Verified by 
Psychopharmacology
Aristotle Meets Managed Care
The Virtuous Psychopharmacologist
Posted January 25, 2015
Similar to virtuous tobacco company publicist, virtuous used car salesman, and virtuous bill collector, virtuous is the last word that might come to mind when thinking of a psychopharmacologist. Relentless vilification in the press and in several recent books has shaped the public’s aversion to psychopharmacology.
Among the targets of criticism was the recently issued DSM-5, the backbone of diagnosis in psychiatry. Many of the more technical details of proposed diagnostic criteria were subject to wide and bitter public debate. For example, the newly allowed diagnosis of depression when a loved one has just died was understood by critics of psychiatry both as “medicalizing” normal human emotions and providing a pretext for psychopharmacologists to make money.
During public hearings in 2008, Senator Charles Grassley of Iowa detailed how the pharmaceutical industry paid large sums of money to many psychopharmacologists to promote their medications under the guise of medical education.
The public relations nadir of clinical psychopharmacology may have been a front page article in the New York Times, titled “Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy,” which featured a psychiatrist who dispensed medication to upwards of forty patients per day in sessions limited to 15 minutes. The psychiatrist, Ronald Levin, M.D., boasted, “I don’t even know their names.”
The 15 minute medication check, with the advent of managed care, has become the standard of care across the country. In many areas, the 15 minute medication check is starting to contract to a 12 minute medication check or even a 10 minute medication check.
In their influential book, The Virtuous Psychiatrist: Character Ethics in Psychiatric Practice, Jennifer Radden and John Sadler apply virtue ethics—an Aristotelian concept that allows for an individual to choose personal virtues and then work toward them—to the practice of psychiatry. The authors discuss many of the role-constituted virtues expected of a psychiatrist. These include empathy, warmth, and trustworthiness. The authors discuss virtues related to psychotherapy, but do not directly address the specific virtues that might be desired of a psychiatrist who prescribes medication. The current stigmatization of psychopharmacologists makes a consideration of these virtues timely.
A central virtue for a psychopharmacologist is knowledge of the field. To prescribe medications optimally, the virtuous psychopharmacologist must be fluent in the field’s rapidly-changing scientific literature. While Dr. Levin avers that there is “not a lot to master in medications,” the truth is exactly the reverse. Genetics, metabolism, coexisting medical conditions, symptom constellation, and interactions with other medications provide complex treatment challenges.
In addition, a crucial psychotherapeutic challenge for the psychopharmacologist is to ensure that the patient is compliant with taking the medication as prescribed. Denial of illness is common in serious psychiatric conditions. Helping the patient understand his or her illness and need for medication is both a psychotherapeutic art and an ethical obligation of the effective psychopharmacologist.
When psychopharmacology is practiced knowledgably, patients can benefit greatly; practiced heedlessly, patients can fail to improve, worsen, or even die.
The virtuous psychopharmacologist has no use for an economic model that treats patients as if they were widgets. The role of a virtuous psychopharmacologist is healer, not assembly line worker. Insistence on 15 minutes per patient, regardless of patient needs, is in obvious violation of this tenet. The virtuous psychopharmacologist should make every effort in working with managed care companies to resist one size fits all mandates and instead ensure that patients are allotted the time needed to be served without compromise.
Radden and Sadler highlight the need for virtuous psychiatrists to avoid any appearance of impropriety—similar to what we expect of judges, military officers, and members of other professions that exercise power over individual lives. The Grassley investigations and subsequent Federal laws have created an ethical dilemma for the virtuous psychopharmacologist: many valuable learning opportunities are now linked with the appearance of impropriety. Psychopharmacologists have been inhibited from attending drug company sponsored conferences by new Federal laws requiring the public posting of each doctor’s name alongside the economic value of any received meals, snacks, or travel associated with the conference.
Although pharmaceutical companies may have committed ethical transgressions, it is also true that much of what is known and practiced in the field of psychopharmacology is the result of their efforts. Keeping abreast of developments in drug testing in the pharmaceutical industry is part of the responsibility of a virtuous psychopharmacologist.
Public posting stigmatizes attendance at conferences and limits the dissemination of knowledge to the field. It is up to the virtuous psychopharmacologist to weigh the intellectual value of the conference against any unfairly imposed appearances of impropriety.
There may well be a unique series of ethical standards for the practice of psychopharmacology. Developing and adhering to these standards will improve patient care and improve the image of the field.
Copyright, Stuart L. Kaplan, M.D., 2015
Stuart L. Kaplan, M.D., is the author of Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created the Diagnosis. Available at Amazon.com.
Picture credit: Wikimedia Commons, Benutzer:Klingsor
