The Troubled History of Psychiatry

https://www.newyorker.com/magazine/2019/05/27/the-troubled-history-of-psychiatry

by hhs • 7 years ago

63 36 7 years ago

phren0logy3• 7 years ago

I'm a psychiatrist, and I haven't read the book yet but the review covers a lot of objectively valid criticisms of modern psychiatry. Everyone involved on all sides of the debate would do well to heed the advice for moderation vs an "all-or-nothing" approach.

I'm not sure if it's in the book, but part of the zeal for a biological and medication-based approach is the number of players who really want it to be true. Talk therapy is inefficient, expensive, and difficult. Good psychotherapy is not "rent-a-friend." Insurance companies, (many) patients, and pharmaceutical companies all really really want the answer to come in the form of a pill.

The problem is, wanting it doesn't make it so. There's a relatively small subset of problems walking into my office that medications can fix. Occasionally, medications are the only reasonable tool for the job, period. Even in those cases, they should ideally almost always be combined with non-pharmacologic interventions.

Another little-discussed part of this picture is that there is a booming number of mid-level practitioners such as nurse practitioners who are providing psychiatric care unsupervised. Their training is far shorter and includes much less psychotherapy, and there are fewer restrictions are their interactions with pharmaceutical companies. The results are predictable. Troublingly, I have seen dozens to hundreds of patients who have previously seen nurse practitioners, and have yet to meet one who knew that they were seeing a nurse practitioner rather than a physician psychiatrist.

Edit to add: It's not as though many in psychiatry haven't identified this issue. Here's one recent publication highlighting the problem - https://www.annualreviews.org/doi/abs/10.1146/annurev-clinps...

jedberg• 7 years ago

As a psychiatrist, how do you feel about a well trained AI being used to reduce the cost of talk therapy? Perhaps the patient starts with the AI and psychiatrist steps in when it gets stuck or reviews the transcript afterwards and comes up with a treatment plan or tweaks the AI for the next interaction?

nickbarnwell2• 7 years ago

Incredibly bearish. To summarise a few decades of common factors research poorly, our understanding of therapy's mechanism of action is limited, and it's not clear that any given technique or modality has superior curative power compared to another. The most important component is pantheoretical, the strength of the relationship between client and therapist. Alexa, Siri, et al. can not reliably determine whether I want the lights switched off in my bedroom or the living room, and we are seemingly decades away from the sort of strong AI required to hold meaningful conversations about the purpose of life or the nature of our interpersonal relationships. The Heart & Sould of Change is an approachable text on the topic if you're curious.

That's not to write it off completely; there have been adaptions of CBT and DBT into text and electronically-mediated forms that show promise among subclinical populations or as an adjunct to conventional therapy, but by and large a human is going to be necessary for a long, long time.

vokep• 7 years ago

Is there any modern AI that would be remotely functional for such a task, that is better than ELIZA?

I can't help but feel something like talk therapy is only going to work with all or almost nothing. You either have a full person that can actually empathize, or an AI of equivalent ability (so, true AGI). Or you become a mirror and let the patient fill in for that capability, like with ELIZA.

phren0logy3• 7 years ago

There's a boatload of data showing that the most critical element of effective psychotherapy is the "therapeutic alliance." While this is a somewhat squishy term, it's broadly linked to the importance of compassion and relationships. For that reason, simply trying to replace a human with a robot faces huge challenges.

But that's the least creative possible solution. I think there are all kinds of behavioral interventions that are difficult or impossible for a human to do that we haven't tried yet. Almost certainly there are lots of them that would work well and would be better delivered by a bot.

andrei_says_• 7 years ago

Consider that a lot of the positive effect of psychotherapy is related to the patient being listened to by another human being. Presence and attention.

btilly2• 7 years ago

As an informed lay-person, psychiatry scares me. There are cases where it is the best we have, but it really feels to me like the state of medicine when bloodletting was an accepted treatment.

In particular we regularly have disaster after disaster caused by psychiatry, psychology, and related fields. Consider the excesses of frontal lobotomies in the 1950s, electroshock therapy in the 60s and 70s, and false memory syndrome in the 80s and 90s. It makes me wonder, what disasters are we creating now?

jdietrich3• 7 years ago

Lobotomy and electroshock therapy have an undeserved reputation as being barbaric and futile. We've substantially refined both techniques and we still use them where other options of failed.

In the case of lobotomy, we now use stereotactic guided procedures to precisely ablate small parts of the brain, mainly for the treatment of severe OCD and treatment-resistant depression. In the case of ECT, we perform the procedure under full sedation and use EEG monitoring to deliver the minimum possible energy. Both treatments still carry a substantial burden of side-effects, but they work when nothing else does.

The uncomfortable reality is that a lot of people have debilitating, life-threatening mental health problems that don't always respond to medication or psychotherapy. Most of us don't want to think about what very severe mental illness really looks like - the person who is too depressed to sit up in bed, the person with OCD who picks at their wounds until they hit bone, the person with mania who is keen to test their belief that they're immortal. If you were treating a patient with that level of disability, what would you do?

The real disaster of psychiatry isn't the failed attempts, but all the stuff that we don't yet know how to treat or don't have the resources to treat. Mental illnesses are the single biggest cause of disability in the developed world. There's so much we could be doing, so much we should be doing, but we're not spending nearly enough on research or treatment. We're watching helplessly as people live short, miserable lives because of diseases that are treatable or potentially treatable.

riemannzeta• 7 years ago

The reviewer seems uninformed about the research reported by Robert Sapolsky (almost ten years ago) that depression is not a unitary phenomenon, but rather likely a combination of imbalance in epinephrine, seratonin, and dopamine. https://youtu.be/NOAgplgTxfc

Was Sapolsky playing fast and loose, or are the multiple components of depression widely appreciated in the field now?

jdietrich3• 7 years ago

The idea that depression has multiple causal factors has been the consensus for a long time; drug companies briefly pushed the serotonin hypothesis to sell SSRIs and some poorly-informed clinicians believed their marketing materials, but the overwhelming scientific opinion is that depression is the product of a mixture of genetic, neurological, cognitive and social factors. In the research community (but not necessarily in clinical practice), it is readily acknowledged that depression can be caused (or at least triggered) by a variety of biological factors such as comorbid diseases, malnutrition, brain injuries and drug side-effects.

Sapolsky's perspective is somewhat fringe, mostly because he's a neuroendocrinologist rather than a psychiatrist. His perspective reflects his research interests rather than a broader clinical perspective. I can't say that I'm hugely familiar with his work, but I'm not sure how much of it is actually clinically relevant.

nickbarnwell2• 7 years ago

For anyone debating whether to pick up the book discussed in the article, I'm about halfway through right now and would highly recommend it. Harrington's a clearly talented writer and has done an amazing job weaving together the separate threads of thought and history to produce our modern conception of psychiatry. If you're familiar with Sarah Bakewell's writing, this is similarly compelling.

perfmode• 7 years ago

What’s the name of the book discussed in the article. I skimmed but didn’t find the name.

GuiA• 7 years ago

Mind Fixers by Anne Harrington

lukifer• 7 years ago

I recently read a book [0] that made a compelling case that mental health conditions can often be perpetuated, if not created, by the drugs that purport to treat those conditions (the formal term being "iatrogenic" [1]). If true, it's a classic perverse incentive, and a stable closed loop that's good for business and bad for patients, even if the vast majority of practitioners are writing prescriptions in good faith, from a genuine desire to help the afflicted.

As a layperson who is suspicious of Big Pharma, I'd be interested to hear other perspectives from those more knowledgable (the book admittedly reinforces my pre-existing opinion!). But however many people are genuinely better off through the use of pharmaceuticals (and I'm sure there are many), I don't think it's controversial to claim that such drugs are often over-prescribed, compared to less profitable solutions (CBT, group therapy, or even basic things like sunshine, movement, and diet).

[0] https://en.wikipedia.org/wiki/Anatomy_of_an_Epidemic

[1] https://en.wikipedia.org/wiki/Iatrogenesis

outlace3• 7 years ago

Most anti-depressants are prescribed by general practitioners, not psychiatrists. I've actually this seen interaction before:

---

(Generalist) MD: Ok so I'll see you back in 4 weeks to check up on your high blood pressure. Oh um.. you seem a little down today, are you depressed?

Patient: Yes, doctor, I've been feeling pretty depressed lately, I ...

MD: Ok would you like to try something for that?

Patient: Uh ok, sure.. I guess

MD: Alright I just wrote you for an anti-depressant, I think that will help.

---

That's definitely not an interaction that would happen with a psychiatrist.

It is true that psych drugs can cause harm, or do nothing. But I've also seen very dramatic improvements in people's lives from psych drugs, and I think its the fact that enough practitioners see enough of these amazing transformations that it seems like its worth it for some subset of people, and justifies the enterprise.

Probably the majority of depression and anxiety we see in modern society is the byproduct of...modern society. Lack of meaningful work and relationships, high work stress, poor physical health and diet, etc. Some of these are the same cause of many cases of high blood pressure and diabetes, but just like with high blood pressure and diabetes, many of those patients just do not have the motivation or desire or ability to make the changes in their lives to improve their physical and mental health. So they want a pill.

However, if you go to an inpatient psych hospital, those are mostly people are seriously impaired. Not all of them will benefit from medications, but many will. A bipolar patient may totally throw her life off the rails during a manic episode but can live mania free if on medications.

It's just a very messy business. I have seen lots of patients who go from being so impaired they cannot lead a normal life to being fairly function on medications. But also many who get no benefit after many med trials. And others who are possibly worsened by meds.

Nonetheless, we're starting to see studies showing that we can predict, based on biological markers, which patients will likely respond to particular treatments. See for example the http://williamspanlab.com/ at Stanford. There they are piloting a study where patients receive a number of biological and symptom-based diagnostic tests, analyzed by predictive algorithms and this analysis is given to the treating physician to help guide treatment. Despite the unsavory history, I really think things are looking up for psychiatry as a field. But surely change will be slow.

ncmncm3• 7 years ago

The biggest problem in psychiatry is that the only reliable way they have to diagnose illnesses, with any precision, is to prescribe things and see which one helps most, if at all.

This problem makes it near impossible to apply generic "gold standard" double-blind trials to psychoactive medications, because those depend implicitly on accurate diagnoses. If your target sample group has six different maladies all labeled "depression", you will never get a clear signal, even if the medication you are testing 100% cures the one-in-six of them that actually have the problem it fixes.

phren0logy3• 7 years ago

I disagree with some of your premise, but agree in general. I sort of think of this as a "science vs engineering" problem. Science can be patient for the correct answer, but engineering needs a good-enough model of the problem to make something work today. Enter the DSM, which is on the engineering side of the aisle. It provides common terminology but is almost certainly lumping too many things together. So if your treatment doesn't help many different problems that look sort of similar all at the same time, it shows no effect at all. Which doesn't mean it won't do a great job with one of two of those narrower subtypes.

This guy does some great work on the topic: https://eiko-fried.com/the-replication-crisis-hits-psychiatr...

outlace3• 7 years ago

As a new psych resident, I'd agree with this. The diagnostic system is not biologically based. It does at least offer a common language for mental health provides to speak, so that if one person calls something schizophrenia then other mental health providers will be on the same page about what that means.

Personally, I'm very excited about direct neuromodulation technologies such as transcranial magnetic stimulation. These tools not only allow us to manipulate neural circuits, but to also test experimentally whether certain circuits causally contribute to a psychiatric phenotype of interest.

As a treatment modality, they're incredibly safe and virtually have no side effects. Given that chemical receptors on neurons are so widely distributed, I doubt that a chemical substance can ever alter neural circuitry precisely enough to cure certain kinds of circuit dysfunctions.

There's also starting to be exciting studies using brain imaging (e.g. fMRI) to tease apart the heterogeneity within conventional diagnostic categories and devise the inklings of biologically-based dimensional criteria.

sjg0072• 7 years ago

ECT has been characterized as rebooting the brain, my guess is that direct neuro-modulation will be seen as rebooting parts of the brain.

billfruit• 7 years ago

I think that is no bar for development of methods. Are methods in surgery developed after double blind trials? Does even the scientific method apply to surgery?

inflatableDodo• 7 years ago

The subject suffers from a mixture of grandiose and persecutory delusions, with a marked compulsion to obsessively catergorise others.

ggm• 7 years ago

It was hard to walk past the "test if they have syph, by injecting them with syph" moment. For me, it summed up why study of mind in this culture of medicine bears very heavy burdens in the roots of the science: People did things which on no rational basis, would be ethical.

The Troubled History of Psychiatry

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