Thursday, January 14, 2010

Antidepressant Effectiveness and False Dualism: It's Time for a New Psychiatry

The JAMA study on the effectiveness of antidepressants has occupied everybody's attention--though perhaps excessively in light of the catastrophe in Haiti. I just read Richard Friedman's response to the study in the New York Times and I agreed with his argument, in which he criticizes the study's methodology, arguing that it is based on a relatively small number of studies, and that studies were chosen that maximize, rather than minimize, the placebo effect.

As I review the various comments about the study, both on my blog and elsewhere, what strikes me is how polarized the debate has become. On one side are those who defend the efficacy of drugs, and on the other side are those who denigrate the medication option and argue that psychotherapy is the true cure for depression. This is yet another version of the old and tiresome nature vs. nurture debate, which has been a staple of the rancorous psychiatrist vs. psychologist turf wars ever since I started my residency at Mass General in 1992.

In one corner of the boxing ring are those "biological psychiatrists" who argue that depression is essentially a biochemical disorder that is logically treated using agents that adjust the biochemistry. In the other corner are those who argue that depression is a response to life stress and is best treated by therapy techniques that help people cope.

But this dualism is illusory. When people become depressed, yes, their brains are disordered in some still mysterious way. The idea that a serotonin deficiency is responsible is only a hypothesis and one that has been weakened over the years by studies failing to demonstrate such a biochemical imbalance. I have confidence that someday we will locate the brain circuits involved and that we will be able to rationally target them with biological cures. But we are still very far from that; the current crop of antidepressants work on neurotransmitters but they may help depression through mechanisms that have little to do with serotonin or norepinephrine.

Meanwhile, we know that many people recover from depression without taking antidepressants--via the passage of time, or psychotherapy, or a placebo pill, etc.... PET scans have shown that cognitive behavior therapy leads to distinct brain changes in patients who recover from depression. Clearly, there are multiple different pathways leading to a "neurobiological" cure.

So my question is, why don't we embrace all these potential cures rather than lining up behind our favorite technique to defend its merits? Drugs work. Therapy works. Time works. And placebos work. If psychiatrists and psychologists could possibly call a truce in their various battles over therapy effectiveness and prescription privileges, we might be able to imagine a different kind of practitioner--one who is skilled in both psychopharmacology and psychotherapy. Isn't this the kind of doctor we would all want to see when it's our turn to get help?

42 comments:

Joseph Arpaia, MD said...

Absolutely agree.

Clinicians need to realize that you can't PROVE anything using experiments. You can only DISPROVE hypothesis.

What is happening is that each side points to experiments that supports their ideas and says "We are right".

That is not science. If we are going to use science we need to point to the data that disproves our ideas and say, "Our current ideas are not correct. How can we make them more correct?"

So the people who really need to look at the studies that disprove the effectiveness of antidepressants are the biological psychiatrists, NOT the therapists.

And the therapists need to look at studies that show that therapy has some serious deficiencies too. That way they can improve the effectiveness of therapy.

Sarah said...

That's how you read the comments? That's not how i read the comments. (I can't speak to comments not on your blog.) And it's not how i intended my comment...

I hate that in these discussions, i always have to point out that i am not against antidepressants, or psychotropic medications, that i am _on_ an antidepressant (weaning off of it) and i was helped by it. The possibility that SSRIs may often be prescribed unnecessarily does not suggest that they themselves may be unnecessary. They are one tool in the toolbox. They are an appropriate tool to use in certain situations. They should be used in situations in which they are likely to be the MOST effective treatment, balanced out by an acceptable level of side effects.

Acknowledging that SSRIs can have undesirable, unintended effects is not the same as saying SSRIs are bad. Nor is questioning your use of the placebo effect. I am sure that an experienced psychiatrist such as yourself can easily spot such unsubtle differences, and i'm hoping you will explain what, exactly, i am misunderstanding here.

djbaxter said...

An excellent post and an excellent summary of the issues and the public and scientific confusion that seems to surround those issues. Thank you.

Anonymous said...

Your premise that there is something wrong with a depressed brain is grossly flawed and at the heart of the failure of biological psychiatry. You think if you find differences in brain circuits you will understand "depression".If I beat my dog every day and he becomes depressed and then I look at his brain in a high tech scanner and it looks different than another dogs, do I really understand anything about what is wrong with my dog? No not at all.How can people be so short sighted as not to see this? The problem with psychiatry is it just does not want to face the fact that suffering can be suffering and nothing more than part of the human condition and studying the brain will never tell us anything about almost all the people who have sadly been seduced by the charade that is contemporary psychiatry. People will always be depressed and there is not a damn thing that psychiatry can do about that anymore than we can stop tsunami's or earthquakes. Psychiatry would never admit that because if it did there would be no place for all its pseudopathologising of normal human suffering.Instead we debate pills vs. paying someone for human contact as a TX for a disease that exists only in contemporary American culture. Maybe antidepressants will help all those victims in Haiti? Shall we send emergency truck loads of Paxil? I am sure they are "depressed". Shall we scan their brains for flawed circuitry?

Joseph Arpaia, MD said...

Sarah,

I don't think Dr. Carlat was responding to your comment. I think he was responding to professionals who are demonizing those who disagree with them. Your comment was nothing of that sort.

Anonymous said...

Dr:C: So you agree with Dr. Friedman about the alleged methodological problems of the JAMA study? Fair enough. But I wonder: Do you have any idea why it is that the two flagship journals of American medicine -- the Journal of the American Medical Association (JAMA) and the New England Journal of Medicine (which published similar findings in 2008)publish such "flawed" research? Aren't these the "A" journals of academic medicine and public policy? Are you and Friedman basically saying that these are hack publications?

Daniel Carlat, M.D. said...

Sarah,

As Joseph said, I was not responding to any specific comment but rather to the overall tenor of the debate, both on this blog and elsewhere. Anonymous, who in the comments to today's post takes a very extreme position against the notion that there can be a biologically-based depression, is illustrative.

Overall, my point is that since psychiatrists have become accustomed to being medication providers, some tend to defend the value of meds to their dying breaths--even if, in their heart of hearts they know that most patients need some therapy to get better.

On the other hand, there are those therapists who feel the same need to defend the value of therapy by denigrating meds.

I see this, ultimately, as an artifact of a training system in psychiatry that makes little sense. By forcing people to go through full-fledged medical training in order to become a psychiatrists, we guarantee that the resulting practitioners will focus on a biological solution to problems, and will be ill-prepared to understand the mind.

Instead of medical school, I propose that psychiatrists-to-be should train in "mental health" schools that teach the basics of physiology and psychopharmacology--enough to learn the art of prescribing meds. This would free up time in the curriculum to learn about crucial topics such as therapy, family work, substance abuse treatment, behavioral treatment, etc.... In fact, for a brief time in the 1980s, such a training program existed in San Francisco, called the Doctorate in Mental Health, a five year program combining the first two years of medical school with three years of psychiatric residency. But ultimately, politics intervened and the graduates were not granted prescriptive privileges. Maybe it's time to try it again. Otherwise, psychologists will surely fill the gap, as they already have in New Mexico and Louisiana, and will soon in Oregon.

Anonymous said...

I appreciate very much Dr Carlat's blog and comments. What I want to know is what exactly is a "biologically based depression" and how is one to know that is what exists, ever? How could one ever know such a thing even if one defines a biological difference in those who complain of being depressed? If I do not have this and say I am depressed, am I not depressed after all even if I say I am? This is grasping at straws by desperate folks supporting what is essentially a religious based belief system. This does not mean that I do not ever believe people cannot be helped by meds but we feel better after smoking weed or drinking booze. This tells us nothing. For the record I am a psychiatrist and I even prescribe these meds on occasion but I also drink booze and am ok with pts who say they feel better smoking weed. Does this imply they/I have a biologic defect that is being fixed? I find few if any psychiatrists ever even contemplate the limits of what can be known and the flimsy conceptual framework psychiatry stands on. I do believe in psychosis and emotion without context like mania but this is very rare and not what most Drs make there living caring for or why most meds are handed out. Dr Carlat do you really feel we should be lumping these people in as far as research and classification with the same groups that we are talking about in these blogs when you infer "biologic based depression"? The vast majority who feel just as good on suger pills. Do you really feel these people(most on anti-depressants) have a fundamental and consistent biological flaw at the core of there emotional experiences? If so what do you base this on other than hope for your field and a desire for legitimacy? Again I thank you for this blog. Dr John

Gallucci, MD said...

Once more a very good post. For those really interested in the debate of this post I strongly recommend the book "The Concepts of Psychiatry: A Pluralistic Approach to the Mind and Mental Illness" (Nassir Ghaemi MD MPH and Paul R. McHugh MD, authors).

Because most psychiatric illnesses are complex phenomena, no single method or approach is sufficient to explain them or the experiences of persons who suffer from them. In The Concepts of Psychiatry S. Nassir Ghaemi, M.D. argues that the discipline of psychiatry can therefore be understood best from a pluralistic perspective. Grounding his approach in the works of Paul McHugh, Phillip Slavney, Leston Havens, and others, Ghaemi incorporates a more explicitly philosophical discussion of the strengths of a pluralistic model and the weaknesses of other approaches, such as biological or psychoanalytic theories, the biopsychosocial model, or eclecticism. This book will be of interest to professionals and students in psychiatry, as well as psychologists and general readers who are interested in understanding the field of psychiatry and its practices at a conceptual level.

Enjoy!

Anonymous said...

I applaud Dr. C for posting the obviously extreme views provoked by the JAMA study. In truth, conflict can be healthy-- it often leads to resolutions and, in science, paradigm shifts that are the engine of scientific advancement. Much like conflict resolution on the individual level, conflict can be a stimulus for personal development and hopefully happiness or greater achievement.
I also appreciate Dr. Arpaia's comments but disagree on one point: "Insiders" rarely see or are willing to acknowledge the flaws inherent in their models or systems. One needs "outsiders" to point these out. So I don't think it is a bad thing that therapists see the pitfalls of medication and vice versa regarding biological psychiatrists positions on therapy. The important point is that we TALK to one another.
Parenthetically, Dr. C, I don't see this as a MD versus PHD or LCSW issue any longer. It may have been discipline-specific in the past, but as a psychiatrist, I can tell you that I know many colleagues who are casting a jaundiced eye on what has been sold to us by the pharmaceutical industry and key opinion leaders in our field who have lined their pockets with drug money all the while failing to disclose their conflicts of interest to NIH, NIMH, and our residents who we are entrusted to teach and mentor! By the same token, I also know many non-medical colleagues who applaud the biological approach to alleviating pain and suffering-- why else would there be the push for prescription privileges for non-MD's? Excluding economic reasons, of course!
I think we can all agree on one point, however and this hearkens back to Anonymous' post regarding Haiti and Dr. C's nice intro on the tragedy in Haiti being more of a concern than academic contretemps over the effectiveness of antidepressants versus placebo. The science of psychopathology can probably best be advanced by doing brain imaging and neural networking on the brains of Pat Robertson and Rush Limbaugh! LOL. Just kidding... sort of.

Joel Hassman, MD said...

I'm curious, what reality am I living in that is based on multiple interventions to treat depression in 2009+ ? How many people are offered other options to impact on depressed features, much less a presentation that defines major depression, that is not meds first and basically only?

It is not about a "New Psychiatry" we should be looking for, but a return to the multifaceted model of illness that is applicable to somatic and psychological illnesses. And just you wait, if this health care reform garbage is passed, you think the evidence based models that will drive what interventions are to be applied will consider other options besides medications?

Is Rod Serling directing this blog of late? Spend some time in the trenches of every day psychiatry. The people I interact with are almost all and only medicated. And in encreasing numbers on 3, 4, even 5 med regimens with a working diagnosis of depression. What the hell is this!? Psychopharmacology gone mad, in my opinion.

Our profession is pathetic as a whole. And if I am the only one with the guts to challenge the state of affairs in psychiatry, then we are all doomed as providers! Because we will become obsolete when PCPs/family MDs/internists/OBGYNs/Nurse Practitioners who will be cheaper to reimburse because they can easily write prescriptions will dumb down psychopathology to a level that will only harm more than help.

What are we going to see next? Put every one in Haiti on Zoloft or Lexapro for PTSD issues? God, it is disgusting to watch the demise of my profession.

Ronald Pies MD said...

I very much agree with the spirit of your posting, Danny (though I still favor psychiatrists going through medical school, I would like to see an expanded residency, enlarging on the "psychosocial" dimensions of illness).

I believe the philosophical roots of these so-called "turf wars" lie in the heritage of Descartes, with his mind/body dualism. This has led, in my view, to sterile debates regarding whether people have "mental" or "bodily" disease. The late R.E. Kendell MD argued that "disease" is properly predicated of persons--not minds, brains, or bodies. Maimonides said much the same thing eight centuries ago: we try to cure not a disease, but a diseased person.

Regards, Ron Pies MD

Sarah said...

Thanks for the clarification. I wasn't referring to my own comment only; several readers questioned Dr. Carlat's explanation of his use of SSRIs as placebo. Regardless of whether one agrees with Dr. Carlat, it's helpful to know that doctors do use medicines in this way!

I was unaware of this "therapy versus meds" mentality among mental health providers, which (perhaps?) speaks to the ability of providers those biases away from clients, which is a good thing. However... with regard to something you wrote...

"Clearly, there are multiple different pathways leading to a 'neurobiological' cure."

(That's a lovely summation, by the way.) Is it really the case that a large number of mental health providers do not understand the above concept? I would find that extremely worrisome.

Stiff man said...

Very interesting discussion from a layman's point of view.

Thank you, doctors!

Anonymous said...

Dr. Carlat, you said:

"Drugs work."

I asked this this in the previous thread but perhaps with all the comments, you didn't see it.

Can you provide a link to an accessible study that shows the effectiveness of an antidepressant over 5 years? If you're going to claim that drugs work, you need to be able to do this in my opinion.

Thanks!

Sara said...

It was a milestone of sorts to see a study published in a medical journal that claims antidepressants are ineffective. Of course, as an opponent of the use of antidepressants in general, I was delighted to see this, even though I found it surprising because, like others, I am well acquainted with the anecdotes of people who claim the meds are "saving their life." And these are people who have all forms of depression, not just the most severe. So I was prompted to read the study in full to see what was up. Well, like practically every other medical journal study in psychiatry I've ever read and analyzed, I thought the evidence was pretty flaky and vague and the methodology inappropriate to the strength of the data; in general it was just pushing weak data around to come up with something that had poor relevance for real clinical practice. The sophistication of the statistical analysis hardly seemed merited by the quality of the data. And not one example from the clinical details. I'm not surprised there have been a flurry of articles by antidepressant supporters, like Judith Warner (quoting Peter Kramer), Richard Friedman, and Danny dissecting the study.

Yes, I admit, as Danny says that "Drugs work" at least in some window of time, but my question is at what price does that "effectiveness" come? I'm not buying it that they should be used just because they "work." Cocaine would probably work too. I think until we really understand all the things these drugs are really doing to our brain and our body they should be avoided. I don't think it's good enough that we see a sad person, give him a pill, and out the other side of some mysterious black box comes someone happier. All very well and good but if we don't really know what's going on I think it's a very risky way to achieve that happiness. It would be fine if things froze at that point but they don't. The drug continues to wreak changes that are ill understood and, from what I've observed, things don't get better over time. Other subtle (or not so subtle) things start to happen and if someone stops the mood problems from rebound -- not relapse -- can be worse than ever unless the withdrawal is handled extremely carefully. The drugs may actually lead to someone being crippled by depression for life when they might not otherwise have been.

It almost seems like this article was written to rouse the a/d supporters from their slumber and get them riled up and defending that wonderful stimulant effect that makes so many people feel "better than well" until they become so impaired they no longer know "well" from "ill." It's time to study what happens when these drugs are used over the long term and also to study withdrawal thoroughly and deeply. That would be a much more effective use of research talent than silly studies like this one.

Nancy Frugé said...

Jay Katz considered the layman's point of view in The Silent World of Doctor and Patient:

"...patients hope that physicians can be trusted to observe carefully, to treat them with care, to alleviate unnecessary suffering, to discuss with them the implications of uncertainty's inevitable presence, to give the unpredictable forces of nature a helping hand, and above all, to remain honestly present and not abandon patients when they need them most...the promise of non-abandonment, or a caring and honest presence that can underlie faith, hope, and reassurance in the face of the limitations of medical knowledge, may be what patients seek to find in doctors as therapeutic agents, and not doctors' promise to do the impossible. Impossible promises--even when only made implicitly as they so often are--leave patients with a sense of distrust that is difficult to reverse."

Anonymous said...

Fascinating post and response comments; thank you. Regarding the notion of a biologic cause for depression; there DOES seem to be some "genetic" component...people more like to be depressed if an immediate family member struggled as well. What does this say about "biology"? And, wrt the meds, I also think we lose sight of significant side effects and difficulty people have weaning off of them.

Anonymous said...

I thought Judith Warner's piece about this was good because it acknowledges that therapy is often at least as ineffective as some pills for some people. To me the problem is our cultural view of depression as a medical disease as the New York Times Magazine piece last week discussed.

I think ssri's change mood for many people some of the time and for some people apparently all of the time and that our culture should be looking into why we think people need a medical excuse to get a happy pill, if eradicating bad feelings for the long term like these pills can do is good for the individual or for society....The biomedical model is a response to the over use of psychotherapy.

As for a new psychiatry, it sounds a bit Orwellian to me sort of like the New Freedom Commission on Mental Health. Old freedom is just fine and in someways pschyciatry is researching itself out of existence which not a bad thing.

Eileen said...

SSRIs and practically all other drug research is short-term (4 to 8 weeks). The groups studied are more seriously depressed at the beginning of the studies, and are not representative of the general population who are taking SSRIs. This is confirmed by the recent JAMA study and other research. The way of calculating success in clinical trials (50% drop in severity of symptoms) leaves people with ongoing symptoms, something we know from research and also from commercials for Abilify which tell us that most people do not get all their symptoms relieved, so they need another drug. Trials are suppressed, conclusions selected and modified to emphasize certain findings, etc. Our understanding of the effects of SSRIs is very poor. Also, most people in this country are on multiple drugs, which have never been studied together (with a couple of exceptions: Prozac w Zyprexa, lithium w Depakote, very recently Abilify and Seroquel with SSRIs). Those were also short term studies. For the Seroquel add-on studies, the difference between the two groups was so small that it did not even reach the small difference that the designers of the research projected. In terms of therapy, of course, good therapy is good and therapy only to keep people compliant with drugs is bad. Don't forget light, sleep, movement and exercise, essential nutrients not produced by the human body, unremitting and multiple stressors, neighborhood effects, adverse childhood and life experiences, etc. The HPA axis, the neuroendoctrine systems and the immune systems are all connected and impact overall health outcomes. People learn behaviors and beliefs in their families and cultures and this is what is passed down, not genes for most behaviors that we somehow have come to believe are under genetic control. Behavior and emotion is not like eye color, which is also governed by muliple genes. Plus, I think it is accepted even in psychiatry that these diagnoses (MDD, schizophrenia, etc.) are heterogeneous disorders, that is, are not one disorder, but many disorders, caused by different things (prenatal infections, birth trauma, other things mentioned previously). A broader framework is the social determinants of health and social determinants of mental health. Relying on one technology (drugs) for everyone and evey problem is not the common practice in health: think of the different technologies for problems in vision and for contraception. Think outside the pillbox.

Rosiecee said...

There should be more studies on what is happening in real life to people on these antidepressants. I agree with Sara that cocaine might make a person feel less depressed. Freud loved cocaine and used it for 5 or 6 years until he realized the potential for addiction on it.

There is no doubt in my mind that antidepressants can change a person's mood and, quite often, their personality. These "studies" are only investigating statistics in a bland, sort of controlled manner.

We need physicians, psychiatrists, psychologists, social workers, etc., who know how to ask relevant questions, especially to those who say they feel much better on antidepressants. Obviously, if the patient is feeling worse, then the expert is going to try something else. But what of those who feel better, especially those who claim the antidepressants "saved their life" and they have a glow about them - an entirely difference ambiance about them.

The expert needs to ask these patients questions such as, "Have you felt the need to shoplift lately?", "Have you decided you can go it on your own - you don't need your spouse and children anymore?", "Are you spending money excessively since starting on the antidepressant?" "Have you had any thoughts or dreams of violence?"

There are 51 [fifty-one] school shootings/incidents at www.SSRIstories.com Not one of the perpetrators was on cocaine. They were all on antidepressants. We need to consider the possibility that perhaps antidepressants, in the overall scheme, are worse than cocaine.

Of the 200+ murder-suicides [media articles] on SSRI Stories, not one perpetrator was taking cocaine or even meth or heroin for that matter. We need to rethink what is happening.

Away with the bland statistics and on into the Real World.

Anonymous said...

There desperately needs to be a clear divide between psychiatry and psychology, if for no other reason than the very fact that as a provider trained in medicine, the psychiatrist should confine him/herself to the MEDICAL aspects of the case and not be doing therapy, which can clearly be given just as effectively by thousands of other (and less expensive) providers. There is no reason for someone with advanced medical training to do "talk therapy" in this day and age; it is a waste of resources and training. It would be nice if the psychiatric profession finally made a break from analysis, therapy and the like and forged headlong into the areas of medicine and brain science on the cellular level--sciences that they should be trained to understand more comprehensively than a psychologist. So too, psychologists have the advanced training to fully appreciate and apply the many varied methods of therapy, as well as provide the kind of support and access that a medical doctor has a difficult time providing. In this age of decreasing funding for expensive health care, it would be more advantageous to have these professionals look to what is the best use of their skills for the patients that need to be treated.

We see this kind of division at work already in the area of physical therapy; the neurologist and physical therapist have entirely separate roles to play and they are able to work together for the patient's interest. Medications are adjusted by the neurologist, and the PT is able to provide all the support that the patient requires on the emotional and (in this case) physical level. It works in this case, because each professional has a clearly defined role for the treatment of the patient.

Yet, in the case of mental health, to have this continued "duality" in treatment is damaging to patients. Both psychiatrists and psychologists want to have one foot in either camp, and neither is fully trained in both disciplines and therefore the resultant care is compromised. It may take a lifetime for an individual to fully study and appreciate their own discipline, so why try to attempt a second discipline? The very fact that the mind/body problem is so very complex is even more reason that these disciplines must break apart and intensify their research, training and treatment in their respective areas, BEFORE one can ever address the mind/body duality problem.

The time has come for psychiatrists to become DOCTORS again, and deal with the brain as an organ that must be investigated medically. Once true meaningful research into brain functionality and pathology is able to be determined with more certainty, both professions can begin to merge their respective data and responses to form a more comprehensive picture of the mind/body dualism which continues to vex both professions.

The difficult path of neuroscience requires that highly trained medical professionals to do the important work that will shed more light into the complexities of mind on the physical level. Any distractions and continued forays into the therapy arenas by psychiatrists are merely prolonging the suffering of patients who are desperately waiting for answers and good, reliable, CURES.

As long as REAL cures remain elusive for the vast majority of mental illnesses, the present way of doing things is flawed. If psychiatry can embrace a new paradigm and put all of its energies into becoming brain doctors, rather than mind therapists, then perhaps there would be hope for the millions who continue to suffer with diseases of the brain that affect their minds.

Sara said...

Anonymous, I couldn't disagree with you more.

As far as I'm concerned psychiatrists trying to become medical doctors is exactly what's wrong with mental health treatment today. Psychiatry is not like any other medical profession (which doesn't mean it's inferior by any means) and the brain is certainly not like any other organ either. IMHO mental illness will never be able to be reduced to cellular mechanisms completely because life forces and choices are always changing the elaborate feedback mechanism in the brain. It's a dynamic responding organism. It is precisely because we have been trying to do this -- reduce mood to biology -- that we have gotten into so much trouble.

Anonymous said...

Well, regarding Anonymous' post regarding the need for a separation between psychiatry and psychology, and the need for MEDICAL doctors to treat BRAIN illnesses, I have one question: Why would we need psychiatrists in this sort of system? Don't we already have neurologists to do this? Anonymous seems to be presenting a case for the end of psychiatry as a medical discipline to be handled by neurology.

Anonymous said...

Regarding Judith W's piece in the NY Times: I thought it was a bit bizarre. She basically stated the JAMA article was good news for the medical treatment of depression because it showed some benefit for medication with VERY SEVERE depression. But, as I read her article, she suggested that medication non-responders were not really afflicted by major depression! Well... suppose I go to my doctor and he says I have a 300 cholesterol reading and he puts me on Lipitor and I do not respond. If he then said I did not have high cholesterol, I would sue him!!! LOL.

Anonymous said...

Because antidepressants are so very dangerous for some people.

David Port, M.D. said...

Several relevant considerations have not fully found their way into this exchange that was prompted by the JAMA article and Dr. Carlat’s blog response to it.

Firstly, many (albeit perhaps not a majority of) psychiatrists fully embrace the “duality” of mind and body by using an "integrative" approach to their patients. These psychiatrists provide psychotherapy alone and, when appropriate, psychotherapy integrated with the administration of psychotropic medications. In this manner, beneficial (and adverse) effects of the medicines can be closely appreciated and quickly adjusted by a single practitioner in consideration of the patient’s week-to-week overall progress.

Secondly, many psychotropic medicines are prescribed by non-psychiatric physicians. I recall an old statistic (but don’t know if it was valid then or would be now), that psychiatrists are responsible for only about 20% of psychotropic prescriptions. This factor would need to be accounted for in regard to the overall use, for better or worse, of psychotropic medicines.

Thirdly, while many non-medical psychotherapists refer their patients to a physician when they feel medicines may be indicated, some will refer only to a psychiatrist while others may refer to a non-psychiatric physician. In this "splitting" of care between the therapist and physician, the frequency, depth, and sophistication of collaborative discussion, if any, between the medicine specialist (psychiatrist or otherwise) and the non-medical therapist is obviously highly variable.

Finally, we might consider that while the doctrinaire approach of some "biological" psychiatrists who provide only psychopharmacological services --offering medicines in the context of brief and infrequent meetings and relegating psychotherapy to non-medical providers-- may be entirely sincere, there are certainly commercial influences in this regard. A mental health center director may require short infrequent sessions. In private practice, the psychiatrist may earn much more, doing several “med-checks” (patients who are seen briefly and infrequently) each hour than by providing a 45-minute psychotherapy session to a single patient.

sarala said...

Dr. Carlat,
Interesting blog to be sure and I plan to read more but should you really allow Google to run weight loss ads on your blog? Promoting health quackery and body image problems for money isn't all that much better than promoting Saphris for money, is it?

Daniel Carlat, M.D. said...

Sarala,

I agree--I can't stand the ads that pop up on my site. For the last several months I have been trying to discontinue the adsense program on my blog but Google makes this incredibly difficult to do. I suggest you use Firefox as your browser and install the Firefox extension Adblock, which eliminates most ads from web pages with the added advantage that pages load more quickly.

Dr Yitzhak said...

Here is the precise language of the conclusion of the JAMA article

"..Conclusions The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial."

after having read the article carefully my conclusion would be worded as :
,,,"Conclusions The magnitude of benefit of paxil or imipramine on HDRS compared with placebo increases with HDRS score and may be minimal or nonexistent, on average, in patients with mild or moderate HDRS scores. For patients with low scores , the benefit of medications over placebo is substantial.The implications for treatment of depression need further study.



Thank you for the opportunity to participate in this blog

Yitzhak Shnaps MD
www.PrincetonPsychiatrist.com

Anonymous said...

So what is Dr. Yitzhak's point? That clinical depression and its severity cannot be measured by the HDRS? Or that it cannot be measured by any instrument? If so, what is the use of doing research? If you can't measure or quantify a supposed disease entity, and choose to go by your gut, then you move out of the realm of science to magic and quackery!

wetnurse said...

In particular, I agree completely with Dr. Hassman's comments(except for the Rod Serling reference), and also the points made by Eileen.

Regarding the feeling of one of the Anonymous' that psychiatrists should restrict themselves to prescribing medications and not try to straddle both disciplines: I couldn't disagree more.

There are many, many psychiatrists who, in addition to being excellent physicians, are skilled analysts and therapists as well.

Indeed, I believe that the kind of psychiatrist that in this day and age is considered a dinosaur is the best equipped to determine when medical intervention is indicated and can better evaluate symptoms.

Rather than having doctors choose one track or the other, I believe that psychiatric residents should no longer be able to "opt out" of the type of clinical supervision that teaches them to practice psychotherapy.

I think psychiatry has suffered immeasurably because of the freedom to pursue such a duality.

David Port, M.D. said...

If a medication benefit is presumed only in cases of severe depression, when a patient with mild-to-moderate depression comes to see the psychiatrist, should he be told to come back for medicine if and when his depression gets severe? In other words, do we believe that severe depression arises suddenly in someone who until that moment was in a good mood? On the other hand, if severe depression has been preceded by some progression of increasingly impaired mood, would it not make sense to medicate the mild or moderate depression, if only prophylactically, so as to prevent worsening of the condition?

Joe Goldberg, MD said...

In the spirit of identifying covert conflicts of interest, it is worth noting that of the 6 randomized trials which the JAMA authors reviewed, 2 were by themselves which involved randomized comparions of structured psychotherapy vs. antidepressants or placebo -- the other 4 studies did not involve randomization to psychotherapy arms. Patients who seek and screen for treatments that could involve psychotherapy may be different from those who pursue only drug-versus-placebo studies. A more fair-balanced analysis would need to account for patient and clinician biases and expectations about outcomes from psychotherapy, pharmacotherapy, or both -- and which types of patients are best suited to each type of intervention. -- Regards, Danny -- Joe Goldberg MD

Gina Pera said...

DC wrote: "biological psychiatrists" who argue that depression is essentially a biochemical disorder that is logically treated using agents that adjust the biochemistry. In the other corner are those who argue that depression is a response to life stress and is best treated by therapy techniques that help people cope.


Funny, I never see the "biological psychiatrists" taking the black/white view equal, but opposite, to that held firmly by the "non-biological psychiatrists."

The "biological psychiatrists" take a combined nature-nurture view. The "non-biological psychiatrists" take the ridiculously unsupportable "all nurture" view.

jamzo said...

there is "fake dualism" and there is the

extraordinary impact of the proprietary me-too antidpressant era

the number of people getting antidepressant rx

the number of people getting antidepressant rx from primary care physicians

the staggering cost of the patent protected proprietary me-too antidepressants and the staggering profits

the number of pharma sales reps laid off as patents for proprietary me-too antidepressants ran out

the shift in pharma marketing from
now unpatent protected, now lower cost, proprietary me-too antidepressants for depression to still patent protected high cost proprietary me-too anti-psychotics for depression

GSK's recent decision to abandon antidepressant research because the market is not profitable

Alex Yufik said...

A very thoughtful and observant post. I completely agree, and I do not understand why there is still any debate over the issue of biological correlates of human behavior. Depression has a biological correlate in the brain, happiness has a biological correlate in the brain, and every human behavior has a neurological component. I am looking forward to the day when psychopharmacology and psychology will finally merge, and that programs will be available for future practitioners who feel equally adept at utilizing meds as well as therapy in improving treatment.

Joel Hassman, MD said...

Read in the Jan '10 issue of Primary Psychiatry the interview with Stephen Stahl and his perverse comment to the question at the bottom of page 33, re 'Is it an unusual case where a single drug fixes a disorder': "Absolutely...in the area of MDD is, given the paltry remission rates with first line treatments, to treat from the very get-go with two or three drugs."

And this is an alleged leader in the field of psychopharmacology? Bah! This is the type of irresponsible thinking that just deepens the field in distrust and disgust by responsible clinicians.

You have a provider who is in the pockets of all of pharma, so he can't be accused of being a whore for just one or two companies, but people miss the point he whores for pharma as a whole.

Hey, Dr Stahl, you know who is going to take your message and screw it up further? The majority of psychotropic prescribers in this country, ie non-psychiatric providers like FPPs/NPs/GYNs/Internists and so forth. And to you, Dr Carlat, you should be concerned to either read directly or have this information brought to your attention.

With this kind of mindset, every illness presented in a doctor's office should be shot gunned: hypertension, diabetes, GERD, hell, even pain issues.

And you wonder why more people challenge the reliability of physicians these days. We have irresponsible KOLs like the above allegedly speaking for us.

Not for me, sir!

Anonymous said...

Wow, what a great blog, I have been working inPsychaitry for approx 12 years, and I am confident to say that meds work 20% of the time , the rest is mindset and educating people the power behind Thought. Thought is under rated and 80% of Mental Illness is Thought Disorders, stop figuring out the Brain. If we focused on Implementing This Knowledge into the schools to educate the young, thoughts would not being left on the Back Burner.We have to start with the young.
But, what do I know..

Laura Fisher said...

Can someone explain to me why psychiatrists continue to state that the SSRI drugs are anti-depressants? My understanding of Irving Kirsch's investigation is that they are "active placebos" at best. Also a person who has not read Kirsch's book seems to me unlikely to realize what the issues are here (FDA, corruption in the approvals process per Angell's recent review on NYRB, harmful side effects of SSRI's considering their supposed efficacy has literally not been shown, etc.). It just isn't science to rely on the anecdote (e.g., "MY patients get better...", etc.).
Help me out. I am a psychiatrist. I prescribed these agents for years. I stopped doing so when I realized they had not been shown to work because I was trained to avoid anecdotes as a substitute fdor data.

Laura Fisher

anonymous said...

psychiatry (which has lost ground in the medical world in recent years in addition to neurology and I'll add rx for psychologists -- need to stay on up on this research as the FDA (for many reasons) makes IRB and clinical trial approval so difficult (and expensive) for new drugs or "new uses" for old drugs -- can be almost impossible to research (see for example -- new = Reboxetine, not approved in US, appears to be for political/ lobby reasons and for old -- Survector an older - Dopamine Re-uptake Inhibitor (DRI) pulled of the market for fears of its addictive potential (uh, and kids get prescribed adderral, as young as 6 for ADHD what? But we can have just as powerful meds for depression in adults? I don't get that personally). Also, using meds like psycho stimulants to treat lethargy for atyical/ treatment resistant depression is arguable vs. behavioral activation as psycho-stim meds might be counter indicated (this is a complicated argument for another time; however -- I still like it as a creative approach in treatment for certain depression sxs), and meds like provigil for energy boosts might be better, which leads to my final point 5) there are many good meds, old, new, and progressive/ creative/ or even aggressive poly pharm approaches to treat psych issues (even for minor disorders like depression NOS), or more serious ones pain (Lyrics is new and promising actually), energy, sleep problems -- but we get down to this "art of prescribing issue," and good prescribes to MH patients/ and medical world or psychiatrist almost start to look like witch doctors (e.g. a "dash" of gabapentin, topomax, a little lexipro over zoloft, and maybe some ritilan to treat chronic pain, mood dysregulation, and low energy in a patinet); but the "why" gets hard to justify with these more "creative" drugs and/ also drug companies are hesitant to pursue (for instance) new clinical trials for off label uses to provide evidence or efficacy for these meds-- for ex. think seroquel for sleep (and allot can be said here, regarding legal issues as well -- the "black box" warning on SSRIs has basically been dis-proven scientifically/ and statistically, but the warning persists). What this comes down to is that there is a high degree of variability between medication prescribes (including psychiatrists) because there are not well articulated practice parameters (and psychologists don't even really have them for behavioral/ psychotherapy tx for that matter) -- that there are no true practice parameters -- for the more creative approaches for treatment resistant mental health/ BH conditions in terms of psychiatric medications. Thus, in conclusion, MH patients suffer. They might not be able to afford/ or understand who the "best" psychiatrists are, insurance won't pay for the best psychologists, and meanwhile they get 60mg of celexa from their PCM/ GP and ultimately their depressive or anxiety symptoms are not well treated. I think a way to somewhat resolve this is advertise the more creative poly pharm approaches and continue to push on the new research for clinical trials (as noted above).

anonymous said...

As a psychologist, I actually like meds for patients (including SSRIs), but here is the catch = I think many docotrs/ providers prescribing meds (including psychiatrists) fail to approach treatment from an aggressive ploy pharm approach (this does become complicated with the more "complicated" the patient or when dealing with patients who have background with addition, but even some of the best treatments for addicts/ addition include kid of mood stabilizers or SSRIs plus some sort of BH counseling). I say take a look at Stephen Stahl, MD (book: "prescribers guide"). he is a psychiatrist who prescribes powerful cocktails outside of the FDA recommend range (e.g. California Rocket Fuel with up to 600 mg to 800 mg of Effexor to kick in dopamine effects). I'll say five things/ points in addition to the above: 1) I think most SSRIs, NDRIs, and other less powerful/ non additive psychotropic meds (e.g. Buspar for anxiety, etc.), just don't do or rather work that well; however, point 2) placebo and attitude/ expectancy effects in patients (especially those naive to treatment are powerful). I see a pipeline here with many of my patients-- they want meds, they get meds, meds don't work well and then they actually engage in CBT, etc. and poof they get allot better, 3) point bottom line: we don't know much about the science of these meds -- it seems to be that when you push down on one part of the brain, something/ somewhere else (neuron) pushes up somewhere else -- i.e. statis, etc. -and- the best evidence says this: meds vs. talk psychotherapy is about the same for most MH patients (not necessarily true for extreme bipolar, psychotic, etc.); and Benefit of no meds is that when you take them away, gains can generally be maintained (with brain imaging studies post BH/ CBT/ etc. treatment confirming this). Mechanism of action = unknown, still! Also, keep in mind that "time" (i.e. time heals all wounds) can also containment treatment effect (that is, for example SSRIs take about 4 to 6 wks to "build up" in someone's system if researchers put SSRIs against time (i.e. nothing) many times -- what might causing -- something like "depression," for someone has went away and thus they could better regardless of meds, -- point 4) there is some cutting edge research going on with dopaminergic vs serotonergic vs neuroadrelnalin as well as glutamate pathways for mood/ anxiety/ depressive disorders (see: http://www.biopsychiatry.com/glutamate-depression.htm - for instance)