The Death of Psychiatry

Psychiatry_0
Yes, I have said it; the cracks within the armor of psychiatry are starting to make themselves more evident as time moves forward. Not only because the heart and soul of psychiatry, psychopharmacology, is undergoing a crisis in every possible sense, but also because students of medicine are less inclined to opt for psychiatry and so gradually becoming less interested in the relevant research as well. On top of this dilemma, you have psychologists in states, excluding New Mexico and Louisiana; where they have prescribing privileges, pushing for the right to prescribe psychoactive drugs and the majority of the time continually being rejected by their states. This effort has been going on for a decade now. Nevertheless, assuming the poor and declined efficacy of psychopharmaceuticals(which I will get into later), why should psychologists push forward for prescription privileges? Physicians (i.e psychiatrists) themselves are having issues with these psychoactive drugs currently? Is it wise to inherit these problems that the field is currently facing? Well these questions I hope to address in this undertaking. My intent is to give reasons why individuals should think psychiatry, as a strictly medical discipline, is either headed down the inevitable path of a massive reformation or a disastrous path of self-destruction. I also wanted to look at the push for psychologists having prescribing privileges and what it means in light of the psychiatric crisis. With such labor involved the in the push for prescription, it is first important to look at whether or not the status of psychiatric medicine is beneficial for both patient and doctor seeking mental health relief.

Psychologists Prescribing?

Some of you reading this may not be aware of the differences of psychiatrist and a psychologist and their fundamental differences. One difference is that a psychiatrist is a physician, a medical doctor with training in medicine. The education of a psychiatrist usually involves 4 years of medical school and up to 4 years in residency training. Another difference is that a psychologist, particularly clinical psychologist, is trained specifically to work at a clinic or any other healthcare facility providing psychological assessments, testing, and psychotherapy and under the right training, hypnosis as part of a treatment model. The education for a psychologist usually involves a minimum of 6 years of graduate work and 1 year of internship or assistant work at an academic facility depending on the type of area of specialization. Anyhow, a psychologist can have a wide variety of expertise depending on the concentration of your choice; those include but not limited to areas such as evolutionary science, health, counseling/clinical, behavioral, cognitive, experimental, research/evaluation, and the list goes on. These variety of specialties are by no means exhaustive, but you can probably get an idea of the wide selection of specialization available for aspiring psychologists. Usually a psychologist, with the exception of clinical or counseling specialists, will most likely be involved in research in academic, private or government and state institutions, and the other half are teaching at university or college level functions. Prozac-001

Clinical and counseling psychologists will most likely be presented with the urgency of being able to prescribe psychoactive medicines, and this is mostly because these psychologists in particular are trained to operate and provide treatment in clinical settings. Specific examples of clinical settings include hospitals, domestic abuse shelters, emergency and humanitarian response facilities, rehabilitation centers, military health clinics etc. As is obvious, psychologists working in these areas would appreciate the ability to prescribe psychoactive medications if the need ever arises.

Pros

In terms of arguments for prescription privileges for psychologists, there are concerns directing attention to the availability of under-served communities such as rural or inter-city areas where psychiatrists generally absent. Which is most likely do to the fact of the shrinking number of psychiatrists available as it is altogether(National Alliance on Mental Illness [NAMI], 2002). Another more practical issue to psychologists in clinical settings is the motivation to better serve the public. Which is of course the concern with any properly functioning mental health care system when efficacy and some degree of efficiency is desired.

Cons

The problem for the psychologist, however, lies in his/her training and qualifications. Many psychologists think that 6 or so years on graduate school leaves you trained for any and all psychological necessities. After all, that is why you go through so much schooling right? Not according to Dr Eugene Rubin. He illustrates (2010a) that psychologist’s assumptions go much deeper. He goes on to say that the critical components to education can make one qualified to prescribe are not included in the psychologist’s schooling. Giving an illustration he says;

“In order to understand the actions and dangers of medications, we believe it is imperative that practitioners undergo detailed coursework in basic and clinical sciences and complement this didactic training with clinical experience involving patients on medical, surgical, pediatric, ob-gyn, neurological, and psychiatric services” (para 3)

He further elaborates on his point;

“Prescribing psychiatric medications effectively involves the integration of information from the fields of molecular biology, genetics, pathology, biochemistry, and neural sciences together with practical knowledge regarding the effects of medications on patients who are ill with conditions that involve multiple body organs”(para 3)

Dr Rubin outlines what could very well be liability issue, which of course would be a likely cause for a gross negligence lawsuit on the part of the prescribing psychologist–probably due  to a clack of specialized medical training in the curriculum of graduate school for psychologists. Biochemical reactions in these prescription medicines, along with possible complications within the central nervous systems, could, in some degree, have a redefining-mental-illness_1negative interaction with body organs, preexisting conditions, and the hazardous possibility of mixing with other medications is not something a clinical or counseling psychologist is trained for, even including graduate study. Their expertise lie in human behavior and psychology; clinical evaluations, psychological assessments, and psychotherapy. Taking psychoactive medications always involves the likelihood of side-effects and the future of those consequences are better left to a medical doctor (in this case a psychiatrist) to examine and anticipate an onset with such medical implications and dangers.

One of the more robust arguments against psychologists prescribing is that prescribing psychologists would eventually drive psychiatrists out of jobs. This is mostly because psychologists are in essence the cheaper alternative to a psychiatrist (Grohol, 2008).

Dr John Grohol also states (2010b) that the area of expertise will be switched over; psychologists, from being primarily the main providers of psychotherapy, will turn out to be medication dispensaries like their brothers and sisters; the psychiatrists. He states;

“The fundamental problem with psychologists gaining prescription privileges is the inevitable decline over time in the use of psychotherapy by those same psychologists. This is precisely what happened to psychiatry — they went from the psychotherapy providers of choice, to the medication prescribers of choice. Now it’s hard to find a psychiatrist that even offers psychotherapy”(para 4)

Quite clearly, there is always the desire of a “quick fix” in a problem with prescription drugs. Many are under the mislead assumption that prescription medication are the quick road to recovery. So there is always the lingering tendency to have option to choose if there is a habit of getting rid of problems out of the way. But where is the importance placed in providing area expertise and experience?  Or in being competent in a certain area? Where is the idea that psychological recovery requires practice and a change in routines/habits?–which requires a period of time and therapeutical intervention! Grohol also states that insurance and pharmaceutical add financial factors in motivation for psychologists to prescribe when you consider rates for them.

With all things considered, you must be thinking in all this commotion: What is all this fuss about? Psychopharmaceuticals of course; but what about their efficacy or it’s state of affairs? Should you even trust mental health prescription medicine to work? What I hope to cover is just that; the efficacy in pharmacology, and the crisis facing psychiatrists because of that. Much doubt has been raised in psychiatric medicine because of the crisis and much of it is because of the rigid treatment model and approach to mental illness that has not seen much change in the last decades. I, however, will get more into this next.

The Death of Psychiatry?

To any avid reader or follower of the behavioral and mental health tradition, psychiatry is known as a branch in the study of medicine which seeks detection, prevention, and treatment of mental disorders and diseases. It distinguishes itself primarily as medically based and, moreover, uses an approach to abnormal behavior and disorders predicated on the idea that all said conditions are brain-based. That is, psychological disorders, diseases, illnesses, and what have you, are brain-based; biologically based. Psychoactive medicine operates with much of the same assumptions. Hence, it is important to see that the crisis in one is the crises of the other. As we will soon see.

Funding Research In Psychopharmacology

Considering the role of funding is crucial in the assessment of any sort of validity to the idea that the science of medicine and mental health is at a crisis. This is mostly because much of the science that supports and maintains developments in psychoactive drugs is the same that supports and maintains psychiatric medicine. Also, psychiatric and psychoactive medicine focus on the functions of different parts of the brain and works off of an agreed upon model that is functional; incorporating illustrations of brain chemistry; for example, the agreed upon examples that help shed light on the levels of serotonin or epinephrine activity, or whether neurotransmitters are working distributing the right amount signals, or even, moreover, whether dendrites are sending the right degree of coding via neurotransmitters etc. Much of the brain structure and chemistry behind a psychologically psychiatry_pharma_bedfellowsfunctioning individual are then used as an example for which to judge others by. As a result, the example is used as an absolute unchanging rule of thumb which psychoactive drugs are used to sustain and regulate.

Nevertheless, funding being given to research in the pharmaceutical industry is absolutely important to keep up with the continuing developments in mental health and so the possibility of funders withdrawing support would be disastrous. However, to much of the dismay, that is just what is happening according to a statement made in the European College of Neuropharmacology (2011a);

“Research in new treatments for brain disorders is currently under threat[…]withdrawal of research resources is a withdrawal of hope for patients and their families” (para 34)

Dr David Nutt, a neuropharmacologist at Imperial College London(2011b), stated at a press conference that “these are dark days for brain science”. Dr Guy Goodwin and Nutt also say that partly the reason for this is because there is still a stigma revolving around the condition of depression. It is furthermore reported that in a 2011 meeting of the American Society for Clinical Pharmacology and Therapeutics, only 13 of 300 abstracts related to psychopharmacology and, again, none related to novel drugs. This situation mirrored that at the 2010 Collegium Internationale Neuro-Psychopharmacologicum, where 8 of 870 abstracts were on human psychopharmacology and four were on “new or relatively new mechanisms of action”, they report (Cressey, 2011b). So in light of this, developments in research have been lacking and that is the primary reason why funding has been withdrawn.

With with the lack of funding, developments and innovations are not up to pace. Consequently, psychiatrists, the presribers are left with psychoactive drugs that are no longer relevant and the main source of work becomes endangered.

–Studies in Antidepressants and The Placebo Effect

Note:: a placebo effect is a beneficial health outcome resulting from a person’s anticipation[or expectation] that an intervention—pill, procedure, or injection, for example—will help them. A clinician’s style in interacting with patients also may bring about a positive response that is independent of any specific treatment (NCCAM)

Research on the placebo effect and the efficacy of antidepressants have also raised doubts as to the effectiveness of psychoactive drugs. Many of the reasons why this is so is because the neuroscience behind psychiatric medicine, as a whole, operates within a small framework and a rigid explanatory reference–which in this case creates the problem. Dr Nathan P. Greenslit and Ted J. Kaptchuck (2012a) argue in much the same way;

“Not only do neuroscientists debate the most basic of biological mechanisms that maybe involved in depression, but some recent analysis of clinical trial data suggest that, overall, SSRI antidepressants like Prozac and Effexor  (venlafaxine) do not work much better than placebos”(para 4)

In addition, Greenslit and Kaptchuk go on to say “the placebo effect has been especially troublesome for pharmaceutical company trying to demonstrate the efficacy of antidepressants in clinical trials”(para 18), which I think partly contributes to the psychopharmaceutical crisis talked about earlier.  This interferes with the treatment and the patient-doctor process and places importance on the patients perceptions.

The placebo effect is mainly dependent on patient expectations which in turn are critical factors as to what direction the treatment process might take. No one is more well-known in placebo studies and slightly controversial than Dr Irving Krisch, who has dedicated the majority of his profession in placebo studies, antidepressants, and hypnosis. In this short clip (2012b) he states quite explicitly “the idea that depression might be caused by a chemical imbalance in the brain turns out to be a myth” (at 00:47).

Refer here: 

He says that yes, antidepressants work but they work primarily because of the placebo effect and not because the chemicals that are in it. Which correlates with both Dr Greenslit and Kaptchuck’s statements.

An associate clinical professor of psychiatry at Tufts University School of Medicine, Daniel Carlat MD cites(2010c) an study in a New York Times magazine article in which the placebo effect made up for up to 3/4 of the improvement on patients using antidepressants. He writes;

“In one study, for example, researchers did a meta-analysis of studies submitted by drug companies to the F.D.A. on seven new antidepressants, involving more than 19,000 patients. It turned out that antidepressants are, indeed, effective, because on average patients taking the pills showed a 40 percent drop in depression scores. But placebo was also a powerful antidepressant, causing a 30 percent drop in depression scores. This meant that about three-quarters of the apparent response to antidepressants pills is actually due to the placebo effect”(para 19)

Dr Carlat happens to also mention that other “non-biological” treatments, such as psychotherapy, have also noticeable effects on the brain;

“In an experiment conducted at U.C.L.A. several years ago, with subjects suffering from obsessive-compulsive disorder, researchers assigned some patients to treatment with Prozac and others to cognitive behavior therapy. They found that patients improved about equally well with the two treatments. Each patient’s brain was PET-scanned before and after treatment, and patients showed identical changes in their brain circuits regardless of the treatment”(para 21)

None of those studies highlighted involved any sort of brain science or psychiatric brain-based interventions. What they did show is the correlation of patient expectancies and patient-doctor interaction and its implications in recovery. What placebo studies show is the current mood about psychopharmaseuticals according to the general populace and how they believe they do work, but they work because they believe they worked.

–Psychiatry and Existentialism

One of the major impacts in our developing process is internalized concept of meaning-in-our lives. As I have written in my previous blog, one of the most critical factors in developmental life, with its implications later on in life, is that we have some sort of reflection period early on in our lives. Along with a planning process for your future endeavors, allowing yourself the space to develop an idea of your sense of self, so that you may know what your dislikes and likes are. All important factors that have effect on your reflection process you have in your later years.

Regardless, Gary Gutting PhD, philosophy professor at the University of Notre Dame, published an article in the New York Times Opinionator(2013) that criticized some of the changes to the DSM 5, due to come out in may of 2013, regarding bereavement and depression. On his opposition to the removal of ‘bereavement’ from the diagnostic criteria of depression, Gutting writes;

“first of all, psychiatrists as such have no special knowledge about how people should live.  They can, from their clinical experience, give us crucial information about the likely psychological consequences of living in various ways (for sexual pleasure, for one’s children, for a political cause).  But they have no special insight into what sorts of consequences make for a good human life.  It is, therefore, dangerous to make them privileged judges of what syndromes should be labeled “mental illnesses.” (para 7)

Gutting’s admission of the “should” in a person’s life holds some merit to my beginning paragraph when I mentioned my blog that is specifically about midlife crisis during the latter stages of developmental life. An individual undergoing a midlife crisis might meet diagnostic criteria for depression, bipolar, or even personality disorders (narcissistic or anti-social) and not get the proper treatment because the psychiatrist is trained to spot, identify and diagnose manifest characteristics, and bases it in a biochemical cause. When this does occur, the patient is not dealing with the core underlying causes not based in the biology of the brain, or “chemical imbalance”. What then happens is that a rug is being thrown over the true causes by the use of a “chemical straitjacket” all the while not addressing the underlying issue. All because of a psychiatrist’s small explanatory framework. The patient suffers. As a result, prescription medicine, if they are used, are less effective and provide little to no relief in symptomatology and the pain it causes the afflicted. It is counter-productive to a health science. As Gutting mentions, it becomes a question involving a “moral issue”. Quite rightly so.

Gutting goes on to further mention that psychiatrists have a purely medical viewpoint and thus are not especially designed to make moral judgments(Gutting, 2013), and props up the case that different schools of thought in psychology take diagnostic criteria, for example bereavement, not as a symptom but a way of living in the world (Gutting, 2013).

Conclusion

So what does the imminent failure of psychiatric medicine mean for psychologists seeking prescription medicine privileges? Well, I hope to have discouraged some from continuing onto that route. This is only because the future does not seem so bright in light of the research trials and the underlying theoretical assumptions that turn counterproductive to a health science. I mean, do psychologists really need something here that has high failure rate and operates on a myopic viewpoint of mental health? Is that what you want for your patients? As I have mentioned before here, funding is now being withdrawn because new innovations in the psychopharmaceutical industry have not been forthcoming. Research in psychopharmacology is expensive and requires a longer substantiation process than other types, in this case, real medical conditions; such as cancer, diabetes, thyroid conditions etc. It then seems reasonable to think the rate of progress will only gradually decline as time moves forward. And so, the studies into the effectiveness of “non-biological” interventions( i.e. psychotherapy including placebos) have proven to shine brighter and leave a significant positive trend in treatment–at the same time lending credibility to the idea of non-biological treatment methods. The idea of a health science is to attain treatment. Psychiatry is becoming to be progressively impotent in this area, and this is all because the narrow framework and limited range of explanatory phenomenon it leaves available to itself. The only solutions I see with psychiatry in the future is either its eventual demise or a reformation so significant to where it is no longer singularly a medical and biologically based science.

References:

Antidepressants and the Placebo Effect: The Emperor’s New Drugs by Irving Kirsch, PhD. (2012b) Retrieved http://www.youtube.com/watch?v=LQ_EixhrFaw

National Alliance on Mental Illness.(2002). Prescribing Privileges for Psychologists: An Overview. Retrieved from http://www.nami.org/Template.cfm?Section=Issue_Spotlights&template=/ContentManagement/ContentDisplay.cfm&ContentID=8375

Carlat, D. (2010c, April 25). Mind Over Meds. The New York Times Health. Retrieved from http://query.nytimes.com/gst/fullpage.html?res=9D01E2D9143CF936A15757C0A9669D8B63&sec=&spon=&pagewanted=all

Cressey, D. (2011b, June 14). Pharmacology In Crisis. Nature. Retrieved on April 11 2013, from http://www.nature.com/news/2011/110614/full/news.2011.367.html

Greenslit, P., N & Kaptchuck, J., N. (2012a, March 29). Antidepressants and Advertising: Psychopharmaceuticals in Crisis. National Center of Biotechnology Information. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3313530/

Grohol, P., J. (2008). While Psychologists Try For Prescription Privilege.Psych Central. Retrieved on April 11 2013, from http://psychcentral.com/blog/archives/2008/03/21/while-psychologists-try-for-prescription-privileges/

Grohol, P., J. (2010b). Why Psychologists Shouldn’t Prescribe. Psych Central. Retrieved on April 10 2013, from http://psychcentral.com/blog/archives/2010/03/23/why-psychologists-shouldnt-prescribe/

Gutting, G. (2013, Febuarary 6). Depression and the Limits of Psychiatry. The New York Times The Opinion Pages. Retrieved from http://opinionator.blogs.nytimes.com/2013/02/06/the-limits-of-psychiatry/

Nutt, D & Goodwin, G. (2011a). European College of Neuropharmacology. 21, 495-499

Rubin, E. (2010a, June 21). Psychologists and Prescribing Privileges. Psychology Today. Retrieved on April 07 2013, from http://www.psychologytoday.com/blog/demystifying-psychiatry/201006/psychologists-and-prescribing-privileges

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9 responses to “The Death of Psychiatry

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