Tuesday, February 21, 2012

How Can Psychiatry Save Itself?

The front page article of the Psychiatric Times is Ronald Pies article: “How can American Psychiatry save itself?”  The only thing more excruciating than watching a well written article stretched across 7 pages of drug ads is the rehashing of what are essentially political arguments against the field.

DSM 5 – good or bad?  Lack of objective markers, lack of a biological basis of behavior or an adequate description of the phenomenology, yada, yada, yada.

The articles about a $3.5 billion shortfall in funding state mental health programs and the elimination of psychiatric services at Cedars-Sinai stand in contrast to the science and philosophy of what is wrong with psychiatry.

Ever since I became a psychiatrist, I have been impressed with the levels of self flagellation in the field.  Psychiatrists will provide any number of debates about what is wrong with the field and in the more extreme cases agree with any scapegoating of the field based on the behavior of a few.  We also seem to have the largest number of experts who want to make a living out of critiquing the field.

A good comparison would be with our colleagues in Cardiology.  There is currently a boom in implantable pacemakers and implantable cardioverter defibrillator devices (ICDs).  The widespread use of many of these devices is at least as controversial as anything in the field of psychiatry and yet compared with the 2100 hits that Dr. Pies got when he Googled “psychiatry is in trouble” – I got NOTHING for “cardiology is in trouble”.  I can go on to pulmonary vein isolation by either radiofreqency or cryosurgical ablation for paroxysmal atrial fibrillation as controversial measure number 2.  It would not stand the scrutiny that the FDA gives antidepressant drugs.  And yet while psychiatrists are ridiculed for using antidepressant drugs, nobody blinks an eye as hundreds of thousands of afibbers get ablation procedures every year despite the fact that reviews describe a 20-30% immediate recurrence rate and a long term recurrence rate of 9% per year.  There have also been no commentaries on the fact that nobody knows what an ablated left atrium looks or functions like 10 – 20 years down the road.

I generally like what Dr. Pies writes.  I like his incorporation of philosophy in his articles.  I like the way he refutes the common rhetoric used against us.   I am awaiting his suggested solution in the second article in this series and hope he has concrete suggestion to refute the rhetoric against us and expose the fallacy that there is more wrong with psychiatry than there is  with Cardiology – even though the Cardiologists have all the procedures and they tend to get paid for their work.

But let's face it - psychiatry's longstanding obsessions about whether or not we measure up to the rest of medicine should have been put to rest a long time ago.  That was when we became and still are the last hope for large groups of people with severe mental illnesses.  Our record of improved treatment in this group of patients ranks with the best treatment achievements in medicine.

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