The Crisis in Psychiatry

In a recent article in the New England Journal of Medicine, Gardner and Kleinman make a point that parallels what I’ve been saying for a long time. Modern medicine is so anchored in the reductionistic disease model that it has neglected mental health care, most manifest by its failure to train the primary care physicians who provide 85 percent of it; psychiatrists provide only 15 percent of all mental health care.

Gardner and Kleinman present parallel material describing a similar reductionistic process within psychiatry itself. Even though psychiatry does address the problem of mental illness, it has forsaken its earlier successes for a unidimensional interest in the biological basis of mental disorders.

Let’s begin by recalling the profound advances made by psychiatry beginning at the turn of the last century. At that point, the rest of medicine had completely divested itself of the psychosocial aspects of its patients in favor of an isolated focus on physical diseases. But psychiatry was the exception.

Preneur de la photo de Freud

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While many of Sigmund Freud’s ideas have been modified or discarded as neuroscience has matured, his articulation of the subconscious and its impact was a monumentally important derivative of his work that guides us to this day.¹ It helped us understand the key role of emotions in the everyday life of patients. Additionally, his concept of listening carefully to the patient and facilitating the flow of conversation persists today in the burgeoning field of patient-centered interviewing, albeit one now located largely outside psychiatry.¹ Central to this broad-based psychiatry was establishing a trusting physician-patient relationship and understanding patients in their psychological and social dimensions in addition to their physical disease problems.

The importance and powerful explanatory role of emotions and other psychosocial factors got another boost from psychiatry during the first half of the twentieth century. Experiences in World Wars I and II brought the widespread recognition in psychiatry that many physical symptoms could not be explained on a physical injury basis but, rather, were associated only with psychological distress.

Called traumatic war neuroses and “shell-shock,” we know them today as post-traumatic stress disorder (PTSD).² In its original conceptualization, it derived from a devastating enemy attack that laid waste to many of a soldier’s friends while he lived, often unharmed. Not relieved to survive, however, life became miserable as the soldier suffered disabling symptoms—not only anxiety, guilt, and frightening dreams but also physical symptoms such as body pain, fatigue, and insomnia. Mental health professionals understood the anxiety of a near-miss, but they puzzled initially about how the terribly disabling physical symptoms came about—there had been little or no physical injury from the attack to account for them.

Today, mental health experts recognize that psychological trauma led to the physical symptoms, that there did not have to be true physical changes to explain symptoms. As with Freud’s influence, they recognized the powerful role of the psychosocial aspects of a patient’s life in their health.

We find a chink in modern medicine’s disease-only approach in PTSD. Outlined in another post, a disease-only model cannot explain the physical symptoms without invoking a disease explanation—even where one does not exist! Far more important now, PTSD is recognized to occur from all types of trauma (physical, psychological, and sexual abuse, especially in childhood). Indeed, many of today’s chronic pain patients are in this category and their management suffers greatly for our inability to address the mind and mental issues so important to their care.²

Despite the promising early potential for psychiatry to hold the line, they faded.³ Psychiatry itself, the last bastion of support for the psychosocial aspects of medicine, fell prey to the reductionism seen in the rest of medicine.⁴ While the early part of the 20th century had seen a more humanistic approach to mental health treatment as psychiatry introduced better interviewing techniques, psychotherapy and the importance of the therapeutic alliance, more humane confinements, and a focus on the whole patient, a sudden turn took psychiatry backwards.

As our scientific knowledge of the brain and its functions advanced and psychotropic medications were developed, psychiatry sought physical and chemical explanations for disorders of the mind, a trend that accelerates by the year.⁴ Psychiatry now relies heavily on drugs, eschewing the more detailed and comprehensive patient-centered approaches of their predecessors—paradoxically scrapping their seminal early advances in medicine. The result has been that the profession has largely rejected the multifaceted whole patient as it, following the rest of medicine, chooses a more unidimensional and reductionistic path forward. We see this clinically—with practices now limited to 10 minutes, during which time medications are often the sole focus.⁴

Gardner and Kleinman home in on this problem and its broader meaning. They point out the stark limitations of medications and modern psychiatric care, lamenting that everyone knows it’s not working but does nothing to change, the field continuing to believe that eventually we will find the right medication for the right disease. They also cite the adverse impact on training in psychiatry from scrapping the very human characteristics of patients it once introduced to medicine; for example, many psychiatry residencies no longer teach psychotherapy and the attendant therapeutic relationship. Further discouraging for psychiatry, a recent study sheds light on the impact of its training in medical schools.⁵ While 49 percent of entering medical students were interested in psychiatry, less than 5 percent retained an interest upon graduation four years later.⁵

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Gardner and Kleinman go on to point out that relinquishing a focus on patient interactions, a therapeutic relationship, and their social, interpersonal, and psychodynamic foundations, psychiatry has little to show from their reductionistic shift to drugs and studies of the brain. Ann Harrington recognized this also and concluded that psychiatry should simply retrench and limit itself to the far fewer and more severe patients with psychotic disorders,³ but the authors disagree.

They argue for a reintroduction of the broader psychosocial features to psychiatry, reclaiming its old expertise and integrating it with the newer interest in the brain and medications—a multidimensional approach jettisoning its present reductionism. They conclude that biologic psychiatry has failed and that psychiatry must be rebuilt. Just as the remainder of medicine, psychiatry has fallen prey to the reductionistic impulses to find biological or disease explanations for everything.