There Is No Identity Crisis in Psychiatry

The New England Journal of Medicine published an opinion in their October 31, 2019 edition titled “Medicine and the Mind-The Consequences of Psychiatry’s Identity Crisis” (1).  Claiming that psychiatry (meaning organized psychiatry and all psychiatrists) has some sort of an identity crisis is a favorite editorial topic these days. It lacks face validity considering over 40,000 psychiatrists go to work every day, have working alliances with their patients, treat problems that no other doctors want to treat, and get results. Furthermore, most psychiatrists are working in toxic practice environments that were designed by business administrators and politicians. As a result, psychiatrists are expected to see large numbers of patients for limited periods of time and spend additional hours performing tasks that are basically designed by business administrators and politicians and have no clinical value.

The authors in this case fail to see that problem. In their first paragraph they critique “checklist amalgamations of symptoms” as if that is psychiatric practice or what psychiatrists are trained to do in their residency programs. I happen to be an expert in these checklists because I have been critiquing them from the outset. The state of Minnesota mandates that all patients being treated for depression in primary care settings have to be rated on these checklists over time, and that data is supposedly analyzed as a quality marker. Anyone familiar with the analysis of longitudinal data will realize that cross-sectional data points on different patients at different points in time are meaningless. But that doesn’t prevent politicians in Minnesota from dictating psychiatric practice and it doesn’t prevent these authors from blaming psychiatry for it.

Their additional opening critique on “medication management” ignores the fact that this procedure was invented by the federal government. This procedure and all the associated billing codes did not exist in psychiatry until HCFA thought it was a good idea to assign these codes to psychiatrists and call them “medication management”. It was only recently that psychiatry could use the same E & M codes that the rest of medicine uses for the provision of complicated care including psychotherapy. Instead of just stating that the authors say “We are facing the stark limitations of biological treatments, while finding less and less time to work with patients on difficult problems”.  Apart from the rhetoric I don’t know what that means. If I have a patient with a difficult problem - I make the time to work on it.  If there were any stark limitations in psychiatry – they occurred before the invention of biological treatments. In those days, people died from severe psychiatric disorders and the associated effects of severe hyperactivity, starvation, and dehydration.  Many people also had their lives disrupted when they were sent to state mental hospitals for years or in some cases decades.  Those were the historic limitations in psychiatry.

They move onto a critique about diagnosis and their opinion that “the solution to psychological problems involves matching the “right” diagnosis with the “right” medication". I don’t know where the authors went to psychiatry school but that is a new one on me.  At a different point in their opinion piece they critique the current diagnostic manual. If they read that manual they would notice there are conditions with strictly psychological and social etiologies that do not require medical treatment. They also minimize the role of tertiary consultants like myself. I see thousands of people who were started on psychiatric medications by non-psychiatrists. There is clearly a lack of expertise prescribing those medications and I make the necessary adjustments including stopping medications that were inappropriately prescribed. I also prescribe the indicated treatment when it was never provided in the first place. That all happens in the context of a therapeutic relationship and providing necessary psychotherapy.

Somehow the authors conclude that a lack of “scientific and intellectual integrity” does a disservice to patients, practicing psychiatrists, and medical colleagues. They suggest that medical colleagues are striving to provide the best possible and “most humane care to people with medically and psychologically complicated conditions”. I don’t know who the authors think is holding up the psychiatric and psychological end of that treatment. I worked in a multidisciplinary clinic with every imaginable consultant for 22 years. Nobody hesitated to refer patients to me for psychiatric care. They knew it would be comprehensive, that the assessment would be exhaustive, and that the treatment plan would be beneficial. We also had an active consultation-liaison team that provided active ongoing consultation to a large medical-surgical hospital. Without those psychiatric services there is no “humane care” to the medically complex psychiatric patient. This psychiatric function is widely known and these treatment plans can be read directly from the pages of the NEJM.

The authors provide a one sentence sketch of brain function and how the external world affects our “brain-minds”. They grudgingly acknowledge that basic science may be a necessity. They bemoan the fact that advances in neuroscience “are still far from offering real help to real people in hospital, clinic, and consulting room”.  That is not what I observed in 35 years of practice. There has been a steady improvement in psychopharmacology both in terms of safety and selectivity. There have been major advances in neuromodulation -both electroconvulsive therapy and transcranial magnetic stimulation. There have been pharmacological advances in addiction psychiatry with more medication assisted treatments. There have been advances in specific conditions like severe psychiatric disorders associated with pregnancy and various forms of catatonia. The diagnostic advances related to basic science research have been stunning. When I first started consulting in nursing homes 35 years ago - every diagnosis was either “senility”, “senile dementia”, or “atherosclerosis”. There were no science-based diagnoses of dementia in those days. We currently have a comprehensive approach to detailed dementia diagnoses as well as a comprehensive approach to diagnosing 127 different conditions associated with substance use disorders all neatly detailed in the diagnostic manual that they seem to have a problem with. Hopefully there is no more “senility” in nursing homes.

The authors attack neuroscience in the usual ways. They state they agree that discoveries in neuroscience are exciting but on the other hand “are still far from offering real help to real people in the hospital, clinic, and consulting room.” They restate that twice in the space of this brief essay. Is that true?  Some reading in the area of translational psychiatry might be in order. Every week I assess many patients for anxiety disorders. A significant number of them have been anxious their entire life. There are currently no good conceptualizations and indicated treatments that separate this group from people who develop anxiety later in life. From the work of Kalin and others (3,4), the biological basis of anxious temperament and potential solutions to lifelong anxiety is now becoming a possibility. Progress in neuroscience has gone from receptors and neuroendocrinology in the 1980s to genetics and multiomics in the 21^st century. Now there is more than speculation and empirical trials. Entire mechanisms that include genetics, transcription, anatomic substrate and the impact of the environment on brain systems are determined.

There is in fact a group dedicated to bringing neuroscience into the clinical realm – The National Neuroscience Curriculum Initiative. It is possible to think of a neuroscience-based formulation as easily as one might think of a psychodynamic formulation.  The point of neuroscience research in psychiatry is the same as it is in any other specialty with one exception - the organ being studied is more complex and generates a conscious state. The basic science of practically every other field has been studied more intensely and with more resources than brain science has been studied. Many other fields have not produced miracle cures when it comes to chronic illnesses and the basic treatments of these illnesses have been static for decades. The cures or disease altering interventions often occur after much more time has been spent studying them then we have spent studying the brain. In that context, basic science brain research is as on track as any other field

The most erroneous opinion advanced by these authors is that psychiatry has somehow abandoned the social and psychological elements of care. They cite an author who is a historian and who suggests that psychiatrists should limit their scope to “severe, mostly psychotic disorders”. There are many authors with similar irrelevant opinions about psychiatry but they generally aren’t quoted in an opinion piece for the NEJM. Nothing that author says is realistic or accurate in this article, but that is typical of the so-called critics of psychiatry. The authors own proposals for change in psychiatry are similarly irrelevant because it is apparent that they have a limited understanding of what is going on in the field or what psychiatrists do on a day-to-day basis.

The next section of their opinion piece is about funding and how biological funding has “replaced all other forms of psychiatric research”. They provide no evidence in terms of actual numbers. I expended some effort to try to do that.  I asked NIH, NIMH, SAMHSA, one of my US Senators and I tweeted the director of the NIMH to get an answer to the question about the proportion of funding for basic science versus psychosocial mental health research. I also searched the AAAS research reports to see if anything was listed there. What I got back was largely devoid of any useful data.  The above links were sent to me by a public affairs specialist at the NIH.   

I remembered reading about an analysis in American Psychologist suggesting that 30% of the $1.6B NIMH budget goes to psychosocial research. I was able to find the article (2) and it was not straightforward as most advocates of increased psychosocial research think. That 30% figure comes from a graphic generated by a review of research abstracts of 15% (2,028) of all funded studies from 1997-2015. They were coded on a 1 - 5 scale by doctoral level students where 1 = entirely focused on biomedical topics to 5 = entirely focused on psychosocial topics.  There was a positive trend in favor of biomedical research but the authors point out several limitations in the data and areas for further study. And they make this important comment:

“A test of the differences in regression slopes indicated that there was, however, no difference in the increase in award size for R01 grants, F(1,475) = 3.97, p = ns, suggesting that the proportion of biomedical grants awarded increased, but they did not receive disproportionately larger awards than psychosocial grants. This is notable given that biomedical research is often more costly because of expensive procedures and larger research teams.” (p. 417-418)

This reference provides a very balanced look at the issue including a discussion of the significant limitations of psychosocial treatments - something that you do not see in the NEJM piece or from the people claiming that basic science research is clinically worthless. 

Although the authors are critical of neuroscience results, they don’t seem to mention the lack of innovation in psychotherapy and other psychosocial therapies. More significantly they ignore the fact that these therapies are routinely not funded by managed-care companies, government insurers, and responsible counties. They blame psychiatry for the “abandonment and incarceration of people with chronic, severe mental illness” when in fact the necessary psychiatric beds and inpatient facilities as well as community housing for these patients has been actively shut down by businesses and governments over the past 30 years.  It seems that counties have adapted managed-care practices that includes rationing services for the chronically mentally ill to the point that they end up in jail. The authors seem to conveniently blame psychiatry for that. Once again they could read about what psychiatry really does in the pages of the NEJM and how these very patients are served by ACT teams. The treatment approach was invented to improve the quality of life of people with chronic mental illness and support them in independent living. It does not work in a vacuum and there has to be a funding source.

The authors suggest that psychiatry needs to be “rebuilt”. From their suggestions about training programs I wonder if they participate in training programs, teach residents, and work on resident curricula.  And if they do - I wonder what that training program looks like. I say that because all the suggestions they have seem to have been in place for decades. In fact, their entire argument is reminiscent of the old "biological psychiatry versus the therapists" argument from about 1984. That argument should stay firmly planted in the "old history" folder.

Their concluding paragraph is a extension of earlier rhetoric.  They talk about psychiatry having an exclusive focus on “biological structure” rather than meeting the needs of real people. I go to work every day and talk to real people all day long. I know quite a lot about the biological structure the brain and its function. I must because I don’t want to be treating a stroke, brain tumor, a traumatic brain injury, or multiple sclerosis like a purely psychiatric problem. I also realize that if I conceptualize the psychiatric disorder as a specific brain area or network - that is still occurring in a unique conscious state. That conscious state is generated by the most complex organ in the body. It is an organ with tremendous computational power. All psychiatrists are treating people with unique conscious states and there is no specialty more aware of that. And in that complex setting psychiatrists are focused on helping the people they are seeing. They are the only ones accountable.

There is no “identity crisis” in psychiatry. Making that claim requires a suspension of the reality about how psychiatrists are trained and the grim practice environments that many of us face. Those grim practice environments are the direct result of governments and businesses actively discriminating against psychiatrists and their patients. That has resulted in discrimination that is so gross that county jails are now regarded as the largest psychiatric hospitals in the USA.  Pretending that these problems are the result some flaw in psychiatrists one of the greatest medical myths of the 21^st century.  These authors and the New England Journal of Medicine are promoting it.  This opinion piece is so poorly done it makes me wonder what the editorial staff at NEJM are doing. It is as bad as another opinion piece that should never have been published in the psychiatric literature.   

The real message from the profession that should be out there is:

“Give us a practice environment where we can do what we are trained to do! Get out of the way and let us do our work! Give us the resources that every other medical specialist has!”

Very few of those environments exist.  They have been rationed out of existence by politicians, bureaucrats and administrators.  People who know nothing about the field seem to be totally unaware of that problem and like these authors they never comment on it. Only people lacking that awareness would believe an article like this - or write it.

George Dawson, MD, DFAPA

References:

1: Gardner C, Kleinman A. Medicine and the Mind - The Consequences of Psychiatry's Identity Crisis. N Engl J Med. 2019 Oct 31;381(18):1697-1699. doi:10.1056/NEJMp1910603. PubMed PMID: 31665576.

2: Teachman BA, McKay D, Barch DM, Prinstein MJ, Hollon SD, Chambless DL. How psychosocial research can help the National Institute of Mental Health achieve its grand challenge to reduce the burden of mental illnesses and psychological disorders. Am Psychol. 2019 May-Jun;74(4):415-431. doi: 10.1037/amp0000361. Epub 2018 Sep 27. PubMed PMID: 30265019.  

I thank these authors for making this paper available on ResearchGate.

3: Kalin NH. Mechanisms underlying the early risk to develop anxiety and depression: A translational approach. Eur Neuropsychopharmacol. 2017 Jun;27(6):543-553. Doi: 10.1016/j.euroneuro.2017.03.004. Epub 2017 May 11. Review. PubMed PMID: 28502529; PubMed Central PMCID: PMC5482756.

4: Fox AS, Kalin NH. A translational neuroscience approach to understanding the development of social anxiety disorder and its pathophysiology. Am J Psychiatry. 2014 Nov 1;171(11):1162-73. doi: 10.1176/appi.ajp.2014.14040449. Review. PubMed PMID: 25157566; PubMed Central PMCID: PMC4342310.



Supplementary:

The Psychiatry Milestone Project: an indication of what psychiatry residents are evaluated on in their training programs. Link.

Graphic Credit: 

The graphic was downloaded from Shutterstock per their standard user agreement.