Magazine article Clinical Psychiatry News

My Wish List for Psychiatry

Magazine article Clinical Psychiatry News

My Wish List for Psychiatry

Article excerpt

I have always been an optimist, but it is difficult for me to see a bright future for the specialty of psychiatry.

The progress we have made over the last 50 years has been miraculous. However, these very miracles have split us into two discrete segments--those who adhere to a biopsychosocial model and those who are wedded to a biomedical model.

T.M. Luhrmann's outstanding book, "Of Two Minds" (New York: Random House, 2000) clearly laid out the struggle in 2000. As we entered the new millennium, we found ourselves caught in a conflict that, I believe, diminished the psychiatrist from a multitalented, multifaceted practitioner to a specialist limited to pharmacologic treatments for the seriously and persistently ill.

The popularity of psychodynamic psychiatry has been waning for about 40 years. We now find ourselves bludgeoned with the term "evidence based," which I presume means "manualized," psychotherapies.

Everyone acknowledges that research psychiatry and the practice of psychiatry are very different. But the myth that the research directs the practice is often repeated, as if to give credence to the idea that we are like other physicians.

We are not like the others. Our scope is broader, and our efforts to span the brain and the mind make it much more difficult to diagnose patients accurately, to use blood tests, and to have quick, definitive, accurate treatments requiring limited interaction between doctor and patient.

The failure of many physicians to understand the power of the doctor-patient relationship is responsible for so much unhappiness expressed by doctors and patients with one another, with the practice of medicine, with the sloppiness we sometimes find in practice, with the disrespect and disregard that patients often feel, and, ultimately, for the 90,000-plus hospital deaths that occur each year.

The biopsychosocial model, which is critical to psychiatry, requires that the psychiatrist address not only the biomedical components of an illness, but also the psychological factors, including the patient's childhood development, personality traits, and the sociocultural context in which the patient developed the mental illness or emotional disturbance.

That is a tall order. It requires an exquisite ability to interview the patient and gather as much information as possible before deciding on treatment. Now the patient is medicated soon after being seen briefly in the emergency department. As a result, the psychiatrist never gets to see the pristine symptomatology and draw conclusions.

Even though one must be well-schooled in pharmacology and chemistry, using the biomedical approach to mental illness is ultimately easier.

Limiting the doctor-patient relationship to occasional med checks is much less stressful on the physician.

I've never been able to view a patient statistically. I was distressed to learn that in the STAR-D trial, depression improved in less than 70% of the cases after four additions and/or substitutions of major antidepressants. All the hype had originally led me to believe that the treatment method used in STAR-D would prove overwhelmingly successful.

Furthermore, there seems to be no curiosity about the etiology of the original symptoms. In fact, the etiology is now deemed irrelevant. The chemical reactions in the brain and any information that can corroborate the presumptive diagnosis are important, but we need to foster and develop intellectual curiosity in our residents, because biopsychosocial approaches will not grow without it.

Psychiatrists and psychiatric residents need to know that metaphor and symbolism are vital to understanding the patient. Furthermore, allied social sciences, such as anthropology, traumatology, sociology, and public health play important roles in the effort to complete the jigsaw puzzle called humanity.

The future of psychiatry also hinges on our ability to fully rid society of the stigma against the mentally ill and their caregivers. …

Search by... Author
Show... All Results Primary Sources Peer-reviewed


An unknown error has occurred. Please click the button below to reload the page. If the problem persists, please try again in a little while.