Monday, March 15, 2010

Psychiatry: An Art Or a Science ?

Psychiatry has evolved from a labour intensive, specialty into something for the masses that bears little resembalce to its early beginnings. The New Yorker of March 1 asks a provocative and seemingly heretical question in its article "Can Psychiatry Be a Science?" by Louis Menand. The article airs troubling questions about the goals and premises of modern psychiatry, which treats depression and other maladies as chemical imbalances.

The article asks if a person who is unemployed and sinks into a depression should be drugged out of their understandable feelings of loss and insecurity. Would it not be better to guide such a person into activities that would improve his or her condition?

Then there is the question of dissatisfaction with society. Gary Greenberg, whose book is cited frequently in "Can Psychiatry Be a Science?" , believes that healthy discontent and dissent is being dissipated with medication. Menand describes Greenberg's concerns as follows.

"The National Institute of Mental Health estimates that more than fourteen million Americans suffer from major depression every year, and more than three million suffer from minor depression (whose symptoms are milder but last longer than two years). Greenberg thinks that numbers like these are ridiculous—not because people aren’t depressed but because, in most cases, their depression is not a mental illness. It’s a sane response to a crazy world."

Additional questions that are explored in the article are whether psychotropic drugs are effective and whether they are even safe. The article reports factually on the role of the drug companies in promoting the development and promotion of psychotropic drugs. It is difficult to escape the seemingly obvious conclusion that scientific research is being skewed and corrupted in some instances by business interests.

Then there is the question of certain types of people being less valued by society. Some people don't fit into the learning and thought patterns of the majority. As a result they are often classified as having some sort of disorder. One wonders what would have happened if Albert Einstein had been drugged into "normalcy"

An example of the pigeonholing of human personality into a list of disorders includes classifying shyness as a disorder, meant to be treated with drugs? What ever happened to learning social skills of even just being shy and learning to enjoy it? The manufacturers of Paxil are of course ready to drug away your shyness. You can even go to the Shyness Research Institute, at Indiana University Southeast.

Anything can be a psychological disorder. I am sure that somewhere in the Empire State Building is a Knucklecracker Suite in which state of the art medications are being prescribed.

Irving Kirsh, whose ideas are discussed at length in the article has an even more subversive idea. He believes that much of the effectiveness of psychiatric medications is a placebo effect. He uses comparison and overview of different drug studies done by the pharmaceutical companies, a process known as meta analysis. This is a difficult process, since it involves integrating disparate studies with varied methods and subject selection methods. Despite this, meta analyses are becoming more accepted in medical research.

One study of the placebo effect was done in 1957 and did not even pertain to psychiatric medication. It concerned anti nausea medication. Louis Menand describes the study as follows.

"He cites a 1957 study at the University of Oklahoma in which subjects were given a drug that induced nausea and vomiting, and then another drug, which they were told prevents nausea and vomiting. After the first anti-nausea drug, the subjects were switched to a different anti-nausea drug, then a third, and so on. By the sixth switch, a hundred per cent of the subjects reported that they no longer felt nauseous—even though every one of the anti-nausea drugs was a placebo."

When you are testing an antibiotic, the placebo effect might be meaningful. But in treating psychological problems, attitude is critical. Clinical depression can depress IQ scores. It can slow down healing from an infection. The modern idea that mental illness is created biochemically has a lot of truth. Unfortunately it leaves out a lot of truth. Constructive or positive thinking creates a mood. The mood has its chemical profile. What is a better way to create a chemical profile of happiness? Should one pump in medication? Should one think happy thoughts? Or should one address the problems in one's life that create unhappiness?

On the one hand, "drugging away discontent" might also drug away changes in the home and the community that would be of considerable benefit to all. There are, however, people who are so imobilised by depression or anger that they are impaired in their daily functioning. A person who is unemployed and takes to sleeping 15 hours a day might take Prozac or some other mood improving drug so they will feel upbeat enough to go look for a new job. They may well decide to toss aside the chemical crutch when they are back at work and satisfied that the job will last.

There are other people who are psychotic, depressed or enraged to the point that they need to be on psychotropic medication for long periods. These are people who would endanger themselves or others if they did not take medication. Some such people should be required by law to take their psychotropic medication. But there is a large number of people who are shoehorned into long term medication regimens.

A half a century ago, Thorazine and other medications meant that people who would otherwise be institutionalised could enjoy some semblance of normal life outside an institution. For some, these medications were indeed "miracle drugs". Unfortunately, what it seems is now happening is that medication is taking the place of counseling. It costs a health insurance company less to have a psychiatrist conduct a 20 minute interview once a month with a patient than if the patient speaks at greater length about changes in his or her life or past experiences. Medication is all too often a labour saving device.

There is, however a time for cutting costs. Sometimes a patient feels ready to terminate therapy and the therapist wants the sessions to continue or even increase in frequency. I knew a man who was going through a divorce and went to a counselor who had him coming in three times a week. Some of the three sessions lasted two billable hours. Each billable hour was 45 minutes. The guy's insurance had a big deductible and soon the bill started getting pretty big. He found another therapist who was able to work things through in a weekly session that lasted for between 50 minutes and an hour. Was the first therapist a fraud? I don't know. My friend trusted his feelings and ended up in a stable relationship and a lot more money at the end of the week.

How accurate are psychiatric diagnoses? Louis Menand tells of a psychiatric researcher named Phillip Ash who discovered back in 1949 that psychiatric diagnoses vary widely from doctor to doctor. Menand notes as follows the story of Ash's research.

"In 1949, Philip Ash, an American psychologist, published a study in which he had fifty-two mental patients examined by three psychiatrists, two of them, according to Ash, nationally known. All the psychiatrists reached the same diagnosis only twenty per cent of the time, and two were in agreement less than half the time. Ash concluded that there was a severe lack of fit between diagnostic labels and, as he put it, “the complexities of the biodynamics of mental structure”—that is, what actually goes on in people’s minds." "In 1952, a British psychologist, Hans Eysenck, published a summary of several studies assessing the effectiveness of psychotherapy. “There . . . appears to be an inverse correlation between recovery and psychotherapy,” Eysenck dryly noted. “The more psychotherapy, the smaller the recovery rate.”

There are undoubtedly times when talking things over with clergy or friends is not possible. Regardless of what theories a therapist subscribes to, there is a need at times to speak to someone who stands outside one's circle of friends and family. Sometimes there is just too much to talk about with people who have their own busy lives.

What worries me most is the extent to which psychiatry bends to societal pressure. Before 1973, homosexuality was considered a disorder. Then the American Psychiatric Association passed a resolution removing it from the list of psychiatric disorders. What changed, other than societal attitudes? Sitting in a national assembly and passing resolutions kind of makes the psychiatrists seem like another religious denomination. I look in the paper to see what the latest resolutions are to come out of Jewish groups. My neighbour checks out what the Baptists have to say. Who is listening to the psychiatrists?

There is a definite need for psychiatry and for psychotherapy. There is also an urgent need for subversive sounding questions that Louis Menand pulled together so ably in his New Yorker article. Menand did a good job of asking tough and subversive sounding questions without being dismissive of psychiatry.

In all scientific fields, we are making new discoveries. A wobble in the orbit of the planet Pluto led astronomers to the discovery of "Planet X", from which the sun that looms so large in our sky is seen as a distant twinkling light. Indeed, a solar year on Planet X is longer than the the entire history of the US as an independent country.

The human mind and the human brain are one of the major stretches of terra incognita, in some ways as mysterious as our solar system. There is certainly much to be discovered about and why we think and feel the way we do.

Can psychiatry be a science? If I ever wanted to interview a psychiatrist, I would ask him(or her) that question. If they would welcome the question I would consider him to be practitioner of a science. If not, I would look for someone else. Because psychiatrist who takes himself too seriously probably does not accord the same respect to his patients.

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