Wednesday, April 28, 2010

Mindless Psychiatry

I just read an article in the New York Times which saddened me. It was titled Mind over Meds and was written by a psychiatrist who discussed his dawning awareness that the psychiatry that he practiced was "mindless" in that it ignored the mind altogether in favor of focusing exclusively on brain function. This is a complaint that I have had with the way psychiatry is practiced in the United States today.

What is the problem? Psychiatry used to ignore the brain altogether. In the first half of the twentieth century the state of knowledge of the central nervous system was limited. Psychoanalytic theories and psychoanalytic practices were predominant, focusing on how the mind operates to create mental disturbance or dysfunction. The stereotype was the psychiatrist with the patient on the couch. In the last part of the twentieth century there was an explosion in the field of neuroscience which continues to advance at a rapid pace today. The response of the psychiatric profession was to take a close look at how the brain itself operated in mental illness, the neurobiology of disorders. But in the process the field lost perspective and abandoned the mind altogether. Training programs no longer focused on psychotherapy and everything was looked at as a "chemical imbalance". One positive result was the significant advancement of psychopharmacology which really does have an impact on reducing suffering but along the way psychiatrists forgot that their patients were real people with lives and stresses that can effect the brain. The new stereotype is the psychiatrist with a prescription pad who is ready to write a prescription for whatever ails you but doesn't have time to talk with you.

Accelerating this problem have been two other factors. One is that the vast majority of continuing medical education credits have been sponsored by the pharmaceutical industry. I do not want to get into big pharma bashing as pharmaceutical breakthroughs have been extremely important in treating diseases that were untreatable before, extending healthy lifespans and decreasing illness suffering. But there is no incentive for the pharmaceutical industry to sponsor continuing medical education focused on the whole person and emphasizing psychotherapy as well as medication. The other major factor is the changing nature of psychiatric treatment reimbursement. Under the current system of health insurance there is no incentive for psychiatrists to spend the time that is needed with patients. Insurance companies will often only reimburse a psychiatrist for a "med check" (I hate the term) for 15 minutes. Therapy time for the psychiatrist is not reimbursed at all. I have said many times that I believe the "med check" to be unethical as there is no way to evaluate the complex factors of psychiatric illness in 15 minutes.

We cannot as a profession continue to operate this way and maintain any credibility. What is becoming increasingly apparent is that while the brain creates the mind, changing the mind also changes the brain both in structure as well as functioning. The limbic system brain structures involved in emotion and behavior are influenced both by the major neurotransmitter systems that arise in the brain stem and midbrain but are also influenced by the cerebral cortex where we do our higher analytic thinking. With this understanding cognitive-behavioral therapy is as important as medication in treating psychiatric illness and must be the domain of the psychiatrist as well as psychopharmacology. A more holistic approach looking at the variety of factors that can influence mental disorders is needed, including understanding the stress management system and understanding the role that meditation, mindfulness, and other spiritual practices have in affecting brain functioning.

If our focus doesn't change and our training programs don't change to reflect a more holistic approach then psychiatry will become irrelevant except in the realm of treating serious mental illnesses such as schizophrenia and other psychoses that no one else wants to deal with. If our profession dies out as a result of not making the change to a more holistic approach then we deserve it.

Thought for the day

No single model can explain the complexity of human behavior, emotions, and brain functioning.

1 comment:

  1. How about seeing a psychiatrist for medications and a therapist for talking? In my experience, teamwork seems to give the best results.


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