Wednesday, March 31, 2010

Carlat Commits Heresy: The Church Responds

It has been an interesting last few days for this particular blogger. What began as a thought-piece about how psychologists prescribing might bring needed balance to psychiatric practice became a lightning rod for rage, mockery, and often interesting debate. No threats yet, though I did get the following anonymous note in the mail today: "Carlat you (expletive) turn coat. Stick this in your (expletive expletive)."

Civil discourse is alive and well in America.

But beyond that enlightening comment, there have been several good forums of debate. There are currently 86 comments to my March 22 post, and they represent a reasonable cross section of opinions on the issue. Many argued that psychologists would put patients at medical risk because a two year masters is not good enough. Some believed that psychologists would end up doing exactly what most psychiatrists are doing--short med check visits in order to make money. My friend Ron Pies tried to bail me out by referring to the post as
"one of the most effective satirical sketches since Jonathan Swift's famous (or infamous) "Modest Proposal" but later posted a thoughtful rebuttal which he later developed into this interesting editorial for Psychiatric Times.

There's also a great forum on the Student Doctor Network. Entitled "Carlat and Overzealous Psychiatrists," there are now 78 comments. While every single person on that thread disagrees vehemently with me, I've enjoyed the back and forth because most of the writers are medical students or residents and seem to at least get a kick out of thinking this issue through.

Ultimately, I think the most valid potential argument against psychologists prescribing is the safety issue. Even though they have been prescribing since 1995, it is hard to figure out how to judge whether they are prescribing safely or not. As I understand it, there are 50 medical psychologists in Louisiana, 25 in New Mexico, and 20 to 30 in the various branches of the military. But nobody seems to know exactly how many patients they have seen or how many prescriptions have been written. Eveybody agrees that the number of prescriptions is in the "thousands," but is it 20,000? 200,000? 500,000? Size does matter here, because the larger the denominator, the more meaningful it is that there have been no complaints about prescribing psychologists to any medical board or any military authority.

I see my role, hopefully, as being an information broker between the psychologists and psychiatrists. I want to nail down some of the safety figures. I want to figure out what kind of safety surveillance would be adequate. There is so much animosity between the two organizations that it is nearly impossible to have a civil and rational conversation. I find that unfortunate, because the best psychiatric treatment is inegrative treatment, and the best way to achieve it is for the two professions to share information.

Whether psychologists end up continuing to snap up states in their quest to prescribe or not, I hope that we can all agree that patient care is our number one priority. Squabbling amongst ourselves over turf is not helping anybody.

56 comments:

Maggie May said...

I am not a psychiatrist and have no training except for a lifetime being surrounded by mentally ill people and the ensuing relationship with psychologists and psychiatrists. Many psychiatrists themselves have such poor knowledge of the appropriate treatment that I have found it mind boggling. My husband has Bipolar, and with 2 years of intensive reading, research and experience I realized quickly after speaking to his last psychiatrist that she had little idea how to approach his medications, including taking into consideration absolutely crucial points like was he a depressive focused Bipolar? Had he had hypomanic episodes or manic? Etc.
Based on this I agree there would be serious concerns about psychologists prescribing.

FunPsych said...

I think what set Dr. Pies off is that he wants psychiatry to go the complete opposite way and merge with neurology, forming something called "encephiatrics."

I must admit I fail to understand why some folks are so uncomfortable with psychiatry today they want it to merge with another entity, whether it's psychology or neurology. Is there so much identity diffusion that we must seek solid ground in the other?

-FunPsych

Dr John said...

"Turncoat"? That says a lot about where most people are coming from on issues such as this.Angry. Everyone thinks they have pts best interest in mind. Luckily such interests are also perfectly aligned with whatever group "I" happen to be in. I think you are as likely to get most Drs to acquiesce to the need for a medical degree before prescribing as you are to get the Pope to declare the last several thousand years of papal bureaucracy was really a bad idea and he is dissolving the Vatican and will spend the rest of his days in the dessert contemplating the mystery of God like John the Baptist did. In his editorial Dr Pies as always makes some good points but drags out the usual tired suspects of the medical/psych nightmare and 3:00 am phone call. What planet does Dr Pies work on. Maybe the mid west is not the real world.Most psych Tx is delivered in both community and private mental health centers. If you call one at 3:00 am with an emergency you will either get a machine or the crisis hotline and young woman with cliff notes on how to handle unstable people. It will be made clear no medical advice is given. The only time you will ever get a Dr is with the increasingly rare private practice or the exhausted resident on house call.Dr Pies also brings out the usual CP450 hand ringing and drug interactions on which entire issues of the green journal have been devoted. All true in principle but hardy the majority of who are taking psychotropic drugs. The truth is the VAST majority of psychotropic drug prescribing is not at all complex. I cannot imagine a psychologist who would spend a good deal of time on it would be worse than an Internist, many who go through training having never done a psych rotation past med school. If people are that worried about the medically ill put restrictions on what types of pts can be seen.He also bemoans the loss of psychotherapy as if someone was out there telling psychiatrists they could not do it. Frankly this is just smoke from a much bigger fire in the house of psychiatry. If Dr Pies wants psychiatry and neurology to merge I fully support him. It is the only hope for psychiatry. As for psychologists prescribing I do not support it. Not because it is dangerous but because Americans are swallowing to many useless GD pills already.

Joel Hassman, MD said...

Did you read at Psych Central how a social worker is now trying to rationalize that field can access prescribing habits as well?

Man, you don't get it, however well meaning you are trying to be. I had to come back and write this just to be at least one voice of common sense in a world of increasingly greater cluelessness, under the guise of helping the patient.

Good luck with this debate,'cause if it is about numbers, you win!

Ronald Pies MD said...

Hi, Danny--As you know, it is my policy not to respond directly to anonymous or pseudonymous "clinicians" who see fit to criticize colleagues who put their names and reputations on the line, as you and I do. On the "planet" I have worked on for nearly 30 year--including in nursing homes, several state (MA) hospitals, and private practice settings--signing your full name is called, "taking responsibility for your professional medical opinions."

So, let's hear from a psychiatrist who actually lives and works in Louisiana, where the psychologists also have prescribing privileges. You can find Dr. Fam's letter on the PsychTimes website, under my editorial. Thanks, by the way, for the "shout out". Here is what Dr. Samuel Fam has to say about my editorial:

"Dr. Pies has succinctly described real-life scenarios. As a Louisiana psychiatrist, I have also witnessed confusion regarding the 'medical psychologist' among the public. As prescribers, they sign: MP - which in handwriting can easily look like MD. The ambiguity also leads to misrepresentation of discipline and "trade" (does this suggest a legal issue?) Unfortunately, people tend to think that a psychiatrist is no more than a psychologist who prescribes, missing the mission and training of a physician altogether. To make matters worse, as of January 2010, medical psychologists are licensed by the Louisiana State Board of Medical Examiners!
I have witnessed, on the other hand, that the need for psychiatrists here has not decreased, and the addition of medical psychologists has not noticeably solved the problem or met perceived needs."

By the way, Danny, I am not deeply invested in psychiatry merging with neurology--that was the position I was asked to defend in an academic debate, and I defended it with some ambivalence (having earlier cautioned in a published paper that simply merging with neurology is not a good idea).

My main argument for "encephiatrics" is that psychiatry needs to be firmly based in medical and neurological science, while at the same time embracing the humanist tradition and the skills of the psychotherapist. Karl Jaspers said much the same thing decades ago, and our Tufts colleague, Nassir Ghaemi has also argued for such "pluralism" in psychiatry.

In any case, psychiatry's problems are not going to be solved by our
colluding in the "prescribing psychologist" debacle. We need to set our own house in order, not allow ramshackle cottages to be constructed on the landscape of medical care.

--Regards, Ron Pies MD

autumns_leaf said...

As a mere leaf, a flimsy transient thing, what's more one that is turning colours for lack of oxygen, perhaps I am not worthy to enter in such a grand debate among Real People. Nonetheless...I am not sure where it was that the Church responded.

The Church in my mind is the APA and anyone in a position of power who espouses the current dogma. The congregation consists of the majority of psychiatrists in lesser positions who seem capable only of mumbling the orthodoxy as their hand scribbles away. The people (and leaves) responding here do not seem to be church goers at all.

Anonymous said...

Dr Pies says:
Psychiatry needs to be firmly based in medical and neurological science, while at the same time embracing the humanist tradition and the skills of the psychotherapist.

SIR:
With all due respect, do you really think that most psychiatry residency training programs teach the "humanistic tradition" and give adequate training to develop the "skills of the psychotherapist"? I don't think so!

Joseph P. Arpaia, MD said...

Multi-theme response

Encephiatrics - I think psychiatry has more overlap with endocrinology than neurology. HPA axis, HPT axis, HPGn axis. Lots of endocrinologic co-morbidity in depression. Psych meds cause endocrinologic abnormalities.

I think the psychiatric focus on the brain is a big mistake. I can change someone's anxiety by changing how they use their diaphragm. Heart rate variability biofeedback work in some cases too. The body influences the brain just as much as the brain influences the body.

Medical psychologists - I think that the worries about "medical psychologists" causing damage to patients are as clinically relevant as the fears people have of terrorists blowing up airplanes. People get so bent out of shape about the latter that they waste energy on that and do not deal with more relevant issues. Psychiatrists can make the same mistake about the medical psychologist issue.

Sure I don't think a psychologist is going to be that skilled after a two year course. But having seen some of the medication combinations in the patients referred to me, I don't think a psychologist would do worse. (120mg Cymbalta, 200mg Zoloft, 400mg Seroquel and the patient was wondering why they felt agitated.)

Dr John said...

If it was good enough for 3 men to write the Federalist Papers as "Publius" I see nothing wrong with FunPsych, autumns-leaf or Dr John doing the same even if we disagree on points. We do not debate names, We debate ideas. As others and autumns-leaf have pointed out, pushing the status quo does not really put your reputation on the line. Dr Pies again claims that "psychiatry needs to be firmly based in medical and neurological science, while at the same time embracing the humanist tradition and the skills of the psychotherapist." In reality what doctor of any type would not make the same lofty claim for the goal of his field? Science and humanism.The fact is by its very nature psychiatry is not at all grounded in medical and neurological science and it never has been despite 100 plus years of trying. The reason Dr Pies and others are so quick to fall back on the need to meld science and humanism in psychiatry is because there is no explanatory science(drug studies do not count) and humanism is the only hope for credibility and continued individualism psychiatry has because its science hand is empty. No field of science can have 2 correct actively used explanatory models for the same thing for long. One must die.People cannot have both hardware problems/chemical imbalance and a psychological problem in need of human empathy as the same causative agent for the same problem. Psychiatry has to fall back to essentially speculative expertise because it cannot know anything for sure and after countless millions have been spent on basic research with little at all to show for it, it is very questionable if most of what psychiatry continues to call pathology will ever have any medical explanatory model.Much philosophy has been written as to if this is even possible. Psychiatrists just do not want to face this. The last best hope for psychiatry to survive is for its doctors to be real experts on the medical problems that cause behavioral manifestations in neurology. They can even be experts in the pharmacotherapy of emotional suffering if they wish but this is not the same thing as knowing anything for sure about primary cause of the vast majority of psych pts being seen bt psychiatrists and psychologists.There is no evidence that psychiatrists are any better at all in talking to folks than any other Dr (or therapist)and that by itself does not create a special place in medicine for those who wish this were so. Pretending that we can lay claim to this special place based on what was essentially a fluke and dubious branch of metaphysics created by a neurologist who had given up on neurological explanations of behavior is just not working anymore. Neither are the claims that psychiatrists are even or should be consistently interested in practicing in this idealized form advocated by Dr Pies.Most psychiatrists I work with have very little knowledge of systematized forms of "psychotherapy" like CPT and are not interested in doing this with their time. He and Ghaemi advocate pluralism only because they know they must.What is really being said is "we have no explanatory science so give us some more time while we re-affirm our special place as the humanists of medicine". I am sure there are some great people practicing psychiatry who bring that caring to their work.Dr Pies sounds like that kind of guy. I also suspect they were that way before psychiatry got a hold of them and they would be bring it to surgery if they were practicing that.I see no sign psychiatric training creates this. Claiming a special seat in front on the humanism bus is just not enough to establish real credibility. My name is John Sorboro MD but I think Dr John just sounded cooler...

autumns_leaf said...

>>Most psychiatrists I work with have very little knowledge of systematized forms of "psychotherapy" like CPT << :-) Freudian slip?

Dr John said...

Yes for sure.CPT=CBT ahahah ahah. Nice catch A.L.

Debra said...

"Squabbling over turf is not helping anybody".
I agree.
This problem is also about cooperation.
And the issue of cooperation goes beyond the identity of psychiatry. It hits on the medical profession as a whole, with respect to all paramedical approaches to the patient.
These days... although I adore my G.P., and think he is a great guy, I will get in touch with my physical therapist about any muscular problem BEFORE contacting my doctor.
Because, rightly or wrongly, I tend to feel that a person who has hands on experience dealing with my muscles has more authority to talk to me about them than somebody who has lots of book knowledge.
(Careful, I didn't say that I was right...)
On the differential identity of the psy professions.
More than twenty years that I have been associated with these professions.
During that time what continually amazes me is that people really don't know the difference between.. a psychologist, a psychoanalyst, a psychiatrist. All these years that the words have been floating around, and still...
What do we tell them when they ask ??
That a psychiatrist has the legitimacy to prescribe meds ??
That's a little slim, isn't it ?...

SteveM said...

Re: Dr. Pies - ”…people tend to think that a psychiatrist is no more than a psychologist who prescribes…”

If that were only true. Most of the Stürm und Drang around psychiatry relates to the fact that many psychiatrists are actually pretty lousy at psychology. And since psychiatry has been thoroughly medicalized over the last 30 years, it would not surprise me if the discipline attracts more physicians without the social skills necessary to engage in an effective therapeutic dialogue even if they are aware of the techniques.

I have a lot of respect for Drs. Pies and Ghaemi. But let's face it, a psychiatrist who is satisfied with 15 minute med checks, is probably not intellectually curious enough to study clinical psychology techniques more deeply, let alone read and ruminate over the writings of Karl Jaspers. Pluralistic psychiatry as a normative practice is only wishful thinking given the psychiatric training and administrative Leviathan that is currently in place.

The lash up of psychiatry with neurology or endocrinology seems to be a red herring. Because both are reductionist pathways that focus on molecular solutions. Psychiatry already knows how to do that pretty well I should think without the formal lash ups. So those relationships are sort of off-topic about what is bothering psychiatry.

Given Dr. John's observations about how uneventful medication management usually is, the fundamental comparative question is which intervention process deficit has the larger aggregate negative impact on patients: Psychologists prescribing medication with less medical knowledge? Or psychiatrists unskilled in psychology who foul up on the diagnostic and preemptively apply psycho-pharmaceutical solutions based on constrained reductive reasoning?

Jim Finley said...

I live in NM, and here at least, a psychologist who wants to prescribe not only has to complete quite a bit of additional training, he/she has to pass a tough test and spend a substantial period under close supervision before prescribing independently.
My experience as a therapist and as a patient has been that there are excellent psychiatrists who understand psychology and see their patients as people, and there are bizarre psychiatrists whose people skills are so lacking that they appear to be suffering from autism-spectrum disorders. Most of the psychologists I've known (I am neither, being a master's-level therapist, so I have no dog in this fight) are relatively knowledgeable about psychopharmacology, more so than the average psychiatrist is about psychotherapy.
We have a dire shortage of psychiatrists and too often end up with general practitioners prescribing psych meds anyway, so I am all for psychologists being able to get the training and help fill this need.

autumns_leaf said...

Egads, there is no need to prescribe MORE medication. If we, even randomly :) , decreased each patient's psychotropic load by 90%, leaving them with say one psychotropic, we would be doing a lot of good right there.

The NEED is for people to learn coping skills and stop calling every 'mood swing' bipolar and ever drug addiction 'bipolar' and every break-up of a 20 yr old with her BF 'depression'. We need to STOP giving medications for every sniffle. We need to stop treating social problems with pills. Arg.

Asslete said...

This debate is so easy to argue from both sides for the same reason psychiatry finds itself so often stuck in a quagmire of rebuke…Ambiguity.

Biologic Psychiatry? Hey, I love the concept. I entered residency during Regan’s “Decade of the Brain” with childlike delusions that in months, the complexities of human angst would be reduced down to a blood test or biopsy. But like Biologic Phrenology…Biologic Psychiatry remains just a bunch of ill-defined bumps on the head of the Green Journal.

I suspect that much of our patient’s improvement (notwithstanding the value of meds for true Bipolar or Schizophrenia) often has to do more with the healing power of time and the patient-clinician bond, than serotinergic deficiencies. Kirsch’s data showing minimal separation from placebo, combined with data that show a patient’s “connection with their therapist” is more predictive of good outcomes than the “style of therapy,” should be reason enough to consider non-MD providers as prescribers. Half of the psychaitrists I work with are so devoid of basic communication skill, that I’d diagnose them with Asperger (or should it be Mercury Induced Developmental Disorder) if I thought there was any validity to the dx.

Shoot, give a psychologist or bartender a crash course on SSRIs and I suspect their outcomes would rival our own. And for those who argue “Dear God…what about drug-drug interactions,” I’d rather hear Sally Struthers wailing about saving the starving children as she adds another two points to her BMI. For the rare time I was justly concerned about an SSRI-P450 interaction…I was a simple Epocrates click away from typing in all of the patients meds and exploring potential drug-drug interactions.

I have no problem with trained psychologist having limited prescribing privileges. Let me focus on the truly melancholic, manic, or delusional, where meds may actually have some benefit…though I still have no idea why. Must be too much dopamine.

Anonymous said...

Hey ASSLETE:
You are the BOMB! LOL. I am a psychologist and have NO interest in securing prescribing privileges. And frankly, most of the psychologists I hob nob with (at a major academic medical center) don't want these privileges either. I think the good Dr. Carlat is over stating the support among rank and file APA members for psychologists prescribing. Whatever. But I do agree with your rather jaundiced assessment of psychiatrists knowledge and current medication practices. You made a funny post with a lot of truth. I applaud you. I think we should leave the prescribing to MD's. But I also think that Psychiatry's problem has little to do with Psychology and MUCH to do with Neurology. Once you folks decided to get in bed with Big Pharma, and define your focus as brain illnesses, and abandon all psychotherapy training (the psychologists did not TAKE this from you, you ABDICATED it in the interest of drinking at Big Pharma's trough) you all became most vulnerable when the Emperor was revealed to have no clothes (i.e. the so-called "efficacy" of antidepressants). I think Psychiatry should merge with Neurology and let you guys do the heavy lifting as to the treatment of schizophrenia and bipolar I, and melancholic depression. Leave the rest to professionals trained to deal with other forms of human misery.

autumns_leaf said...

Now, for some balance, let's talk about how pathetic psychologists are in dealing with "human misery" with their research based training and heartless CBT.

A la guerre...

Debra said...

Hey, I keep harping on the necessity of considering BOTH/AND solutions rather than caving in to the so easy EITHER/OR solutions.
It so happens that during MY melancolic depression, antidepressants (not the first, but the second...) REALLY HELPED.
Now... sticking all the eggs in one basket (either/or) and handing out a prescription drug with nothing else does not do lots of good, I think.
When people get better it is because their lives are becoming richer, their contacts are improving, they are seeing more people, doing more things, maybe some physical exercise.
Another way of saying that treating "mental illness" (or should I say, spiritual crisis, I like that better...) involves breaking out of specialist approches to "illness", and compartementalizing human beings.
And... at this point I certainly am not defending.. psychotherapy as SALVATION. (No more than I would defend drugs...)
The key word is "salvation".
Like... this is THE ONLY WAY TO DO THINGS.
The only way to do things because.. this is what I, a practicioner, believe in, and.. YOU BETTER BELIEVE IT TOO, OR ELSE.
Na. Some people will get better by finding faith, or through a religious experience. Some by doing theater. Some will learn to accept that their lifestyles, though marginal, and frowned upon, are just right for them.
What we want is a rich, varied, differenr world, right ?
What we want is to DIMINISH SUFFERING, RIGHT ??

Dr John said...

SteveM, just to clarify my point, I do not at all feel that the majority of today's current psychiatric pts would be best served by attempts to marry psychiatry with the field of neurology. This is what has been done for the past 20 yrs and I believe is an unmitigated failure. My position is that within the field of medicine there is a small group of pts with medical/neurological illness that manifest with behavioral problems. I think they would best be dealt with by neurologists who had better training in this.This could even include folks with psychotic illness and BAD1 as "anonymous" suggests.Psychiatry was a misguided attempt to medicalise human emotional problems almost all of which do not need a DR. This being said I actually believe folks were better off 30 yrs ago when psychiatry was more entrenched in psychological models and mostly these Drs just talked to people. If you give psychologists prescription pads there is little reason to believe they will turn out any different than today's psychiatrists. So I do not think this is a case of one being better than the other or worse. As autums_leaf suggested the problem is that we are treating every conceivable complaint with medications and this is just not psychiatrists but APRN's, primary care and even non-medical people who push for this approach. I do not want to see anyone suffer but at least in theory I think one thing psychology has over psychiatry is they can see struggle as a normal part of process without rushing to squelch it with meds.There are very real concerns that giving people both antipsychotics and antidepressents may realize them some short term benefit(debatable as asslete points out) but create a long term problem for them making them chronically emotionally unwell.(The work of Robert Whitaker outlines this) 20 years of watching psych pts on an in pt psych unit has convinced me a huge part of the problem is iatrogenic. Because psychiatry operates in the medical netherland I think clearly medically ill people should see neurologists/medical Drs who can prescribe them meds and the rest should be seen by people who work with pyschological models to assist them and who cannot pull the trigger on the medication gun. Some maybe not so easy to identify but the point here is that making psychiatric meds more easily accessible from anyone is I think a bad idea.

Daniel Carlat, M.D. said...

Here's a good exercise for all you psychiatrists out there. On your next clinical day, during each one of your patient visits ask yourself the following questions:
1. What aspect of my medical school training did I use in assessing and treating this patient?
2. How much of this expertise is truly dependent on all four years of medical school and the one year of medical internship?
3. Could the medication decisions I just made have been made by a psychologist undergoing roughly half of my medical training?
4. Was there some type of psychological treatment that my patient really needed that I was unable to provide because I never received the proper training?

If you do this honestly, I guarantee you will find that the majority of your patients could have been treated just as well by a medical psychologists or a psychiatric clinical nurse specialist. About a quarter of your patients really required your extra expertise.

Ronald Pies MD said...

It greatly saddens me to see so much misunderstanding about the field of psychiatry, both regarding its foundational concepts and its treatment philosophy. The caricatures of my profession that appear in these blogs are so far removed from the field I was trained in that I can hardly recognize it! Some of the disparity is unquestionably due to the distortions in psychiatric practice, owing to our ramshackle health care-system; market forces impinging on psychiatrists; and the baneful influences of “Big Pharma”. But in many of these comments, there is also a serious misunderstanding about the philosophical underpinnings of psychiatry; the efficacy of its treatments; and what distinguishes psychiatry from psychology. It would take a long essay to flesh out a decent response to all these issues—maybe even a book! I hope, within the next day or so, to have a co-authored response, with Nassir Ghaemi MD, addressing some of Dr. John Sorboro’s positions on what is or is not “medical science”. I do appreciate Dr. Sorboro’s identifying himself by name, and his temperate comments on Dr. Ghaemi and me. I think that sets a good example for responsible, professional exchanges in a medium that too often allows for anonymous sniping at colleagues.

In the mean time, I would urge Dr. Carlat to describe exactly why (in his view) about one-quarter of the patients seen by psychiatrists do require significant medical expertise. I have the sneaking suspicion, Danny, that I spent the last 28 years treating those patients! And, if you read over the Oregon “psychologist prescribing” statute carefully, I think you will find that there is absolutely nothing in it that allows for any distinction between that “one quarter” of very seriously-disturbed, complex patients; and those with so-called “problems in living”. There are no restrictions on the nature of the patient seen by the “medical psychologists”; the medical complexity of the cases; or the type of medication (lithium? antipsychotics?) that may be prescribed. One positive thing I take out of this entire discussion: it is abundantly clear that this debate is far from being a mere “turf battle”. As I argued more than 20 years ago [J Clin Psychiatry. 1991 Jan;52(1):4-8. The "deep structure" of clinical medicine and prescribing privileges for psychologists], the debate goes to the heart of what constitutes medical science; medical practice; and the safety and well-being of the general public. More anon, I hope, from Dr. Ghaemi and me. –Ron Pies MD

Joseph P. Arpaia, MD said...

Danny,

Your point seems to be that because I don't need my medical training to deal with most of my patients most of the time then someone else should be seeing them for those sessions.

I completely disagree. I use 95% of my medical training to deal with the 5% of the time that things don't go as expected. And to anticipate such events.

Also, I cannot separate my medical training from everything else I do. It comes through in the way I communicate and the metaphors and examples I use.

What if we were to apply this to other fields? Lets look at pilots. The FAA requires far more skills than most pilots use on most flights. Does that mean we should allow less trained people to fly commercial aircraft? Perhaps "cockpit practitioners" who could handle the flights that are usually routine?

The real problem, as other commenters on this blog have alluded to, is that people are experiencing distress and want help. No one really knows how to help them because much of their distress is simply not fixable. But we don't admit that, we (physicians and therapists alike) pretend that everyone is supposed to be happy and content all the time, and if they, or their insurance company pays us enough, then we will get them there with whatever bag of tricks we are trained to use. This is a deception, but few want to acknowledge the truth.

The vast majority of psychotropics and therapy visits are given for mild to moderate symptoms. We need to know how to differentiate severe symptoms from moderate or mild symptoms and explain to patients that the latter are a natural part of living on planet earth and are not a sign of pathology.

What we can do as professionals is teach people who are suffering from mild or moderate symptoms how to prevent those from escalating and becoming severe. One of the major principles in this is to avoid pathologizing the symptoms as a sign of a disease.

Daniel Carlat, M.D. said...

Joe--I don't think we disagree, and this is a fascinating example of how difficult this issue is to discuss.

Because this whole topic has been deemed unspeakable and heretical by psychiatry, there is no history of discourse that we can draw upon in order to even agree on basic terms.

So when I say something like, "do we need all of our medical training to treat all of our patients" some interpret this as the rather more insulting question, "do we really need any medical training to treat all of our patients." In fact, medical training is not an either/or proposition. If medical training equalled medical school, then the thousands of nurse practitioners who have been prescribing independenty for 40 years have no medical training. But of course they do--just not as much, not nearly as much, as psychiatrists do. And yet, I think you would agree that the NP model is an example of how we are able to create a mini-version of medical school that can produce perfectly competent and safe practitioners.

This proves that there is nothing sacred about medical school in terms of training people to prescribe safely. If one agrees with this proposition, then it would be illogical to claim that another version of medical training could not be designed for psychologists that would allow them also to prescribe safely.

Unless you argue that NP training is the new minimum sacred standard of training--but what could one offer as evidence of this?

So my point is that many of my patients can be adequately treated by someone with less medical training than I have. Not NO medical training.

Best,
Danny

autumns_leaf said...

I've known physicians who were fired from hospitals where they were well liked because they either could not pass their boards due to performance anxiety, or forgot to renew them! In the case of psychiatrists, who did the hospital hire instead? NPs!

How does that make ANY sense?

Why not reduce the legislative and administrative burden on physicians? Why can't we go and practice in any state with one license? Why do we need to go through the ridiculous and demeaning credentialing process and rinse and repeat every two years? Why should a secretary decide if you're fit to practice? Why should some stupid insurance company rule control your ability to earn a living?

So I say, yes, let's open up the market, but let's start by removing all the barriers to physician employment If you've finished training, you should be able to pay 10 dollars, get a license, and that's that, go and work wherever you want, in any state.

AleksPsych said...

I am approaching this debate from the perspective of a clinical psychology doctoral student about to complete his Ph.D. I should state upfront, I have the upmost respect for well trained and highly knowledgeable psychiatrists, social workers, and psychologists. The key words there are “well trained” and “highly knowledgeable.” I believe appropriate knowledge and training in diagnosis, psychotherapy, and psychopharmacology is the KEY issue in this debate.

Diagnosis: I agree completely with Dr. Carlat that the diagnostic process in mental health is largely psychological. The training experiences of psychiatrists and psychologists allow them to render the exact same mental health diagnoses. In almost all cases of mental disorder diagnosis, medical training (i.e., 4 years of medical school and 1 year of medical internship) is absolutely not required. A true mental disorder diagnosis can be made ONLY if a medical condition has been ruled out. This is the reason all patients should have full physical evaluations to rule out true medical conditions before they are referred over to a mental health specialist for treatment. The important point here is all mental health patients do not have medical illnesses that are causing their psychological symptoms. If they did, they would not be mental health patients, but rather medical patients who should be treated by neurologists, endocrinologists, etc. Here is an example from my clinical experience: a male psychiatric inpatient was referred to me for psychotherapy for “depression.” Over the course of psychotherapy it became clear to me that his “depression” was not like other depressions I had seen before (i.e., the patient was also reporting having neurological symptoms). The man was referred to a neurologist and was ultimately diagnosed as having Parkinson’s disease and a form of dementia (he did not have depression as a psychological disorder and psychotherapy was terminated). I knew to refer this patient to a neurologist not because of medical training but because of my psychological training. That is, by virtue of my training in psychopathology I knew what a true psychological disorder is like and it was clear in this case that this was not a true psychological disorder.

Another issue relating to diagnosis is that in typical clinical practice diagnoses are not made using the standardized DSM diagnostic criteria. Despite the fact that DSM diagnoses are not perfectly valid and reliable constructs, it is a sad fact that many patients are misdiagnosed when structured interviews are not used (see the work of Zimmerman on bipolar disorder misdiagnosis for a perfect example of this). The fact that almost all psychiatrists and psychologists do not used structured diagnostic interviews is extremely problematic...

AleksPsych said...

Psychopharmacology: It is clear that psychiatrists are the only mental health professionals who receive extensive training and supervision in psychopharmacology. Is appropriate training required to understand how to monitor the effects of medications on the various bodily organs and how medications interact with one another, obviously yes! This training is only provided (as of now) in medical school and psychiatric residency training. There is absolutely NONE of this training in even the best clinical psychology doctoral programs. I cannot say, however, if 3 years of didactics and supervision given to a clinical psychology student like myself would allow for the accurate and safe prescription of psychotropics. It might be enough, but it might not – this is an empirical question. The bigger problem I have with psychologists prescribing is not the training issue (I do believe a doctoral student is intelligent enough to be appropriately trained to prescribe psychotropics if this type of program was available to him or her), but rather a scientific one. The vast majority of mental health conditions (e.g., anxiety disorders, mild to moderate major depressive disorder, personality disorders) are treated effectively with psychotherapy alone. Generally speaking, medications offer little (if anything) more than psychotherapy in the short-term and less than psychotherapy in the long-term for these conditions. These patients do NOT necessarily need medication. If I have to see another borderline patient who is prescribed five different medications that have never been shown in a single clinical trial to have efficacy in treating BPD… just ridiculous! The same is true for patients with PTSD, who are rarely given PE therapy but mainly given various psychotropics. At the same time, I have worked with patients with various psychotic disorders who refused to take medication, and psychotherapy did not alleviate their hallucinations or delusions. Meciation likely would have. Psychologists, who are generally the best trained in psychotherapy, should be voicing their outrage that patients are being prescribed medications that have never been empirically supported to treat these given conditions, and they should be promoting the use of empirically-supported psychotherapies for treating these conditions. Psychiatrists, the only mental health specialists who are trained to prescribe medications, should treat patients with conditions that most resemble neurological disorders and that benefit from medications (i.e., psychotic disorders, bipolar I disorder, severe and melancholic depression, drug and alcohol intoxication and withdrawal), and patients with neurological conditions that affect cognitive functioning (e.g., Alzheimer’s disease, traumatic brain injuries). To me, this role makes the most use of the medical training psychiatrists receive. The medical model has little to no use in treating, for example, borderline patients who repeatedly attempt suicide after interpersonal conflicts. Psychiatry can definitely be absorbed into a specialty area of neuropsychiatry. Mental health patients who are being treated with psychotherapy might minimally benefit from medications, which can be managed appropriately by general practitioners/PCPs in collaboration with psychotherapist psychologists and social workers who know infinitely more about psychopathology than GPs/PCPs.

Ultimately, this debate can be resolved by science and not by politics. Diagnoses are most appropriately rendered using structured diagnostic interviews (i.e., a psychological process, not a medical process), which psychiatrists and psychologists have equal training to use (social workers could use these interviews as well if they have appropriate training in psychopathology and psychological diagnosis). Mental disorders should be treated using empirically supported treatments, and whoever has the appropriate training to provide these treatments should provide them. Some mental conditions are best treated by physicians and most others best treated by psychotherapists.

AleksPsych said...

Psychotherapy: My training in psychotherapy thus far has included the following: approximately 1000 direct hours of psychotherapy; 200+ hours of reviewing full psychotherapy session recordings; 600 hours of individual/group supervision on psychotherapy cases over 5 years (one year each of CBT, psychodynamic therapy, emotion-focused therapy, and experiential therapy); and 200+ hours of didactics in psychotherapy. I have seen mildly depressed outpatients to severely suicidal borderline inpatients for psychotherapy. While I cannot speak to the actual training hours (didactics, supervision, reviewing therapy session videos) psychiatrists and social workers receive in psychotherapy, I would venture to guess that the training social workers and psychiatrists receive in psychotherapy does not approach the 2000+ hours of didactics, supervision, and practice in psychotherapy that clinical students in doctoral programs such as mine receive. I am not suggesting that social workers or psychiatrists are unable to practice effective psychotherapy; however, I am suggesting the training that the best trained psychologists receive in psychotherapy is far more extensive than the training of the average social worker or psychiatrist. Generally speaking, clinical psychologists (not necessarily all of them) are the best trained professionals in the area of psychotherapy. If social workers and psychiatrists could receive this level of training in psychotherapy that would be incredible for the field of mental health! Generally speaking (based on the scientific literature), psychotherapy should be the primary treatment for most anxiety disorders, most severity levels of depression, and all personality disorders. For psychotic disorders, accurately diagnosed bipolar I disorder, and severe and melancholic depression pharmacological interventions are clearly the empirically-supported treatments...

SteveM said...

Re: Drs. Arpaia & Carlat,

I think it important to separate out to two major questions of these exchanges.

1) Are psychiatrists in general, properly trained and socially competent to holistically treat patients with life management problems?

2) Are mental health care providers who are not physicians competent enough to prescribe psycho-pharmaceuticals?

Let me use a brief case study by psychiatrist Dr. Robert London in Psychology Today to explore Question1 :

http://www.psychologytoday.com/blog/two-minute-shrink/201003/do-you-have-dependent-personality

Dr. London describes a patient with Dependent Personality Disorder. The patient's resulting symptoms are depression, anxiety and attention problems. The characteristics of Dependent Personality Disorder appear to closely map to the Victim role of psychiatrist Stephen Karpman's Drama Triangle paradigm. In the Karpman model, the root causes of the psychological dysfunction are family relationships, not brain chemistry.

If the therapeutic meta-objective is first understanding the root causes that make someone miserable, the associated process question is, what percentage of psychiatrists are competent enough and willing enough to engage in a careful elicitation to tease out what the root causes of a patient's problems really are?

Therapeutically, Dr. London describes some self-help techniques that would allow the patient to more positively manage his life. But what would the typical psychiatrist who subscribes to the biological model see in that same patient? Well reductively, he would see depression, anxiety and perhaps ADD because they map to psycho-pharm indications. Unfortunately, the Drama Triangle is not an indication on psychotropic labels. So the psychiatric solution strategy could be an antidepressant, anxiolytic and maybe a stimulant.

The patient then is fundamentally misdiagnosed and is probably in for a wild ride of psychopharm experimentation over the course of a year or two because the root causes are never addressed at “med checks”. Perhaps the medication would provide some relief, but the therapeutic benefit is equivalent to papering over a wall with a crack in it. Frankly, it would not surprise me if the need for long term "maintenance" psycho-pharm medication is often because extrinsic root causes are not properly explored and resolved in a psychiatric relationship.

If Drs. John and Arpaia are correct about the distribution of patient complaints, and those are coupled with a cohort of psychiatrists with insufficient training in psychology and/or poor social skills, then there are indeed many patients with life management problems who are ill served by seeing a psychiatrist first and getting locked into a psychotropic orbit. One obvious solution would be to refer patients to psychologists for the diagnostic. But that is probably infeasible because of professional pride. So then if the phenomenon is true, how to fix that?

P.S. About PCPs, nurse practitioners and other non-psychologists who prescribe medication. The ancillary question is whether they too diagnose and prescribe reductively?

P.P.S. Of course psychology has its share of strange ducks. But the Perfect is the enemy of the Good Enough. I'll let you guys sort it out with 8 ounce gloves and Marquis of Queensbury Rules.

Asslete said...

My office is adorned with fancy diplomas, awards, and articles that I have written. It serves two purposes:

-It feeds my insatiable ego.
-It somehow cues patients to look at me with rapt awe as I complete phrases like "chemical imbalance "and "bipolar II "without getting laughed at

I do believe that 4 years of medical school and 4 years of residency put me in a position to amass these paper accolades (though no doubt a good laser printer, a few forged documents, and a complete lack of conscience would yield the same result)…and I use them to my advantage. Here is one example.

Not too long ago, all 6-foot-6, 380 lbs of Kenneth stormed into my office as a new evaluation. He didn’t like any of the “G-Dang medications these “F-ing shrinks put me on for my Bipolar disorder” and wanted a second…or in this case, fourth opinion.

Ken’s case was rather typical. He had a chaotic upbringing with an alcoholic/physically abusive father and passive mother as his role models. Ken often got into fights himself and used his size to intimidate others. When things didn’t go his way, he either brooded or acted out. At one point, someone cut him off in traffic, so he followed him to a gas station and punched a dent in the hood of his BMW to “teach him a lesson”. Ken endorsed symptoms of occasional sad mood, decreased motivation, decreased pleasure, as well periods of extreme irritability, impulsivity, and some passive thoughts of death. These symptoms always occurred in conjunction with clear stressors (albeit often miniscule stressors).

After the hood-punching incident…yeah, he got arrested. He saw a local and respected psych who diagnosed him with bipolar and placed him on Seroquel and Depakote (Depakote was also for migraine prophylaxis). Over the ensuing several months, Ken gained 100 lbs (280 to 380), saw two different psychs and received Abilify, Lamictal, and Lithium along the way, before grumpily entering my office with the same complaints.

I listened to him vent, asked questions trying to elucidate any prior/current psychosis, grandiosity, flight of ideas, boundless energy, or suicide attempts. There were none. So I asked him a simple question that forever changed his life. It went a little something like this.

“I am going to ask you a rather rude question. And I apologize in advance for its rudeness. But I just don’t know a polite way to ask this. Help me understand why you are Bipolar, and not just an asshole?”

I suspect that had anyone else asked him that question, they would have been rendered unconscious with single blow of his meat-hammer fist. But like a magician’s assistant, my diplomas/certificates bedazzled and distracted him. He gave a rather stuporous blink and said, "I don't really know. Maybe I am just an asshole."

I apologized again and said, "I'm sorry, I just don't have a pill for asshole. But I still think I can help ".

Over the next few weeks, I tapered him off his antipsychotic du jour and his Depakote and instead placed him on Topamax 100 mg daily (for migraine prophylaxis, and yes, off label weight loss). I told him to go out and find God, Budda, Freud, or just a good massage therapist...just find some non-asshole inducing healthy activity to embrace. He found mixed martial arts and now can either render me unconscious with his meat-hammer fist or force me to tap out with a rear naked chokehold. But he has done neither. Instead he made steady improvement towards "normalcy". He is back down to 275 lbs, and while occasionally grumpy…he is far less ass-like…and far far less “Bipolar”

To Dan’s questions…What aspect of my medical school training did I use? How much of this expertise was truly dependent on education? Could the medication decisions have been made by a psychologist? Was there some type of psychological treatment that my patient really needed? My answers are the same as they would be to the question, “How did Houdini saw that girl in half?”

I don’t know.

But then again…maybe I am just an asshole

Ronald Pies MD, Nassir Ghaemi MD said...

[Pies & Ghaemi, In 2 parts]

We appreciate Dr. John Sorboro’s comments on our work. Dr. Sorboro believes that "...by its very nature psychiatry is not at all grounded in medical and neurological science," and that "…people cannot have both hardware problems/chemical imbalance and a psychological problem in need of human empathy as the same causative agent for the same problem." We believe these views are based on a classic conceptual error that has lasted 200 years: equating science with positivism (or “logical empiricism”).

Science is not a matter of objective facts, isolated and independent, as positivism has it. Science involves hypotheses and subjective aspects, too. Psychiatry differs from no science in this regard. A modern philosophy of science reflects this, and most philosophers of science think this way. One approach is to think of two modes of knowing as summarized in Wilhelm Dilthey's, and later, Karl Jaspers' terms, erklaren [explanation] and vesrtehen [understanding]. Psychiatry, as we conceive it (see SN Ghaemi, The Concepts of Psychiatry), involves a recognition of two basic methods of knowledge, which occur in all sciences, including psychiatry: physical-causal explanation, and meaning-based understanding. For example, the psychiatrist seeing a severely depressed patient may view the problem using two basic schemas: 1. "This individual's brain function--her serotonergic system, nerve growth factors,
etc.--may be aberrant in some way that is causally contributing to her depression" [erklaren]; and 2. "In addition, and equally important, this person's recent job loss has led to a profound loss of self-esteem, which
helps me understand her current depression." [verstehen]. We can analogize this dialectic to viewing that famous "perceptual ambiguity" picture, which
may be seen either as a young or an old woman, depending on what elements of the picture you are attending to-- there is only one picture, but two ways
of perceiving it.
[http://www.psychologie.tudresden.de/i1/kaw/diverses%20Material/www.illusionworks.com/html/perceptual_ambiguity.html]. Neither view is definitively right or wrong in an abstract way; each method has different strengths and weaknesses. Empirical scientific research shows which approaches are more fruitful and productive and which are less so.—End, Part 1

Ronald Pies MD, Nassir Ghaemi MD said...

Pies & Ghaemi, Part 2
Nor does the psychiatrist's inability (or perhaps, unwillingness) to identify a "primary cause" of a patient's depression mean that we are operating outside the paradigms of medical science. Often, the patient's condition is highly over-determined [see Pies R: J Affect Disord. 2009 Jul;116(1-2):1-3]. Moreover, there are numerous idiopathic conditions in
medicine and neurology that have eluded precise, uni-causal explanations,
and whose diagnosis relies heavily upon the patient's narrative of suffering
and incapacity; for example, many idiopathic chronic pain states fail to
yield a specific pathophysiology. We believe it is a misguided application
of logical positivism to insist that medical science must always be able to
point to a specific cause or pathophysiology, in order to be "scientific".
Indeed, when Dr. Sorboro insists that psychiatry "cannot know anything for
sure", he is not asserting anything peculiar to psychiatry; most
philosophers of science would argue that no branch of science or medicine
can know anything "for sure", owing to the countless subjective judgments
and non-verifiable assumptions built into all scientific theories (see S.
Okasha, Philosophy of Science, 2002). Even the most definitive scientific theories or "facts" are not absolute, unchanging species of knowledge. Science is organic; it changes and progresses precisely because its knowledge is approximate, not absolute.

There is another more concrete sense in which psychiatry's "science hand" is
far from empty. In the process of making a diagnosis (literally, "knowing
the difference between"), psychiatrists must exclude a multitude of medical,
endocrine (as Dr. Arapaia would have it), metabolic, and neurological
factors. This means that a diagnosis of, say, schizophrenia cannot be made
without a simultaneous understanding that the patient does not suffer from
Wilson's Disease or a tumor of the temporal lobe. This is yet another reason why psychiatry is a branch of general medicine.

Finally, we do not believe that psychiatrists are necessarily unique among
medical professionals, in bringing together scientific and humanistic
world-views. As Dr. Sorboro implies, all good physicians--indeed, all good
clinicians--probably do this, either by instinct or temperament. This tradition goes back to Hippocrates. It is an integral part of any medical model that is not pure, biological reductionism. Despite the lamentable, market-driven distortions of psychiatric -- and indeed all medical -- practice in recent decades, we believe that psychiatry’s pluralistic foundation remains strong.

Ronald Pies MD
S. Nassir Ghaemi MD
Tufts University School of Medicine (Dr. Pies & Dr. Ghaemi)
SUNY Upstate Medical University (Dr. Pies).

SteveM said...

Re: Drs. Pies & Ghaemi "...we believe that psychiatry’s pluralistic foundation remains strong."

Respectfully, in a de jure sense, perhaps. But in a de facto sense, obviously not. Otherwise, why would you guys be having all of these conversations about how/why psychiatry is busted? And why the need for a self-flagellating "Couch in Crisis" section in Psychiatric Times?

It's Domino's Pizza time for psychiatry. Somebody has to step up and not only say that the recipe ain't right, but also take a leadership role in fixing it.

P.S. There's nothing more banal than recycling the same issue over and over and doing nothing about it.

Asslete said...

AleksPsych...I agree with much of what you wrote. But I have an honest sense of skepticism in one of your key points.

While I agree with your contention that psychologist have far more extensive training in psychotherapy...and while also agree that with your contention that empirically-supported treatments should be used...I have yet to find a credible study that demonstrates that the level/hours of psychotherapy training one receives, translates into better outcome. I know it sounds reasonable, but in my mind, a pound of lead should weigh more than a pound of feathers...I mean, come on...its freaking lead!

Intuitive reasoning can often be flawed reasoning. Berman's 1985 study "Does professional training make a therapist more effective" demonstrated quite nicely that professional and para professional therapists had equal outcomes.

http://www.psych.umn.edu/courses/fall07/brunnquelld/psy8542/Session%2007/Berman%20session%207_1986-02211-001.pdf

I may be completely wrong, So if better data exist, I would love to see it. Until then, I'll keep looking at feathers and lead with abject suspicion

Dr John said...

I thank Drs Pies and Ghaemi for their thoughtful response.I cannot disagree with much of what they say on philosophical grounds. On practical grounds I do not agree. Speculating as to knowing even using a pluralistic approach is not the same thing as having a working model that gives you a glimpse of knowing. As I have said and other students of science have stated, a model must allow accurate prediction and intervention to be a useful model. No model of any psychiatric disorder really allows this on any individual level. We have NO physical causal explanations despite the spurious mention of a depressed person/serotonin/nerve growth factors. Psychiatrists who make any such connections are practicing self deception.Seeing them as spiritually bereft is as empirically valid as the bio-babel explanations we now have. We are the ones that provide meaning to things in the dyad depending on our religious/education/philosophical/sexual backrounds at times under great protest by our pts. I agree there are numerous vague non-specific syndromes in medicine that suffer from the same flaws as our own DX. Fibromyalgia is one that comes to mind. There is not much we can say at all about the suffering of those who make such complaints. We do not advance our knowledge by creating poorly supported constructs. I am not saying we should not try to help but attaching a name to a group of complaints is not really knowing something about it and after doing so we give people license to process all their problems through it. We should not be so afraid to say so "I don't know".Drs Pies and Ghaemi are indeed correct in implying all knowledge is provisional and imperfect but we must judge in some coherent manor none the less what we have. I do not think one needs to be an expert in the philosophy of science to see the difference in the knowledge base behind Quantum Mechanics, Evolutionary Biology, Infectious Disease( all incomplete and imperfect) as compared to the "knowledge" behind psychiatric science. Both of them are clearly thoughtful, insightful individuals. I do not think one can step back objectively regardless of our disagreements and say things are going that great for our field. The winds are blowing. I am not sure where any of this is heading. John Sorboro MD

autumns_leaf said...

I've suddenly realised what separates M.D.s from the rest. "Congratulations, you've had a breakthrough!" [Antz]. It's something that happens between that middle of the night code and watching a young child die from a horrible degenerative disease. I think only soldiers in battle experience this to the same degree. It's something that happens to most people a few times in their life, but only when they are at the wrong end of a personal tragedy.

It's a sense of proportion.

Oh, and I don't believe in structured diagnostic interviews and all that. It's like trying to measure a sunrise. Don't make any sense. You gotta get the gestalt of the person in front of you, or you got nothing.

Joel Hassman, MD said...

Dr Carlat:

Your April 2 9:15AM comment really bothers me! That is the kind of rationalization that leads to dismissing the role of doctors as a whole in the end. And I think Dr Arpaia's reply says it well for me.

With your logic, here are my questions to decide whether MDs in general are needed:

1. If you have a non-surgical issue, and your symptoms do not require immediate hospitalization needs, why not just go to a minute clinic, or to an accupuncturist? I mean, why go through the bother of a physical exam and potentially needed lab/radiological studies, since you can live with gall stones, crohn's disease, migraines, arthritis, hell, even asthma if not with serious SOB?

2. Why require nurse practitioners to have an MD for supervision, after all, they get a training that is medical in backround, get the right to prescribe, and can even advise non pharmacological interventions as trained from a nursing perspective?

3. Why not let pharmacists prescribe at least simple meds for hypertension, non insulin needed DM, arthritis, maybe even broad based antibiotics for simple infectious issues like UTIs?

4. As I wrote at the beginning of this thread, why not let social workers get the pharmacological training to prescribe. Then they can do everything: diagnose, therapy, meds, and maybe even psych testing. After all, isn't that what LCSW-C stands for: licensed social worker Completely!?

It is this kind of twisted, however well meaning, logic and justification that reinforces what my mentors in med school and residency taught me to beware of: every one is a doctor until the true responsibilties and accountabilities play out, and guess who is out the door first when the stool hits the fan? It ain't you and me and the patient, sir! And that is why med schools don't accept 500 people a year to be in class.

You dumb down and simplify the craft, you might as well substitute the commercial of everyone who comes onto the tennis court to play, and the professional just stands there scratching his head thinking "what the hell is going on?" and have a doctor standing in the exam room while the family members, the cleaning staff, the lawyer in the next office all holding stethoscopes and arguing what the heart sounds really mean.

And now you will have Obama care take these rationalizations by KOLs and find the cheap ways to offer care. And it won't help colleagues like me who won't be sticking around, or be asked be available for that matter, for these additional 30 million people to get care.

By the way, some of the commenters might want to use paragraphs in your comments, as it is not easy to read a 50 line comment without a space.

Hey, it is the way I see and experience it. The road to hell is paved with good intentions.

Dr John said...

As Drs Pies and Ghaemi got two parts I will add this last comment. I am not a denier of the concept of psychiatric disease. There are very limited symptom clusters such as OCD, Catatonia and psychosis which may eventually, perhaps allow for a partial biologic explanation. That being said I will leave with a quote from the man who's photo I chose to post as myself, Sartre. "Emotions are our way of interacting with the world" They are about how we see ourselves in that world and the context we see it in. The rest of what science looks to "explain" really is not saddled with this existential baggage and in the end makes almost all of what psychiatry is trying to do "unscientific" so we should not really even try to apply such principles. Unless psychiatry as "medical science" changes course and dramatically narrows the scope of what it is trying to treat and understand it is doomed to drift endlessly as an intellectual dead end or it will just break apart as we know it. I think there are signs in some respect this is beginning to happen.

Anonymous said...

Just as an aside to this debate--I notice that advocates of CBT and other drug-free therapies imply or actually state that psychiatry has found no biological cause for mental illnesses. Dr. John in particular seems to be saying that.

But what about severe cases of OCD? I was under the impression that that HAS been determined to be related to a seratonin inbalance. Have I been misinformed?

Joseph P. Arpaia, MD said...

I do not think most scientists would agree with the position taken by Drs. Pies and Gaemi.

Science is a process for investigating nature. Observations are made. Hypotheses are formed, tested, and eventually disproved. These observations lead to new hypotheses. (I realize that politics disrupts this process in all fields but that is considered to be a deviation from science.)

Most of psychiatry and indeed most of medicine, is not scientific, and cannot be made scientific at this time.

Science as a process requires accurate measurement, reproducible results, and controlled studies. Psychiatry has none of these.

Accurate measurement: There is nothing in psychiatry that is even close to meeting the standard of measurement precision required in any of the physical or biological sciences. Furthermore the rating scales used do not meet the mathematical criteria that are required by the statistical methods that are used to analyze the data. In fact the phenomena we are studying may not be amenable to any of the mathematical tools in existence. We still can't model the human visual system, let alone a psyche. Yes the computer programs produce results, but "garbage in garbage out".

Reproducibility: A test done by one experimenter must give the same results as the test done by another. This is routinely violated since every drug company has studies showing that their product is more effective then their competitors. Even studies done by independent labs do not give the same results.

Controlled experiments: In a scientific experiment only the variables studied are different. All other variables are held constant. This can't be done in psychiatry, or even most fields of medicine.

So until psychiatry can measure accurately the phenomena it presumes to treat, run the same experiment and get the same results, and control variables that are not being tested, any claims to its being scientific are false by the definition of science as a process for investigating natural phenomena.

Even though psychiatry is not scientific we can still help people. After all, fire, the wheel, and agriculture were discovered without formal scientific experiments. I think the field would be better off if we gave up our scientific pretensions as we are not fooling anyone but ourselves.

Anonymous said...

Dr Pies:
As Bill Clinton might say; "I can feel your pain." I am sorry you feel that so many posts have constituted caricatures of your beloved profession. But I wouldn't idealize your profession: Why just this week we had another drug company fined for pushing a drug (Neurontin) for treating an illness (bipolar) when no evidence for its efficacy actually existed. And, in fact, research was slanted and cooked to make it appear that the drug worked. And just who prescribed this medicine for bipolar disorder? Why, psychiatrists of course! And the psychiatrists are not blameless-- how many KOL and academic psychiatrists took money to talk about the wonders of Neurontin? Too many to count. As Vonnegut would say, "And so it goes...."

wetnurse said...

Asslete:

YOU ROCK!

AleksPsych said...

Asslete: The issue of whether more experience with psychotherapy produces better results....

While many studies do find that greater level of experience is not related to better outcomes (e.g., Beutler et al., 1994; Christensen & Jacobson, 1994), these findings are controversial. For example, most studies examining experience only consider number of years practicing therapy (or years of graduate training) rather than more relevant components of experience such as number of specific clients treated or level of training in the particular treatment (e.g., Beutler, 1997).

Some studies show that when therapists do NOT use manualized treatments greater experience does produce better results overall (e.g., Crits-Christoph et al., 1991). There are other studies that have shown that anyone providing an empirically supported therapy (when doing it correctly) can produce good outcomes (e.g., Dunkle & Friedlander, 1996; Franklin et al., 2003).

Generally speaking, professionals who are appropriately trained to use manualized psychotherapies can all produce good results. This makes sense given that the strict guidelines of a treatment are being followed session by session. However, psychotherapy outcome studies do have their own flaws, which we must take into account (e.g., how outcome is measured). It seems as though once a professional deviates from a manual (which, by the way, is how typical psychotherapy practice works) experience might matter.

Another point to make is that there might be psychologists who have horrible interpersonal skills and do not produce good psychotherapy outcomes. The same can be true for social workers and psychiatrists. Therapist interpersonal factors have been shown to effect outcomes.

The issue of psychotherapy training and outcomes is quite similar to the issue Dr. Carlat is bringing up about psychopharm training and outcomes. The issue of safety is always brought up when discussing psychopharm, but it is rarely if ever brought up when discussing psychotherapy. I believe an inappropriately trained therapist can do damage to the most vulnerable patients (e.g., suicidal patients, horribly traumatized patients).

David M. Allen, M.D. said...

Joseph P. Arpaia, MD : I agree with you that most of the studies in our field do not measure up in terms of precise measurements and total control of environmental variables seen in the physical sciences.

In fact I just posted on my blog an entry about how "data" in psychiatry really is the plural of "anecdote"

I must disagree, however, with your rather narrow view of what constitutes legitimate science.

Your view would preclude all of mental life from scientific investigation, since we cannot read minds. And if one believes in free will, a human being can choose to respond or not respond to a therapist's intervention, no matter what the therapist does.

Does this put all of psychiatry and psychology, not to mention medicine as a whole, in the same boat with religion? Do we have to take everything we do on faith? Are all theories in the field equally valid?

I don't think so. Scientific evidence never has consisted entirely of controlled experiments (think astronomy, for instance). Observation is the first step in the scientific method.

Joseph P. Arpaia, MD said...

David M. Allen, M.D.

David,

Since this is off the topic of the original post my apologies to the other readers of this blog. But I think it might be useful to have a bit of repartee on what should be considered science.

My reason for using a narrow definition is that "science" has powerful connotations in our society and any system of thought which cloaks itself in the mantle of science is automatically given credibility.

I also do not think my definition is quite that narrow.

For example, astronomers do run experiments. They make predictions based on observations and then figure out ways to test those predictions by gathering other observations and controlling for confounding variables like atmospheric perturbations, background light, dirt in the telescope, etc. If the observations do not match the predictions then they revise the model they use. (They don't revise the observations, which is what seems to happen in too many drug studies).

My point it that those measurements are precise, and the data adhere to specific mathematical properties which make the calculations used to analyze the data valid.

The data in psychiatry and medicine do not meet that standard as you pointed out.

However, just because we are not able to do science by a narrow definition does not mean we are limited to calling what we do religion. There needs to be middle ground for systems of investigation that are neither science, nor religion. Perhaps we could call those "engineering"?

The difference between those systems of investigation and religion is that religion postulates some statements as non-disprovable. For example, if one is a Christian there is no experiment or observation that will disprove the statement that "Jesus of Nazareth is the Son of God". And similarly for other religious systems. (And I have nothing against the fact that people have such beliefs.)

I would agree that we can still investigate phenomena such as internal mental states in a useful manner and that such investigation should be done. I use hypnosis in my clinical practice. It can be extraordinarily useful. But I would not consider any of the research I have read to be rigorously scientific. That is not to put down the researchers, who show incredible brilliance at times in attempting to control variables and measure precisely. But, whatever happens inside the person who responds to hypnosis is simply not measurable with the tools we have today. We have still learned a lot from studying hypnosis and it has given us insights into various other forms of communication.

I guess its a bit of a hot issue with me that labeling a finding as "scientific" raises that finding on a pedestal and makes it immune to questioning. Why else would so many advertisements use words like "scientifically proven" "proven by research" "proven [scientifically] safe and effective". This is actually confounding science with religion, but that is the way society uses the term "science". Hence my desire to narrow the definition.


Thanks for your disagreement. It helps me work hard to clarify my thinking instead of believing it.

-Joe

Debra said...

Wow, I am really excited about this debate. It is getting more and more interesting...
A few points.
It seems to me that the basis for the scientific method, ALL DOMAINS INCLUDED is what could be called... "clinical" observation.
We can debate as to whether to call this "scientific" or not, as we used to talk about the... "art" of medecine.
It comes to me that... if observation, clinical analysis is obviously "scientific", then what we DO with that observation is probably NOT scientific.
It is the.. ART of medecine. The ART of psychotherapy.
Because there are limits as to where the scientific approach can take us, and when we are faced with flesh and blood individuals who are all different in how they react to drugs and psychotherapy (the norm is a statistical construct, an abstraction, not a... person...), then maybe... the ART of interpersonal relation has its place.
Can you teach it ? Not in manuals.
When people learn in manuals, they apply a formula. You apply formulas to things, not to people. You may be able to predict how "bipolars" are going to react, but NOT HOW THIS PERSON IS GOING TO REACT. Important distinction.
Doctor Pies, while I agree with much of what you are saying, and thank you for lifting the debate to an extremely subtle level, I submit that you are functioning in either/or mode, and not both/and.
A psychiatrist SHOULD be making clinical observation from BOTH a physiological point of view, AND an interpersonal one. No boxes, please. People are complex.
Finally... for some fun, go back and read Freud's early observations in the Studies in Hysteria.
The observations where Freud is developing his clinical approach AT THE SAME TIME he is constructing psychoanalytic theory.
Edifying. Our... predecessors STILL have lots to teach us, when we want to crack the books...
And you will get a glimpse as to why Freud pulled the psy profession in the direction of science.
Among other things because... "science" was a religion in the 19th century. So... in order to enjoy more legitimacy, Freud HAD to lodge psychoanalysis in the "science" box. So that his contemporaries would find it easier to... BELIEVE in it. (All this unbeknowsnt to himself, of course.)
One last thing.
I keep harping on about belief.
One of our biggest obstacles lies in OUR DISQUALIFICATION OF BELIEF. Treating those who believe, as soon as what we "know" turns into what we "believe", as dupes.
This is our infantile disappointment at work.
Our infantile temper tantrums at not being able to believe in Santa Claus, the way we would like to.
The only way to really believe in Santa Claus in a meaningful way is to... BECOME Santa Claus.
Not wait for him to show up on Christmas Eve...

David M. Allen, M.D. said...

Joe and Debra,

Thanks for your comments. I participated in a long and involved series of e-mails about the nature of scientific evidence among members of the Society for the Exploration of Psychotherapy Intervention (SEPI) which you might find interesting. It's posted on line at http://sepiweb.org/science.htm.

Joe - it sounds like we actually agree more than disagree; we just seem to be debating semantically what is entailed by the term "science."

The problem with drug studies today is that they are BAD science. For example, a recent article in the New England Journal of Medicne purporting to show that antidepressants do not work in bipolar depression used a sample of folks that probably contained a large proportion of patients who had already failed one or more antidepressants. This was not acknowledged at all in the paper!

Debra - I agree with your comments about both/and thinking, the fact that a lot of what we do is an art, and the problem with treatment manuals. One psychologist, I'm not sure who, said that the only thing that psychological tests can predict is a person's performance on other psychological tests.
- David

Ronald Pies MD said...

Dr. Pies's "sign off" comments [in 2 parts]:
I feel I've already said quite enough, but I would like to conclude my contributions to this discussion with a few observations and comments. First, thanks to all who have contributed, even to those with whom I've strongly disagreed!
1.We will probably never agree on an “essential” definition of “science”—i.e., one that infallibly specifies the “necessary and sufficient” conditions for some activity to be a “science.” I would take care, however, not to confuse “science” with “physical science” (such as chemistry) or with the philosophy called logical positivism, where the only data that count are those that involve logical necessity or direct empirical observation. As philosopher of science Samir Okasha states,
“…science is a heterogeneous activity, encompassing a wide range of different disciplines and theories. It may be that they share some fixed set of features that define what it is to be a science, but it may not.” [Philosophy of Science]. Recently, the British Science Council spent a full year developing a definition of “science.” Their conclusion? "Science is the pursuit of knowledge and understanding of the natural and social world following a systematic methodology based on evidence." http://www.guardian.co.uk/science/blog/2009/mar/03/science-definition-council-francis-bacon
By this definition, both medical science in general and psychiatry in particular more than qualify as “sciences.”
2.It is easy to underestimate the amount of scientific data already known to psychiatrists, in comparison to so-called “hard” sciences. I believe the finding of elevated cortisol in a large proportion of patients with melancholic major depression is at least as secure and well-founded as the quantum physicist’s claims that there are particles in the universe called “quarks” and “bosons” [see: Taylor MA, Fink M. Melancholia: The Diagnosis, Pathophysiology and Treatment of Depressive Illness. Cambridge, UK: Cambridge University Press; 2006]. By the way, re: astronomy—when we were all growing up, Pluto was a planet. Recently, the astronomers decided (by vote of a committee?) that Pluto is no longer a planet. Which is the more exact science—astronomy or psychiatry? [tongue-only-slightly- in-cheek].
Pies, end part 1

Ronald Pies MD said...

Pies, part 2
3.I am not one to “idealize” psychiatry; but neither will I stand by and watch psychiatry be demonized. On the Psychiatric Times website [psychiatrictimes.com], our blog site is named “The Couch in Crisis” for a reason (I know, since I named it). If readers take a look at my blogs and articles, they will see that I find many problems with psychiatry as it is practiced in today’s mucked-up, market-driven, non-health-care system. Yet I believe the conceptual foundations of the field remain solid, if far from perfect; and that the average psychiatrist gets up each day, tries to do his or her best to keep desperately sick and suffering people alive and functioning; and gets less respect for this than deserved. That said, we have a long way to go, in terms of regaining (or gaining) the public’s trust. We have made many mistakes along the way, and we need to reform ourselves from the inside out. This means refusing to be ensnared in a purely “biological” paradigm, distancing ourselves from “Big Pharma”, and scrupulously adhering to principles of medical ethics and informed consent, in everything we do. By the way: the notion that psychiatry residents no longer receive much training in psychotherapy is a huge and simplistic generalization. As an upcoming article in Psychiatric Times will show, some programs, such as my alma mater (Upstate Medical University) provide robust and intensive training in psychotherapy, over several years of the residency.
4.Dr. Carlat’s ideas about revising and condensing the medical school curriculum, perhaps by eliminating some pre-clinical material, is reasonable and worth exploring; but this is an entirely separate issue from what disciplines should now be permitted to have “prescribing privileges.” If the medical school curriculum is shortened, say, to 2-3 years; and research shows that graduates of this program prove as competent and skilled as current MDs, then any other professional (social worker, psychologist, etc.) should be able to enroll in that shortened curriculum and be able to practice medicine. But granting “prescribing privileges” to psychologists now puts the evidentiary cart before the horse. By the way, Danny: the reason you are able to identify the “25%” or so of psychiatric patients who are medically complex, and therefore in need of a psychiatrist, is precisely because you gained the medical knowledge to make that determination—in medical school and residency!
And now, I’ll leave the debate to the wisdom and good sense of the rest of you!—Best regards, Ron Pies MD

SteveM said...

Re: Dr. Pies

Claiming that psychiatry is being demonized is personalizing the problem. I think few people that recognize the deficiencies of how normative psychiatry is currently being practiced have that kind of Manichean point of view. Labeling other well intentioned stakeholders as absolute adversaries serves no purpose.

And keep in mind that the people who are most "anti-psychiatry" are those who have been grossly injured by the profession. Nobody suddenly wakes up in the morning with the revelation that pyschiatry is a mess and therefore must be attacked. Nope, they are aggrieved because they had been turned inside out by psycho-pharm first. When are you guys going to run on column on how to repair patient relationships that have been ruined iatrogenically?

Re: "elevated cortisol in a large proportion of patients with melancholic major depression is at least as secure and well-founded as the quantum physicist’s claims...”

Few would argue with that claim. That is not the issue, which is that a normative psychiatric solution to life/mood problem is de facto psychopharmaceutical. Mindful meditation, yoga and weight training at the gym reduce cortisol levels too. But how often are those nondrug prescriptions part of psychiatric therapy? Instead toxic Cymbalta as a first line treatment? That drug stinks. And you should be blasting away from your Psychiatric Times perch at the Eli-Lilly DTC claims that it is.

Now I'm sure that one can point to academic programs that have a stronger psychotherapeutic element in their curriculum. But the proof is in the pudding. When those graduates start practicing on their own, do they do so "holistically"? Or do they fall into the normative psychotropics-first paradigm? Now there's some simple statistics that can be scientifically validated.

BTW, another thing that hurts you guys (except for the occasional Danny Carlat) is in not excoriating and shunning bad practitioners like Dr. Kayoko Kifuji, corrupt practitioners like Drs. Joseph Biederman and Charles Nemeroff and researchers like Dr. Joan Luby (a menace) who claim that half of all kids are mentally ill. Who in pyschiatry has challenged Luby's apparently ridiculous statistics? You mainstream guys should be taking explicit shots, but instead those are limited to the (relative) iconoclasts like Dr. Carlat.

Dr John said...

I have read all these comments. In the end what many are asking is "special pleading" for psychiatry and that it should be judged on different grounds as far as science goes. The clinical practice of medicine is not always scientific true. That being said it is a gross error to claim that the rest of medicine is unscientific. Study what has happened the past 200 years in the fields of microbiology, genetics, immunology, cell biology, laboratory science and radiologic medicine.Wonderful basic science. All of this has profoundly changed the perspective of Drs who operate in them from all fields of medicine but psychiatry. Other than telling people what is NOT wrong with them not one bit of any of this has any application to psychiatry. Psychiatry alone this can be said of. Instead of seeing how profoundly important this fact is we are asked to just dumb things down by using what again is just essentially wordy excuse making for our field. Work like Jaspers in theory is reasonable but regardless of what set of glasses you want to put on all you have in the end are different approaches to speculation and no evidence to support your contention that stands up as science in any other field. If those at the top want to be judged by a different set of rules than they and their practitioners should make it clear to people they are doing so. Documents like the DSM and TV commercials touting the benefits of drugs for your "real medical disorder" depression certainly do not leave our pts with the understanding of this.We are ripping people off by this obfuscation. We should at least come clean and admit it.

Debra said...

But Doctor John...
You didn't read my comment about medecine as science AND art, did you ?
There is certainly a scientific attitude towards medecine which founds clinical observation.
Hey.. I apply this kind of "scientific" method when I read literature or sit down to work HARD at playing the piano.
But dealing with patients in interpersonal relationships, I don't think that that is the, uh, PLACE, necessarily for focusing our consciousness on the relationship in an acutely analytic fashion.
Analysis means tearing things apart.
Our patients don't WANT to be torn apart, I think.
Well, not under their noses, at any rate.
There is a delicate balancing act that needs to be carried out between analysis/tearing things apart and empathy/identification.
And that is.. the ART of medecine.
And the ART of psychiatry too, while we're at it.

alex said...

Maybe this could be merged with the original provocative post and published - this is an incredibly rich (although somewhat depressing - a sad reminder of how primitive the level of our understanding is) discussion.

I have one quibble with Dr. John who said, "People cannot have both hardware problems/chemical imbalance and a psychological problem in need of human empathy as the same causative agent for the same problem."

This is overly dogmatic. The truth is, we just don't know which is dog and which is tail. If memory serves, Salvador Minuchin's move into family therapy was launched by wondering why certain children were going into diabetic crisis without any dietary contribution. Looking at the record and interviewing the children, he realized that family crises were causing higher cortisol levels and the physical symptoms were the result of external stress.

The basic problem is that we don't really know what's going on and lump along trying to see what makes sense and what seems to work (the art and science part of this discussion). Reading the catalog of psychotropic drugs in one of the Carlot newsletters I was struck by the number of medications that were described with "mechanism unknown." Some seem to work, some don't, how much is placebo?, etc.

With this in mind, reading Thomas Insel's slightly (to me anyway) geewhiz article "Faulty Circuits" on 'malfunctioning connections' in the April 2010 Scientific American made me shudder a little. Remember, this is one of the hands on the research spigot. It may come to pass that medical psychiatry will soon be replacing psychotropic medications with implanted nanowidgets and then we'll all be complaining about the CME's being paid for by General Electric.

The mechanisms will still be unknown, but the funding stream goes on and on...

Dr John said...

Alex. Certainly pathology can be "triggered" and you describe a trigger in diabetic crisis.There is a very substantial difference in the models in psychiatry. They do not look to describe psychological causes for biological disorders as the example you give. There is not a discipline in medicine surrounding the understanding and TX of DKA using family therapy nor do we understand the pathology of DM using family systems analysis as a descriptive explanatory model despite stress as a trigger.

In mental health these models both look to essentially describe the same pathology not act as a means of describing one as a trigger for the other. Nor do they look to alter it in the same way. I get your point about being careful with dogma but again the models used in biological psychiatry and psychology are not complementary by design. They are independent descriptive models devised by themselves to describe and offer interventions on the same pathology in different ways.That is not at all what you are describing in your example of diabetes triggered by stress. Both descriptive models may have their advantages at times(biopsych in my opinion almost never as its bad science and not even good metaphysics like some psychological models) but they are as exclusive in describing the same phenomenon as Newtonian physics and Quantum Mechanics.

Anonymous said...

I think alex is a genius. Can we have more posts by you? You are very insightful. I mean this sincerely.

JHSmdjd said...

Dr. Carlat,
I have been involved in the issue of psychologist prescribing in CA. I would concur with your observation that safety is the central issue.
I also spent 25 years in the Navy. The ostensible reason that the DOD stopped training psychologists to prescribe was cost. Reading the report of the program's history indicates that competence was the underlying issue. Currently, it is unlikely that more than a handful of such individuals are still on active duty in any branch of the armed services.
I know that Psychiatry has an obvious financial conflict of interest regarding who prescribes.
I would concur that bickering over turf is neither seemly nor effective. But in this case it is a critical issue that is more than a simple turf war.
V/R: JHSmdjd