The Direction of Psychiatry: Our ship is blown-off track

Are psychiatrists being marginalized into becoming pill pushers?

This is the direction of psychiatry that I am both witnessing and experiencing now as a staff psychiatrist in the state of our current healthcare system.

Well, it seems that our profession (the specialty of Psychiatry) will be relegated to a 15 minute med check office visit with 10 minutes of documentation in each of the 30 minute patient encounters. This goes against what I was trained at Harvard to be and practice, which is a doctor with enough office time to understand the patient as a person, to explore the etiology of their suffering, and to provide enough time for empathic validation and brief, targeted supportive psychotherapy to address their concern. It's really not feasible to do this in 30 minute blocks of time. It’s a conveyor belt of patients—one poor soul rolling in after the other. I really feel that one can’t do anything substantive & enduring for them from a psychodynamic perspective to address their psychic issues and conflicts. As a medical doctor, a specialist in psychiatry, I prescribe pills for their problems. Pills are not the panacea. I know from my training that they provide little/minimal impact upon the pathology. Heck, I’ve seen the studies at Harvard where oftentimes placebo pills were superior to the drugs! How? We reasoned in our Grand Rounds and resident meetings that there is a strong impact from the therapeutic relationship with one’s doctor, being on a structured ward, having someone listen to you, etc.

Is this the direction of psychiatry? Have we lost our roots in exploring intrapsychic conflicts; are we moving further and further away from Freud and Engel?

Prozac now trumps Freud.

Now it is all about medications. Many psychiatrists are no longer doing psychotherapy; we are abandoning it to the psychologists and social workers. Yet, so many of us recent graduates received 3 years of full-time training in psychotherapy during our 4 years of residency. I have noticed now that at each office visit, there is ALWAYS a change, a tweak, in the patient’s medication. Why? Because I always see a patient that continues to have pathology with this form of mental health care delivery model. Evidently, pills are not the only answer. That is why there is still pathos, still suffering; a patient still symptomatic, still anxious, still depressed, still can’t sleep. This model—pill pushing by the psychiatrists and physician assistants, and psychotherapy by the social workers and psychologists, is not an effective approach. I see it 12 times per day in my office, 5 days per week = 60 patients who are short-changed by a health care system that is more interested in costs than in people’s mental health.

Dr. Glen Gabbard, who I met at Harvard in 2008 when I was in my last year of residency training, wrote an article this past month about “Deconstructing the 15 minute med check.” He states that we can’t parse treatment into a psychological dimension and a biological dimension. The “mind” and the “brain” are not separate and don’t require different treatments. We can’t lose the biopsychosocial spirit of psychiatry.

Dr. William Osler noted that “It is more important to know the person that has the disease, not the disease that the person has.” Mental life cannot be explained in terms of physiology, and our choices should not be fixed and determined by the laws of chemistry. Patients are not likely to buy into the same conceptual model that the treaters are trying to impose on them. Patients don’t show up at their doctor’s appointments to limit the content of their appointment to the side effects or therapeutic effects of their medication. Psychiatry has made far too much of a distinction between psychotherapy and pharmacotherapy. Psychotherapuetic skills are needed in every context in psychiatry. All clinical work in psychotherapy depends on attending to the therapeutic relationship. According to the NIMH (National Institutes of Mental Health) Treatment of Depression Collaborative Research Program: “The strength of the therapeutic alliance accounts for an equal, if not greater, impact upon outcome (response and/or remission) than the treatment method itself. “(J Consult Clin Psychol. 1996; 64: 532-539).

Psychotherapy is a biological treatment, and knowledge of neuroscience should be brought to bear in understanding the psychotherapeutic action of psychotherapy.

Psychiatry must retain a biopsychosocial perspective to treat the whole person.

The bottom line is this: There is a problem inherent in the division of mental health care delivery into psychiatrists providing pharmacotherapy and non-psychiatrists (social workers, psychologists) providing psychotherapy.