950s and meaningful psychiatric medications came to the fore, the state of psychiatric care in this country was abysmal. Patients with serious mental illness faced institutionalization, insulin coma, and electroconvulsive therapy, lobotomies, and many other therapies that in some cases proved dehumanizing – and ineffective.

Today, thanks to advances made by the pharmaceutical industry, medications can improve the quality of life for millions of people, especially in the treatment of infectious diseases, cardiac illnesses, hypertension, GI disorders, rheumatic and metabolic illnesses, allergies, and of course, psychiatric illnesses.

Why, then, do questions about the efficacy of medications for psychiatric disorders continue to persist with such “all or nothing” negativity? Perhaps that’s because some psychiatric medications do, indeed, fall short, as a recent study showed. The study looked at 267 veterans who had been diagnosed with military-related posttraumatic stress disorder who continued to experience symptoms despite taking serotonin reuptake inhibitors (JAMA 2011;306:493-502). About half of the veterans received risperidone as an adjunct, and the other half received an identical-looking placebo. The results? Six-month treatment with risperidone compared with placebo did not reduce PTSD symptoms.

On the other hand, I could cite other studies showing positive results. As Dr. John M. Oldham, president of the American Psychiatric Association, wrote in a letter to the editor in response to Dr. Angell’s critique: “…Missing from her review is an unequivocal if perplexing truth about psychiatric drugs – on the whole they work. Antipsychotics for schizophrenia, stimulants for ADHD, hypnotics for insomnia, benzodiazepines and SSRIs for anxiety disorders – in all these cases, drugs are robustly more effective than placebos in double-blind controlled trials.” Clearly, these medications are far from perfect, and much depends on whose data you want to believe. But that’s not the point.

What is important is the quality of the clinical care. Each patient is different, and monitoring each person is essential. We must ask: Is the patient better? Are the symptoms reduced, or have they remitted? Is there general improvement in the patient’s level of functioning? The problem is not so much the medications, as Dr. Angell points out, but how they are used and who’s using them? That is to say, when one medication after another is added to a patient’s treatment with no therapeutic benefit and the side effect profile proves to be as troubling as the illness itself, we’ve got a problem.

Cognitive-Behavioral Approaches

For years, many psychiatrists have felt like we were out of the mainstream of medicine, partly because of the endless open-ended types of talk therapies that dominated the field for a good part of the 20th century. But, as I repeatedly emphasized in my Psychiatrist’s Toolbox column, cognitive-behavioral therapy, guided imagery, and behavior modification strategies such as my own learning, philosophizing, and action technique work well for certain types of depressions, panic disorders, PTSD, obsessive compulsive disorders, anxiety disorders, insomnia as well as numerous behaviors with psychological origins. Psychiatrists need to know how to use these techniques – not just about them. We also need to be able to create structured treatment programs that can be codified and presented in clear terms to insurers.

The problems facing psychiatry are multidimensional. We must work more closely with primary care doctors and perhaps develop training programs to make them better equipped to prescribe for psychiatric patients if a psychiatric consultation is not available. We must realize that prescribing is not a once-size-fits all proposition. Each patient’s needs must be assessed and each patient’s reactions must be monitored with great care. Finally, psychiatric training programs across the country must support and teach some of the cognitive and behavior modification techniques with proven track records. The support of the major psychiatric organizations such as the APA is necessary to gain traction for these broader-based treatments. Such support would further ensure that psychiatry patients get the best care available – and that the field is able to survive <[QM]>n

Dr. London, a psychiatrist with New York University Langone Medical Center, has no disclosures. He can be reached at cpnews@elsevier.com.