
The Troubled History of Psychiatry - hhs
https://www.newyorker.com/magazine/2019/05/27/the-troubled-history-of-psychiatry
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phren0logy
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...](https://www.annualreviews.org/doi/abs/10.1146/annurev-
clinpsy-050718-095416)

~~~
jedberg
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?

~~~
andrei_says_
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.

~~~
ncmncm
Good therapists offer what seem like obvious suggestions for practical
accommodations that patients could have thought of if they were not impaired
and distracted. Sometimes this amounts to just contradicting a thing the
patient has always believed, without reason. "When you can't get it together
to make dinner, you can get the same nutrition from the separate ingredients"
has been a revelation to many.

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ncmncm
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.

~~~
outlace
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.

~~~
sjg007
ECT has been characterized as rebooting the brain, my guess is that direct
neuro-modulation will be seen as rebooting parts of the brain.

~~~
outlace
I think rebooting is a fair metaphor for ECT since it induces a generalized
seizure.

But neuromodulation acts to mildly strengthen or weaken existing synapses
within a brain region or circuit. The patient is awake and usually watching TV
or something during the procedure. So I wouldn’t call that akin rebooting.

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lukifer
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](https://en.wikipedia.org/wiki/Anatomy_of_an_Epidemic)

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

~~~
outlace
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/](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.

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

~~~
GuiA
Mind Fixers by Anne Harrington

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

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ggm
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.

