Recently, a psychiatric study on first episodes of psychosis made front-page news. People seemed quite surprised by the finding: that treatment programs that emphasized lower doses of psychotropic drugs, along with individual psychotherapy, family education and a focus on social adaptation, resulted in decreased symptoms and increased wellness.
So begins a thoughtful essay considering the state of psychiatry.
This week’s Reading: “Psychiatry’s Mind-Brian Problem” by Dr. George Makari, which was published recently in The New York Times.
You can find the article here:
In this short essay, Dr. Makari, a professor of psychiatry at Weill Cornell Medical College, opens by contemplating the new American Journal of Psychiatry paper by Dr. John M. Kane et al., which shows that first-episode psychosis patients treated with more than just medications – individual psychotherapy and family education and a focus on social adaptation in the study – did better than those treated with just meds.
The real surprise… was that this was considered so surprising.
He wonders if in our rush to see mental illness as a “brain disease,” we have lost the biopsychosocial model “which acknowledges that, in ways not fully understood, biology, psychology and social forces can all affect mental health.” In this way, he touches on the old joke – psychoanalysts see the world as brain-less; psychopharmacologists see the world as mind-less.
Dr. Makari sees no laughing matter, however.
Unfortunately, such clinical pragmatism has seriously declined in the United States, as psychiatry has veered toward pharmacology. After the emergence of Prozac and the newer antipsychotic drugs like Risperidone some two decades ago, there was a sustained effort by academic research leaders in American psychiatry to promote these successes, and to fight the stigmatization of the mentally ill by forgoing the complexities of the biopsychosocial model for a simpler, more authoritative claim: Mental illness is a brain disease.
This is a concise piece and doesn’t require much explanation.
I highlight, though, a few points:
· Dr. Makari taps history, noting the origins of our field. “Around 1800, Philippe Pinel and Johann Christian Reil founded ‘mental medicine’ and ‘psychiatry,’ respectively. They employed models in which environmental stresses, psychic events and brain functioning were intertwined.”
· He notes the on-going tension, but suggests that the pendulum has swung.
· Indeed, he notes the constraints on NIMH funding (the largest funder of mental health research in the world). “Since 2014, in order to receive the institute’s support, clinical researchers must explicitly focus on a target such as a biomarker or neural circuit.” Dr. Makari wonders if John Kane’s new study – suggesting that people with schizophrenia do better with therapy. But he notes the lack of a biomarker or a neural circuit focus in the paper. Would such work be funded today by NIMH?
A few thoughts:
1. This is a good essay.
2. Psychiatry – like much of medicine – is heavily influenced by “fashion.” In the 1950s, it was fashionable to see everything through the prism of analysis; in more recent years, psychiatry has been reduced – and I choose this word carefully – to biology. Both approaches seem limited, not simply in terms of understanding disease processes, but in terms of understanding our patients.
3. I’ll make the same comment I’ve made before: it’s wonderful for us to embrace more than just medications as clinicians – but it’s also important for us to realize that much of the care our patients receive is restricted to medications. As a psychiatrist working in a community hospital in Toronto’s east end, a first episode program is available to my young patients literally a few minutes away, at the next hospital. And downtown Toronto is rich in thoughtful, biopsychosocial-based programs (in my training, I was fortunate to work with physicians like Drs. Ofer Agid and Andrea Levinson). But many Canadian patients who face schizophrenia don’t have access to individual therapy nor are their families offered the meaningful education that Dr. Kane’s study suggests is so helpful. And, of course, the problems with access aren’t confined to those with schizophrenia. For those suffering from depression and anxiety, CBT has been shown to be as effective as medications for mild and moderate cases – but many Canadians receive only the option of meds (if that). If psychiatry is really more than just brain diseases treated with pills, our public policy has much catching up to do.
Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.