Thursday, August 18, 2011


I'm just bumping up this post, originally from July 2008, because there have been some new comments.  

There are a lot of strong opinions out there about psychiatry.

Some people are concerned that the practice of psychiatry has caused harm, perhaps by "over-medicalizing" issues that should be considered matters of personal challenge, character, individual choice & responsibility, spirituality, or normal human experience. Other concerns are that psychiatry is overly influenced by large pharmaceutical companies, whose agenda is to earn larger profits by selling more medication. Critics holding these concerns often consider the results of research studies to be biased, since they have often been sponsored by drug companies.

I think these concerns need to be heard and respected. There are specific examples about some of the concerns having some validity to them. In the history of psychiatry, as in the history of all other human endeavour, mistakes have been made. Small mistakes and large mistakes. On a systemic level, I think some of the core theories about psychiatry over the past hundred years have been laden with huge inaccuracies, despite the many nuggets of wisdom contained within them (Freud's ideas are one example). Many times, attempts at treatment have not helped, or perhaps have reduced a symptom at a very great expense to other aspects of the patient's life. There have been trends and fashions in treatment, such as the widespread use of anxiolytic drugs in past decades--while only later do we discover that these treatments can cause entrenched problems with addiction.

Conversely, there are some testimonial accounts of individuals who have had long histories of conventional psychiatric therapies, who have gone on to thrive once leaving all of these behind (perhaps pursuing alternative or naturopathic medicine, or making some other lifestyle change).
I think it is important to step back and examine the evidence closely, with a critical eye (in future posts I will refer to some of the evidence). I hold that there is a vast body of evidence about psychiatry to look at. And the evidence shows that the treatments are truly helpful. The evidence also shows that the treatments are not perfect, and that typically 30% of people do not have a good response from a given psychiatric treatment. The evidence also shows that up to 30% of patients respond to "placebo treatments". These facts lead to several criticisms about psychiatric treatment: first, there are many (perhaps in the first group of 30%) who have tried "conventional psychiatry" and have found that it hasn't worked for them. Second, there are those who have tried "non-psychiatric" treatments, and found that these HAVE worked for them (perhaps these people are in the 30% "placebo" group). Both of these groups may have a tendency to criticize psychiatry; yet there is another 40% -- a group whose ailments have resolved as a direct result of their psychiatric treatments.

This has always reminded me a bit of other areas of medicine, such as cardiology or oncology: the treatments in these specialties can be remarkably curative for some, only palliative for others, and may not work at all for others still.

I do agree that we must never "over-medicalize" any human ailment. It is rare for a problem to be truly cured by a pill. Usually, for any human concern or challenge, any therapy that helps has to be accompanied by holistic changes in lifestyle & behaviour. For the cardiac patient, this means rehabilitative exercise, healthy diet, no smoking, etc. For the mind, just as for the heart, there are many lifestyle habits that are healthy, restorative, and protective against recurrent illness.

Yet, very often people are too ill to be able to institute the "healthy lifestyle habits". The cardiac patient may require medication to control blood pressure and angina before being able to safely or comfortably exercise. Similarly, there are medical treatments in psychiatry that can hopefully provide enough symptom relief to allow the patient to energetically change their life for the better.

I have observed that the "anti-psychiatry" group can be very vocal. I could understand that the individuals among this group could have good reasons to hold such strong, forceful opinions. But I don't want this site to be a forum to spend a lot of time on this debate, I would rather focus on my own beliefs about ways to manage the mind's symptoms in the healthiest possible ways.


Anonymous said...

I know that you don't want your blog to be taken over by discussions about "anti-psychiatry"-- but I do want to say this:

It often seems to me that the term 'anti-psychiatry" is over-used. The threshold for referring to something as "anti-psychiatry" seems much too low sometimes, eg I've heard David Healy referred to as an "anti-psychiatrist", etc. It sometimes seems to me that many criticisms of current psychiatric practice-- however thoughtful or respectfully made-- are quickly labelled "anti-psychiatry", and in this way the criticisms (and the people doing the "criticizing") are shit down or silenced.

With respect to your comment that the evidence shows that treatments are truly helpful-- well, I don't mean for this to sound critical or disrespectful , but I often find it very hard to take a lot of psychiatric research seriously. (I REALLY don't mean for that to sound critical or unnecessarily provocative). I am suspicious about a lot of medical research, not necessarily because I am distrustful of pharmaceutical companies, but because I am not always convinced that many research questions can be answered through the type of research studies that are conducted.

I think that this is especially true of psychiatry. The problem to me is that I don't completely see that various symptoms or psychiatric phenomenology generally are well understood or appropriately defined. So it seems hard for me to see that the populations in many of these research studies are necessarily representative of actual patient populations. I guess my point is that I don't see that it's actually possible for real research to take place unless the diagnoses that are used by clinicians (in the DSM, and elsewhere) are better defined.

As an example, I don't see that the DSM criteria for "major depressive disorder" (or many other DSM disorders, actually) is particularly useful in helping to define "depression". I remember reading a book by Edward Shorter, who made the observation that there are probably many different "types" of depression (and not just the subtypes identified by the DSM), and that without better elucidating what these different types are, it seems difficult for research to advance. If individuals with MDD as per the DSM are such a heterogeneous group, then it seems difficult to conduct further research (on putative pathophysiologies, or treatments) without gaining a better understanding of the different problems.

I remember once looking at a research study design hierarchy, that placed "n=1" research trials at the top, above RCTs. I remember being confused about this. I am confused in particular why there is so much emphasis put on huge and sophisticated studies, when perhaps a more personal approach is best. (Obviously I understand that this is complicated, especially when it comes to allocating resources, or establshing safety for various medications--etc).

I do believe that psychiatry helps people-- that psychiatric treatments help people-- yet at times I find that the reliance on research studies or "evidence" to be a bit frustrating or off-putting. I also personally agree that psychiatry is (and should be ) a medical specialty, yet again I find sometimes that psychiatric jargon (including diagnostic or research jargon) to be off-putting and unhelpful. I don't like to think that my views are "anti-psychiatry"-- and I don't think that they are-- yet I suspect that many people would argue that the above beliefs DO constitute a type of "anti-psychiatry", and this bothers me.

I do appreciate your very non-dogmatic approach to psychiatry-- you are remarkably open-minded about so many things-- I hope that this comment does not seem critical of you. (That isn't my intention!-- I hope that this is clear from this response).

GK said...

Thanks for the comment. A healthy self-criticism or self-awareness is required for health--ironically this is a foundation of much psychotherapeutic theory. So of course such self-criticism by psychiatrists is required for the health of psychiatry itself.

Yet of course, as with an individual person's problem with highly recurrent, reflexive, or compulsive self-criticism, constructive self-reflection if excessive can become an obstructive cynicism which prevents growth or positive change.

I tire of an over-reliance or excessive preoccupation with viewing large randomized studies as the motivation for any kind of decision about how to help someone. Careful stories about an individual's life ("N=1 studies") are so important to gather and work with for good care.

Yet, part of psychiatric practice does involve treatments such as medication, or perhaps some specific type of non-medication treatment (analogous to some style of coaching athletes or teaching math, etc.). Coaching practices have advanced over the decades because of such systematic research. Medications, despite all those biases and problems with big corporations, etc., are often useful and helpful. But the process of developing a new medication involves years of work, study, risk, and expense. Unless there is some systematic way to measure effects on a large population sharing reasonably similar problems, it would be very much more difficult to develop new medications. One can see this type of phenomenon in other areas of medicine, such as oncology or infectious diseases: some drugs for treating cancers may ideally need to be extremely, exquisitely tuned to the individual's unique case (and here, molecular genetic analysis, etc. is coming more into practice as a device to optimize cancer therapy), but in order to develop the drugs in the first place, mass studies need to be done to screen for the possibility that the drug could help people at all. In infectious disease, the degree to which an antibiotic separates from placebo in a large study often yields similar results as a psychiatric study comparing an antidepressant or antipsychotic with placebo. Yet, one person's pneumonia may differ substantially from another's (in terms of location, organism, individual reaction to the organism, immune response, etc.)

But of course, this type of study can only translate indirectly into trying to help an individual: as with treating pneumonia, the studies may give us a reasonable suggestion for what to start with, but beyond that it may be a very individual search. In pneumonia, if one antibiotic fails, or if physiotherapy fails, then it is necessary to have an open mind and some wisdom to figure out what to do next.

Among the problems with abandoning the current attempts to do large-scale systematic psychiatric research and focusing exclusively on N=1 data, include spurious practices similar to what one sees in some types of alternative medicine, where one individual's testimonial account of cure becomes generalized by treatment providers. This type of practice can often cause a lot of harm, both due to direct negative impacts of the factitious therapy, but also due to the delays in getting a more substantive treatment.

I am annoyed by a lot of the jargon as well. It seems to be spoken by many in a way which seems to aggrandize the treatment somewhat. For example I can think of CBT-oriented therapists talking about a "cognitive intervention" while, in my opinion, really talking about simply having a conversation with someone solving some life problem. I do acknowledge, however, that some of the jargon, like all jargon, can be a shorthand to discuss ideas more quickly, and the presence of jargon need not be automatically considered a negative. I do think it is important to have some self-awareness and humility about these things.

Anonymous said...

Thanks for your response. I do find you to be very open-minded about this.

I probably did not express myself very well in my first response-- I think that a bigger problem than study design is the problem with the diagnoses themselves. I just don't see (for example) that the DSM criteria for MDD is getting at something concrete, meaningful, or discrete. I know that probably many clinicians (maybe you, too) would say similar things. It isn't that I don't think that "clinical depression" exists, but I don't see that the diagnosis is necessarily helpful. It seems strange to me that so much research is done to discover treatments for depression, when I still don't see that there is a clear understanding of what it is. On the other hand, I see that it is not always possible or good to wait until various diseases or disorders are completely understood before engaging in further clinical research on prevention, treatment, etc. But I think that the problem to me is that for many (though not all) medical conditions there is at least the benefit of an objective disease marker, and there is some objective way of establishing treatment response. Eg, a study for patients with high blood pressure could define hypertension as 140/90, and treatment response could be defined again by certain objective measurements. I think that it is definitely possible to still have problems with this (eg, debates about whether the definition of hypertension is too strict or not strict enough; or if this definition is meaningful; etc)-- yet it still seems easier to identify what the problem is and have a discussion about it. I think that the main problem for me is that often when people talk about psychiatric research-- especially to respond to 'anti-psychiatry" critiques-- there is a lot of focus on the role of pharmaceutical companies (and I don't necessarily see that pharmaceutical companies are necessarily any worse than independent researchers), or arguing about whether mental illness is "real" or not. I suspect (maybe I'm wrong) that many people who hold critical views of psychiatry don't dispute that it's real, the dispute often is with the way it's defined.

In an earlier post you compared depression to pain, ie the idea that perhaps depression is a symptom that is in response to various underlying conditions or stimuli. I do think that this is a useful way of looking at it.

You wrote in this post that "the evidence shows that the treatments are truly helpful". Again, I would dispute this, because I don't see that depression is well-defined or well-understood, and as a result I don't see that the patients in these studies necessarily have a common illness, that I share, or that the way treatment response is defined or measured (eg improvement on scores like the HAM-D or BDI) are meaningful. I suppose what frustrates me is the tendency in the media to portray depression as a well-understood illness, with known and effective treatments, etc. I do think that these treatments for some people, but I don't see that the research warrants the kind of excitement and enthusiasm that I see. I think often that people are encouraged ++ to seek psychiatric care, there's this idea that there is absolutely no reason to suffer because of the many many effective treatments that exist-- yet I think that the actual clinical picture is a bit greyer than this (I think even many clinicians feel a bit more pessimistic about the treatment of various psychiatric problems) and I wish that this greyness was emphasized a bit more by clinicians, researchers, etc.

GK said...

There are lots of important issues you raise here.

I do not agree with you that the existing dsm diagnosis of depression is not concrete, meaningful, or discrete. Presentations of depression as defined in the dsm are common, often accompanied by a full collection of these symptoms, and often do resolve fully upon fairly mainstream treatments. Symptom score resolution in these cases coincides largely with individual's subjective report of satisfactory recovery. Furthermore, there is a very reasonable basic science foundation for this entity, represented for example by tryptophan depletion studies, etc. --in which a relatively full and consistent collection of relapsed symptoms are induced by neurotransmitter depletion.

I do agree very much that the existing definitions of depression are inadequate in a variety of ways. They do not account for the nuances of individual experience and history.

The biggest problem, in my opinion, is not really about the diagnostic definition--but is about the cross-sectional nature of the diagnosis. Cross-sectional depressive states are arguably very treatable in most cases. But chronic or highly recurrent depressions, particularly those that have existed through developmentally sensitive time periods such as childhood or young adulthood, utterly change the way the brain forms. A depression with this type of history cannot merely be "cured" in some kind of cross-sectional symptom-relief fashion. There may be years of dark, painful memories, repeated experiences and learned expectations of emotional or social deprivation, many life skills or positive life experiences not attained or missed out on because of the symptoms. But then even if the symptoms do remit, these deprivations and losses remain, and perhaps render any symptom relief much less meaningful or useful. In cases like this, I believe that a model of long-term care, with attention to nurturing relationships, relationship skills, education, vocation, etc. is most likely to help, if these things are desired. But I also think that cross-sectional symptom relief strategies have a role as well, and may allow other long-term work to proceed more enjoyably and easily. But such cross-sectional symptom relief alone is not likely to help with the existential sorrow, losses, and deprivation caused by the previously chronic state.

An analogy can be made with hypertension as well. A target bp under 130/80 could be a reasonable goal; similarly a Beck score under 10, etc. Just like in acute depressive states, there will be some hypertensive patients who do not respond to one, two, or even three antihypertensive drugs in combination; so there is a "treatment-resistant group." In any case, improvement in these symptom scores alone, if attained, will not undo the damage caused by 20 previous years of hypertension. For this damage to mend (e.g. cardiac hypertrophy) there may need to be complex long-term rehabilitation, to permit an entirely different lifestyle for many years into the future. Yet, this long-term work may certainly require that acute treatments to treat the blood pressure (or the depression) be used aggressively.

Anonymous said...

Hi GK,

You don't have to post this if you don't want to.

When I reviewed this post again I have a slight tendency to cringe at the broad quantification of affects in percentages without proper operationalization of the terms being used. (ie: 30%, 40%, 70%).

This just brings up too many questions:
1) What is considered psychiatric treatment? Can it be a psychological treatment? Can it be a physical activity? a practice? For how long of a trial is considered adequate?

2)When you describe treatment as being helpful who is reporting this? How is it being measured? How much symptom reduction is classified as help? How would you differentiate psychiatric treatment from the therapeutic relationship or simply meeting with someone who cares about you and listens to you?

3)One of the other big concerns I have is this may be the exact type of oversimplification that confuses many people struggling to find something helpful. For example, is the 70% who found help, the result of one single treatment or is this the percentage of people who did find something that helped after 1 medication trial, 2 medication trials, psychotherapy/adjunct medication trials/, building a community..etc...?

If you were referring to the total of all people who found help eventually I would believe this number would to be quite high. (Althought at some TIMEPOINT you would have to consider that patient death by natural causes or even the "regression toward the mean")The time between initial assessment and a noticeable relief in symptoms may take a long amount of time and many trials. This picture would foster a more hopeful realism.
(Although I have to acknowledge the few people who rapidly return to a symptom free life after one treatment)

4) Lastly, are this numbers taken from somewhere specific or are they numbers that you have come across over and over again in the literature? I know you said that you will post examples (which you have) however there is so much variability, the idea of using numbers to quantify help seems a little confusing?

I hope I am not being picky, but I do think it is important to include these very realistic parameters when you make such statements. I could understand how someone would see these figures and feel greatly discouraged after their first treatment was unsuccessful.

On the other hand, I can understand if it was more of a "quick post" in which case you could emphasize that it had "been your experience of the literature" which you follow that....

(I acknowledge the difficulty with following a wide/broad range of literature when it is not specifically relevant to the treatment of your patients.)

GK said...

The main idea in this post was to give a general overview of my opinions in defense of psychiatric practice, while conveying some empathy for those who might have different views or experiences, while establishing that this blog is not intended to be a forum for a hostile debate on this subject.

Many of my posts are what I might call "editorial pieces" and I enjoy the fact that I do not always have to prepare a research paper in order to express a considered opinion
The quantification of effects (and "affects" too) from therapies of different sorts tends, in my opinion, to show a frequent similar proportion of individuals responding or recovering, fairly similar placebo response rates (with several notable exceptions), and similar absolute reductions in symptom scores, irrespective of how these are defined or "operationalized."
Of greater interest to me than what I consider to be well-established truths of this sort, is to consider how to help a particular individual better, when good efforts of evidence-based therapy (this evidence based on group studies rather than individual ones) are not working well enough.
I do not care much about semantic destinctions
, such as psychiatry vs psychology vs attentive compassionate companionship: all of these are aspects of attempting to be helpful--i believe that good psychiatric practice would be open-minded to allow for any style of help to be adopted, provided that there is a good probability of it helping, and a low probability of harm.

Anonymous said...

I am perplexed by OP's posts regarding defining depression or study of it, as if there is a particular standard that tells us when something is perfectly defined and when it can/should be studied.

I can not anticipate a time when we will all agree on what depression is. This is not pessimistic thinking but rather based on an understanding of the difficulty of defining what a mental illness is.

DSM is merely descriptive in order to avoid the messiness that comes with theorizing (e.g. psychodynamic as opposed to behavioral). This, of course, has some shortcomings but so do other approaches.

But a guiding principle in treatment is about one's functionality. That's important to consider as it explains quite a bit. So once we decide to label something as a mental illness (somewhat arbitrarily, mind you) and study it, it ultimately comes down to the level of distress the person is experiencing and his level of functioning in the society.

Surely a depressed person with bipolar who has been able to direct his energy into creative endeavors in an adaptive way, may not come for therapy in the first place. He who comes for therapy, even with a less severe mental illness, is coming to get some help. That can be provided as meds or therapy or whatever, but all within a client centered framework.

Yes, it is true that some psychiatrists may cram their own view, the biomedical view of mental illness, down the patient's throat, which is wrong. One would talk about childhood or a breakup in relationship, and like a preprogrammed robot, the psychiatrist may claim "chemical imbalance" as the cause.

I think as long as psychiatrists are humble enough, explaining that this is one way of looking at things, of framing things, and of treating the individual, it's good.

As long as the patient feels that the psychiatrist is on his side and based on his training, trying to help him as best as he can, it's great. But psychiatrist is not a priest. He is not a family member. He is not a best friend. He is a professional with particular training and particular view of patient's suffering. Patient should be told this. Have realistic expectations.

Based on all the research I've read, therapy DOES work. People should certainly try different things before coming to a psychiatrist or try meds unless they're in serious suffering or of danger to themselves or others.

In those cases, meds help. They allow you to think more clearly, in a less agitated state, so you can consider your options. It's about management not cure. Then, of course, you can look at maybe cutting back on work, spending more time with friends, taking up exercise, going to church, read poetry, reflect on life, see a psychoanalyst, take up martial arts, whatever. But we have a biological body. There is no denying it. Either reducing body/mind to pure biology or completely denying it is not going to change that.

Putting the Big Pharma talk and incessant advertisement aside, I think once we see psychiatry for what it is, neither idolizing it nor denigrating it, but seeing it as merely another way of easing our suffering, patients and psychiatrists can have a better relationship.

just an opinion.