Mental Health Matters: As human beings we all face the problem of living
February 25, 2015
I began post graduate speciality training at the dawn of the biological era in psychiatry, the 1960s. Subsequently, mental illness was increasingly viewed as a brain-based disorder driven by aberrant chemical reactions.
Drugs designed to correct supposed chemical imbalances in the brain constituted the new science of psychiatric treatment.
"Old school" psychiatric practitioners trained in talk therapies were increasingly supplanted over the next 50 years by "modern" science based psychiatrists both at academic institutions and in the practice community.
The "50-minute hour" devoted entirely to exploring your problem came to be seen as inefficient. The failure to prescribe medication during those 50 minutes could, over time, become the cause of a malpractice claim.
Today, the 20-minute psychopharmacology visit in which symptoms are collected and pharmacotherapy dispensed is the new "evidence based" medicine. The general practitioner may perform this service instead of a psychiatrist. Should pharmacotherapy alone not suffice, the patient is referred to a non-psychiatric mental health practitioner.
So, what happened to me along the way?
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First, I noticed that many if not most of my brethren in psychiatry wholeheartedly embraced the new "science" based pharmacological treatments, i.e. antidepressants to treat depression, anti-anxiety drugs to treat anxiety, and antipsychotics to treat psychosis. Now we were "real doctors" just like other physicians who diagnosed and treated disease.
Second, I noticed that many, if not most of my fellow psychiatrists reported excellent results with these powerful new medications, particularly in the treatment of depression; give the right antidepressant at the appropriate dosage and, voila, the depression disease remitted.
I had a problem with these marvelous new drug therapies. Most importantly, somehow my patients didn't seem to respond to antidepressant medications nearly as well as the claims made by my colleagues about their patients. The scientist in me wondered why.
Then there was the problem of my interest in what makes people tick or, "What is it about your life that might lead you to become depressed?" For me, brain chemistry might be a partial explanation. But it was never a sufficient explanation.
Stuff happens to people, and it was that stuff that interested me and, I believed then, and now, substantially contributes to emotional ailments.
I did make other clinical observations: My patients with severe mental disorders responded better to medications. Those with situational acute or subacute problems did much better with talk therapies.
Patients with primarily anxiety-driven problems rarely thrived on anti-anxiety medications, both because they have addictive properties and because they undermine the tough work that learning new coping strategies entails.
Summarizing, I was far less enamored of pharmacotherapy than most of my colleagues. Still, given the temper of the times, I generally prescribed medication along with psychotherapy.
After all, the accepted wisdom was to prescribe, and so I did. Indeed, if one medication didn't do the trick, I tried another one. This "empirical therapeutic strategy" was also part of accepted wisdom.
Logic seemed to dictate that if mental ailments were brain-based chemical imbalances, then finding the right medication should make you better.
The pharmaceutical companies loved it and so did their shareholders. Academics made careers of doing research with pharmaceutical company funding, and achieved results "proving" that drug therapies were superior to all others, both in terms of outcome and time management.
Pertaining to the latter issue, prescribing medications is a lot less time intensive than exploring, to name just a few, the contours of a troubled relationship, a reclusive temperament or dysfunctional behavior patterns.
Even now, "Medication Management" to treat emotional ailments is among the most lucrative propositions both for drug companies and psychiatrists.
For several years I continued to subscribe to the dominant ethos in psychiatry, prescribing medications for most of my patients including those with less-severe psychiatric ailments even though the pharmacotherapy results with this group were less than stellar.
Too bad I didn't allow my nascent intuitions about these medications to evolve. Fortunately, in the past 15 years or so, others have done the work for me.
Turns out that much of the so-called research on antidepressants in particular, and less so with other psychotropics, was mistaken, either due to poor research methodology or a propensity to draw conclusions that may have satisfied drug manufacturers at the expense of scientific accuracy.
Now, we know that medications usually don't work well for people with mild or moderate depression. For severe depression, efficacy data is far more solid.
We also know, with rare exception, that anti-anxiety drugs should only be used short term, as in for two to four weeks; talk therapies are generally the treatment of choice for these difficulties.
Finally, here's what I know that is most consistent with most research in mental health treatment: As human beings we all face the problem of living. It works out better for some than others. Failing to solve a problem that threatens to drag us under, we would be wise to seek professional assistance.
The central and most important element in any psychotherapy is not the school of thought of the therapist, the methods used by the therapist, and not even the technical skills of the therapist.
The most important dynamic in successful therapy, and arguably in building a successful life, is the quality of the relationship between the participants.
Incline Village resident Andrew Whyman, MD, is a clinical and forensic psychiatrist. His column focuses on drugs, mental health and substance abuse in an effort to raise better awareness. It appears every other week in the North Lake Tahoe Bonanza and Sierra Sun. He can be reached for comment at firstname.lastname@example.org.