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.
With few exceptions, every major class of current psychotropic drugs — antidepressants, antipsychotics, anti-anxiety medications — basically targets the same receptors and neurotransmitters in the brain as did their precursors, which were developed in the 1950s and 1960s.
Sure, the newer drugs are generally safer and more tolerable than the older ones, but they are no more effective.
So begins this week’s Reading, which considers the state of psychiatry, and psychiatric research funding.
Here’s a quick summary: the author suggests that the neuroscience revolution is something of a bust and that psychotherapies are worthy of more study and use. This may seem like a strong argument. And it is – particularly given the bias of the author, who is, by his own description: “a psychiatrist and psychopharmacologist who loves neuroscience.”
This week’s Reading: “Psychiatry’s Identity Crisis” by Weill Cornell Medical College’s Richard A. Friedman was recently published by The New York Times.
The article can be found here:
Let me highlight a few points raised by Dr. Friedman.
· While psychotherapy has been shown to be as effective as medications for “very common psychiatric conditions” and is the preference of the majority of Americans (over meds).
· Dr. Friedman suggests that relatively fewer Americans are getting psychotherapy as part of their treatment.
· Just as importantly, psychotherapy research is a low priority in terms of psychiatric 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.”
He goes on to argue that:
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…
Even if this premise were true — and many would consider it reductionist and simplistic — an undertaking as ambitious as unraveling the function of the brain would most likely take many years. Moreover, 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.
Citing successes like exposure therapy in PTSD, Dr. Friedman suggests that a research investment in psychotherapies is overdue.
A few thoughts:
1. This is a well argued piece.
2. Research into neuroscience doesn’t necessarily translate into treatment of psychiatric conditions – at least in the short term. That said, Dr. Friedman’s point about the effectiveness of treatments is true, as is the lack of truly novel agents in recent years.
We could push further: Parnate, Lithium, and Clozaril are the best of their classes (antidepressants, mood stabilizers and antipsychotics, respectively), yet all came to market long before the neuroscience revolution.
3. Dr. Friedman makes a good case for the research of psychotherapies. Is he being too narrow in his view? Should we be looking not simply at psychological interventions – yes – but also all non-psychopharmacological options?
I note that Housing First has changed the way we think and interact with one of the most disenfranchised populations. Consider the new study suggesting that the At Home/Chez Soi project actually saw a decline in drinking in the homeless, not simply greater stability in housing.
And that last point is worth returning to in a future Reading.
Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.