Tuesday, May 14, 2013

Lost in Medication


This piece by psychiatry resident Sarah Mourra appeared in The Atlantic on May 10, 2013.

Begin Excerpt

"In many places psychiatry has become a biological enterprise, with some psychiatrists even introducing themselves as "psychopharmacologists." In no other specialty does a physician define themselves by the medication that they use. As one of my psychiatry professors once commented, "I have never met an oncologist who says "I'm an onco-pharmacologist." Increasingly, we are convinced that medications are what make patients better -- and that if only they would stay on them, if only they would take them as we have prescribed them, if only they were on the right one or the right dose -- they would get better.
In reality the process of getting better is much more complicated. Medications can play a large role, but other factors are enormously important -- environment, sense of purpose and meaning, the person's perception of their illness, and their relationship with the people who treat them. Studies have shown that patients taking placebo who have a good relationship with their psychiatrist have better outcomes than patients taking the active drug who do not have that strong personal connection. In the outpatient setting, a well-trained psychiatrist will follow what's called the biopsychosocial treatment model -- which values the biological, psychological, and social aspects of a person in considering their treatment -- and consider these other parts of the patient's healing process, in addition to medication."

End Excerpt

Let's stop there for a moment. First of all, check out the Results section of the abstract that she linked to (Mckay, Imel, & Wampold, 2006. Psychiatrist effects in the psychopharmacological treatment of depression. Journal of Affective Disorders):

"The proportion of variance in the BDI scores due to medication was 3.4% (p < .05), while the proportion of variance in BDI scores due to psychiatrists was 9.1% (p < .05). The proportion of variance in the HAM-D scores due to medication was 5.9% (p < .05), while the proportion of variance in HAM-D scores due to psychiatrist was 6.7% (p = .053). Therefore, the psychiatrist effects were greater than the treatment effects."
This is data from a randomized double-blind placebo controlled clinical trial of an antidepressant. The psychiatrists were handing out meds to depressed patients, giving placebos to some and active drugs to others. What is stunning to most people is that the degree of your recovery from depression (as measured by BDI and HAM-D scores) was affected more by which psychiatrist you happened to be treated by than whether he or she gave you "real" or "fake" drugs. However, this study (don't you love how we always write, "studies have shown" and then we only cite one study to support our statement?) doesn't say anything about "strong personal connections" between psychiatrists and patients.

For the most part, the patient encounters in this study consisted of the standard "15 minute med checks." Thus there was scant opportunity to build the "strong personal connections" that Dr. Mourra believes were formed, and which she believes explain the findings. But the quality of the "therapeutic alliance" between doctor and patient was not measured in this study. Therefore, it is just as possible that other factors, also not measured by the researchers, played a role, e.g., whether diplomas and certificates were prominently displayed in the doctor's office, whether or not a male psychiatrist wears a tie, the quality of the magazines in the waiting room, etc. You can't just add this study to the ample literature that shows that therapeutic alliance is the most important predictor of psychotherapy outcome (see here, and here, for recent examples).

So, yes, it matters which psychiatrist you happen to see. Some psychiatrists seem to be more effective than others, and their patients tend to do better whether or not the patient is receiving active or placebo medication. But the reason for this is not necessarily because some psychiatrists have formed "strong personal connections" with their patients while others did not. It could be that some of the less effective psychiatrists were non-native English speakers.


"Now do you understand why you stay awake all night, horrified that you are wasting your life?"

Continue Excerpts

"Often under pressure from insurance companies, inpatient psychiatric units experience a tremendous push to medicate patients quickly and discharge them as soon as possible....Often involving numerous rotating caregivers working in shifts, moonlighters, or trainees on one rotation and off to another, patients often complain, "I only saw my doctor for ten minutes!" ....Overpopulated psych units resulting from hospitals trying to keep out of the red often lead to burned out staff members who would rather silence a psychotic, agitated, or complaining patient with medication than sit down and talk to them. ... I remain baffled by the expectation that patients could easily begin the process of recovery from mental illness on most inpatient psychiatric units....These units are designed to keep patients safe and prevent adverse outcomes like a suicide in the hospital or emergency room. However, the therapeutic value of the physical setting is often overlooked as strapped hospital budgets prioritize other needs.

Fed up with the apparent "mill" of psychiatric hospitalization, a process that seemed to lose the person in the cycle of checkboxes and protocols, I wondered out loud to one of my supervisors whether anything like the old asylums existed. Though these institutions had many flaws, it seems as though things have swung too far the other way. The value of fresh air, therapeutic work, and a community of peers seems to have crumbled away in our quest for quicker and faster discharges and a focus on crisis management.


This isn't to say that people don't need to be on medication -- but this psychopharmacological myopia is dangerous in that most psychiatrists of my generation pay lip service to the "psychosocial" part of the biopsychosocial treatment model while failing to put it into practice. This is no fault of our own. I come from a generation of psychiatrists who will never see someone come into a hospital, be taken off all medications, and get better. And for many in my generation, if you don't see it, you won't believe it's possible."

End Excerpts

The often repeated quip is that psychiatry follows the "bio-bio-bio" model, rather than the biopsychosocial model. One of my recent patients was told by her psychiatrist (she came to me because of her dissatisfaction with her medication treatment) that her depression was "100% biological" and could only be treated with medication. I do not doubt that he believes this. Most psychiatric residents don't get much training in psychotherapy (compared to clinical psychologists) and fewer psychiatrists spend much time practicing psychotherapy (44% of psychiatric office visits involved psychotherapy in 1997 versus 29% in 2005; source). This response by Ronald Pies to this rather damning New York Times article seems rather weak to me, in that the type of "psychotherapy" provided by psychiatrists he is talking about seems to involve occassionally listening to patients talk about their lives ("supportive psychotherapy") and not the type of  focused, consistent (e.g., 16-24 weekly 50-minute sessions) psychotherapy that I and most of my clinical psychologist colleagues practice.

In the comments section of The Atlantic article, someone called bystander sums the situation up even better than the author of the article:

"It's a weird moment in science. On the one hand you have physicists proclaiming to have answered the ultimate questions posed by the universe, human spirituality, etc. etc. On the other hand, psychiatry, which should be the application of all that insight to the problem of healing people psychologically, is floundering from what looks from the outside like the obvious blunder of thinking that a human being is nothing more than a mass of chemical reactions and physical processes. (That's what the near-exclusive reliance on medication means, right? If you think a human being is a mass of chemicals, then a psychological problem is a chemistry problem, and a chemistry problem calls for a chemical solution.)

Here's hoping the scientific and medical communities get a does of common sense and humility and realize that the spiritual and psychological sides of human being are far from having been explained, let alone explained away, by science, physics and chemistry, and that some old-fashioned common sense, empathy, emotional contact and yes, spiritual insight would go a long way to correcting this weird and weirdly arrogant imbalance."
I'll let Abe Maslow have the last word:

I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.
  • The Psychology of Science: A Reconnaissance (1966), Ch. 2, p. 15  


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