In his book “Unhinged: The Trouble with Psychiatry—A Doctor’s Revelations about a Profession”, Daniel Carlit, describes his motivation to pursue a career in psychiatry to be related to the tragic death of his mother who committed suicide as a result of her depression. So he went on and graduated from medical school and completed his psychiatry residency at Massachusetts General Hospital, which is the main affiliate of Harvard Medical School. After completing his residency, he, like most psychiatrists of his generation, specialized in psychopharmacology, where he spent 15 to 20 minute medication visits prescribing psychotropic medications to his patients. Over the past few decades, beginning in 1992, following the introduction of the second generation antidepressant fluoxetine (Prozac®) psychiatrists in the US have devoted most of their time to prescribing medications while referring their patients to other mental health professionals for psychotherapy and counseling. As a result the general public and the mass media began and continue to portray psychiatrists exclusively as pill pushers, who have abandoned the need to understand and connect with their patients ‘ most inner being ,and their psyche.
The purpose of this commentary is twofold: First is to review some of the factors that influenced psychiatrists to limit their profession to prescribing psychotropic medications. Second, to reemphasize the identity of psychiatrists as physicians who collaborate and combine the benefits of psychotherapy, social and spiritual interventions with medications to practice their time honored mission of restoring and healing the human psyche from the suffering and pain that are inflicted by mental illness.
psychiatry, psychopharmacology, psychiatrists, medications, psychotropic, pill pushers
The word that accurately describe psychiatry derives its origin from both Greek and Latin. Medieval Latin psychiatria, literally meant "a healing of the soul," and the Latinized form of Greek psykhe which meant "mind", "Psych" “ breath” ,“life”, or “soul “ [1-4]. The term "Psychiatry" was first coined by the German physician Johann Christian Real in 1808 and literally means the “medical treatment of the soul” . Based on this description psychiatrists are physicians who specialize in healing the soul and in restoring the human psyche to a state of wellbeing. The advent of psychopharmacological agents, along with increasing knowledge of psychiatric conditions that can be treated with medications, have led to a vast expansion in treatment options available to psychiatrists. Studies and clinical experience have also consistently demonstrated that, psychiatrists who collaborate and combine the benefits of psychotherapy with psychopharmacology ultimately improve their patients’ quality of life . To fulfill their core mission 21st century psychiatrists need to reestablish their identity as specialized physicians who combine their psychopharmacological expertise with psychological, social and spiritual interventions in the treatment of mental illness. By treating and alleviating the distress, the suffering and the impairment caused by mental illness, psychiatrists could substantially contribute to the reduction of the global burden of mental illness and its related disability .
Did psychiatrists abandon psychotherapy?
In the 1950s psychoanalysis was primarily sought by socially established and educated individuals suffering from situational stress, anxiety, unhappiness, or boredom. It was later generalized to treat other patients with severe psychiatric conditions. The evolution of psychoanalysis led to the development of several types of psychotherapy which became an integral component of psychiatric treatment. Psychiatrists were also considered the only mental health professionals credentialed to provide psychotherapy . In the ensuing decades other mental health professionals especially psychologists sought legislations to allow them to treat mental illness using psychotherapy which was later followed by social workers and other counselors .These disciplines instituted educational and training requirements that allowed their professions to acquire the necessary credentials to provide psychotherapy . In the same period psychiatric treatment was being transformed toward the adoption of a medical model which emphasized the notion of a cause effect relationship between biological brain dysfunctions and the development of many psychiatric disorders such as psychosis, mania, severe depression and anxiety which would require urgent and ongoing pharmacological treatment . Some psychiatrists even proclaimed that multilevel models of interpreting psychopathology, especially those including psychological and social explanatory perspectives, are irrelevant to psychiatric treatment. As a result a rift between the biological and the psychological treatment of mental illness began to develop and to progress. The rift seemed to have widened by George L. Engel's description of the bio psychosocial medical model of mental illness  and Eric R. Kandel's work on the cellular basis of behavior . Even at the height of promoting the effectiveness of pharmacological treatment in the 1980s and 90s; it was recognized that unconscious dynamics play an important role in the therapeutic alliance between patients and their psychiatrists, and that interpersonal factors strongly influence patient’s progress and recovery from psychiatric symptoms. By the 1990s psychiatrists were persuaded to devote their time to prescribe psychotropic medication and to refer their patients to other mental health providers for psychotherapy. By then the treatment of mental illness with psychotropic medications was categorized as psychopharmacological treatment or meds check appointment .
The challenges of psychiatric services reimbursement
Reimbursement for mental health services is based on specific numerical codes that are assigned to each psychiatric diagnosis. Every year, Medicare, Medicaid, and insurance companies reimburse billions of dollars to hospitals, physicians, pharmacies and laboratories based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) psychiatric diagnostic codes. The DSM has been revised several times since its first 1952 edition. It is published by the American Psychiatric Association (APA), one of the oldest national medical specialty societies, that and it is considered the largest psychiatric organization in the world with over 36,000 members . The APA has great influences on the goals and directions of psychiatric practices in the US and beyond [15,16]. The DSM-I and DSM-II used comparisons to prototypical descriptions for diagnosis that were not tied to reimbursement codes. In contrast the DSM-III, which was published in 1980, was solely symptom-based and included several revolutionary changes using checklists of features in order to enhance diagnostic reliability which was important in legitimizing psychiatry as a medical specialty . The DSM-III improved the statistical reliability of psychiatric disorders by “meeting criteria” to validate patients ' diagnosis for one or more defined disorders . As a result DSM-III diagnostic codes were used as the basis for mental health services reimbursement . DSM-III was revised to DSM-III –R and then followed by DSM-IV and DSM-IV-TR; which reflected the rise of “evidence-based medicine.” and despite their neutrality toward recommending any particular treatment of psychiatric disorders, their diagnostic codes were used for mainly reimbursing psychopharmacological treatments . In 2013 and following long contentious debates and controversies the APA released DSM-5 which unprecedentedly expanded the scope of mental illness to many conditions which were not previously perceived as psychiatric disorders . Psychiatrists perceived the 15 newly added DSM-5 diagnosis as an opportunity to help previously undiagnosed patients, but their reimbursement remained tightly correlated with the pharmacological treatments .
Under typical reimbursement rates, psychiatrists would have a lower reimbursement rate if they spent their time conducting 45-minute psychotherapy sessions but would receive higher reimbursement rate if they saw patients for shorter 15- 30 minutes medication management appointments . These reimbursement rates discouraged many psychiatrists, especially those in private practice and those receiving public sector salaries, from providing psychotherapy and they devoted their office appointments for medications management . As a consequence of this shift in the scope of practice, psychiatric follow-up appointments were ironically titled as” “meds check visits” and for the skeptics these visits were equated as “pill-pushers”.
The importance of psychopharmacology
The discovery in the 1950s of the antipsychotic drug chlorpromazine (Thorazine®) led to the gradual dismantling of state hospitals and insane asylums . For the first time in modern history the mentally ill patients were unshackled and liberated from life-long isolation and separation from society . Thorazine revolutionized psychiatric treatment and represented a major turning point in the management of the chronically mentally ill patients and eventually replaced obsolete treatment modalities such as, hydrotherapy, and insulin shock therapy . As physicians who specialize in the treatment of mental illness; psychiatrists must constantly perfect their knowledge and their expertise in prescribing psychotropic medications. They must assume leadership roles in educating their primary care colleagues and other non-medically trained mental health providers about the importance of psychotropic medications. The advent of safer psychopharmacological agents with less troublesome side effects, along with increasing knowledge of the broad array of syndromes treatable with medication, have led to a vast expansion in treatment options available to the psychiatrists . Studies and clinical experience have also shown that combining psychotropic medications with psychotherapy is an ideal treatment for many psychiatric conditions . Psychiatrists also need to acquire knowledge and expertise in medication interactions and in prescribing appropriate medications for patients with co-occurring medical illnesses, such as diabetes or heart disease; and in understanding how psychiatric medications have different effects depending on the age, the gender and the racial backgrounds of the patients they treat . As experts in psychopharmacology, psychiatrists need to maintain constant vigilance in monitoring potential metabolic effects of medications; and mitigating medication adverse effects without undermining otherwise successful pharmacotherapy . In addition many patients derive psychological benefits from receiving medications, because they consider it a caring, nurturing act that validates their suffering as genuine .
The pharmaceutical industry and its influences
As a society the US is consuming a large proportion of psychiatric medications which contribute to spiraling health costs and may drain much needed resources from other mental health services such as residential and day treatment programs [7,29,30].The discovery and use of psychiatric medications in the 1950s was not initially associated with massive advertising campaigns or profit making .Then the floodgate of aggressive marketing opened with the discovery of the novel antidepressant fluoxetine (Prozac®) which was associated with an astonishing surge in its sales in the wake of publishing Kramer’s 1993 bestseller book “Listening to Prozac”, where as an author he coined the term "cosmetic psychopharmacology" to describe Prozac’s amazing effects of making people feel “better than well' . Prozac was then hailed as a medication that gave social confidence to the habitually timid, made the sensitive self-assertive, and transformed the introvert into a socially skilled salesman . Sales of psychotropic medications also broadened as pharmaceutical companies developed what some are now calling "a strategy of marketing diseases as an effective way of marketing drugs”. Thus creating a trend toward turning daily life’s vicissitudes into mental disorders that require medications. The promotion of the idea that any feeling or thought of emotional discomfort is abnormal and is due to certain brain chemical imbalances was capitalized and emphasized as proven scientific facts rather than just theories. Although DSM-5 and its predecessors did not address the chemical imbalance as a possible etiology for mental illness and psychiatrists saw DSM-5 as an opportunity to identify and help patients who were suffering from psychiatric conditions; the pharmaceutical industry cheered the expansion of psychiatric diagnosis and saw a boundless opportunity to promote the prescription of medications for a ‘quick fix’ . Constant aggressive marketing reached surreal proportion and psychotropic medications continue to be depicted as amazing agents of cure that would turn every sad moment, every worrisome event and every sleepless night into a joyful, harmonious life of happiness and bliss .
The importance of psychotherapy
Psychiatry training was once synonymous with learning psychotherapy, and many graduating medical students choose psychiatry as their future professional career in order to learn and practice psychotherapy . Residents in psychiatry training programs view psychotherapy as integral to their career development and as an essential part of their professional identity [34,35]. Moreover, the accreditation of psychiatry residency training programs require the devotion of a substantial portion of their education curriculum in acquiring core competency in different psychotherapy approaches and techniques . Despite the recent advances in biological psychiatry, neuroscience, and pharmacotherapy, psychotherapy is recommended in many clinical practice guidelines . Psychotherapy plays an important role in changing maladaptive behavior patterns and provides the basis for improving interpersonal interaction, resolving inner conflicts and in strengthening coping with situational and environmental stressors . Psychotherapy provides patients with an opportunity to modify some of their inaccurate assumptions about their personal identity, their surrounding world and the psychological means of restoring a meaningful and fulfilling existence [7,8].
Maturity as psychotherapists is essential for psychiatrists to assume a leadership role and to provide supervisory and consultation services to the mental health multi-disciplinary treatment teams. With their medical training and psychotherapeutic skills, psychiatrists are expected to assess patients and recommend a broad range of psychological treatments. This role is vital in order to match patients’ needs with the appropriate treatments that leads to a successful outcome [36,37]. There are growing challenges in training psychiatrists in both medication management and evidence based therapies, and the potential to have psychiatrists emerge from training with lower levels of expertise in both areas is real . To address these challenges it is important to reemphasize the intensity and complexity of providing psychotherapy and its necessary training requirements. The significant barriers created by lower reimbursement schemes should be removed to allow for the provision of psychotherapy by psychiatrists[38-40]. Increasing public information efforts are needed to heighten public awareness of the value of psychotherapy as an essential part of psychiatric care and to promote the holistic approach which combines biological, psychosocial and spiritual interventions as essential components of psychiatric treatment which is most cost-effective because it goes beyond episodic care of temporary symptom relief with a “pill” .
What does the future hold?
Psychiatry is the medical specialty that seeks to assess, diagnose and treat the suffering and burdens of mental illness [2,7]. The field of psychiatry is moving towards a collaborative approach with other medical specialties, especially with primary care providers .As a result psychiatrists need to sharpen their knowledge and increase their acumen in recognizing the many psychiatric disorders that stem either from medical conditions or are co-occurring with other psychological issues. The rapidly changing health care environment demands integrated, accountable, and collaborative care. Health care reform offers psychiatrists, many opportunities to assume leadership roles on collaborative care teams and to improve patient outcomes .
The APA leaders must change their mission from just revising and publishing newer DSM’s versions that reduce the practice of psychiatry to documenting diagnostic codes that are tied to reimbursement schemes to the restoration of psychiatry’s mission as a compassionate healing profession [15-20].The APA with its economic and political influences should assume a leadership role in the development of a model of mental health care that integrates the mind, the body and the soul [9,15]. Psychiatrists must and should resist the multiple pressures that force them to redefine their role as” medications check clinicians “, “prescribers “or “pill-pushers” . The future of psychiatry will depend on psychiatrists’ willingness and determination of reversing this trend and on restoring their time honored and core mission of healing the mind and the soul [2,9]. To ensure its broad public health relevance in the future, psychiatry must reintroduce its identity as a discipline that incorporate the biological , psychological , social, and spiritual dimensions of each patient in the assessment, diagnosis and treatment of his or her psychiatric conditions. By their extensive training psychiatrists are well prepared to evaluate patients in their own context and to understand the complexity of the human condition. To do so effectively, psychiatrists need to maintain their skills not just as physicians but also as practitioners of psychotherapy who intervene to restore a meaningful existence for their patients’ lives despite the agony and the sufferings inflicted by their mental illness [7,9,15].
There is general popular perception and economic factors contributing to the notion that psychiatrists are only medically educated and trained to specialize in the psychopharmacological treatment of mental illness and that the psychological, social and aspects of patients’ symptoms should be addressed by other mental health professionals such as psychologists , social workers and counselors. By its definition and historical inception, psychiatry’s ultimate goal is to heal broken spirits. At its core, it is an attempt to better understand human developmental stages, thoughts, feelings, perceptions, cognitions and behaviors and to allow this understanding to contribute to its healing arts. Despite modern and recent advances in the diagnosis and pharmacological treatment of psychiatric conditions; such treatments should be utilized in conjunction with psychological, social and spiritual interventions.
It is hoped that this commentary will encourage the 21st century psychiatrists to reestablish their identity as healers of the human psyche by practicing their cherished profession within its wider humanistic historical perspectives and its modern scientific discoveries.
To my wife Lynn and my children Andrea, Andrew and Adam, my sisters Hoda and Héla, my brother Hadi for their support and encouragement.
To Drs. William C. Torrey and Alan I. Green from Dartmouth-Hitchcock Medical Center and Dartmouth Geisel School of Medicine, for their commitment to excellence.
To Drs. Robert W. Hierholzer Avak A. Howsepian and Andrew W. Goddard from the University of California, San Francisco School of Medicine, Fresno Medical Education Program, for their inspiration.
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