Two days ago, the magazine section of the New York Times featured a powerful article by fellow PT blogger Daniel Carlat called "Mind over Meds." The article went straight to the top of the Times' most-emailed list, where it remained until this morning—a considerable accomplishment, suggesting it has resonated strongly with many thousands of doctors and patients, including readers of Psychology Today.
I commend Dr. Carlat for urging his colleagues in psychiatry to expand their treatment options to include psychodynamic psychotherapy—a robust, long-standing, and highly effective method of treating dozens of conditions that too often are viewed as treatable only by drugs. As Carlat observes, a generation of psychiatrists trained in the age of Prozac and on the promise of evidence-based medicine has grown "skeptical" of psychotherapy and often dismissed it, condescendingly, as but an empty legacy from the past, without scientific bona fides or empirical support.
One result of that prejudice, Carlat argues disturbingly, is that numerous psychiatrists have little actual curiosity about how their patients tick, and are not especially adept at listening to their concerns. Instead, the "information" these patients supply is channeled into the pre-existing grooves of a DSM diagnosis, with the psychiatrist moving to rule out diagnostic options in his or her sometimes-rapid attempt to narrow the problem to one particular disorder. "A psychiatric interview has a certain rhythm to it," Carlat observes. "You start by listening to what your patient says for a few minutes, without interrupting, all the while sorting through possible diagnoses. This vast landscape of distress has been mapped into a series of categories in psychiatry's diagnostic manual, DSM-IV. The book breaks down mental suffering into 16 groups of disorders, like mood disorders, anxiety disorders, psychotic disorders, eating disorders and several others."
Yet though I knew Carlat's article would eventually move to discussing the benefits of including some talk therapy in a psychiatrist's arsenal, as I read his account of how he used to conduct these psychiatric interviews I felt more troubled than reassured—no doubt because so many of his colleagues still operate just as he used to do.
"Toward the end of the hour," he writes about one patient dubbed J.J., "I felt confident that I had arrived at [his] diagnosis. "I think you have what we call ‘generalized anxiety disorder,'" I told him. It may start with a defined series of causes, as was true for J.J., but then it spirals outward, blanketing the world with potential threat. J.J. worried about what the future would bring and experienced a predictable series of physical symptoms: insomnia, muscle tension, irritability and poor concentration."
"'I'm going to write you a prescription for a medication called Zoloft," Carlat continues, "picking up my prescription pad. He [the patient] asked what was causing his anxiety, and I began one of the stock neurochemical explanations that psychiatrists typically offer patients about low serotonin levels in the brain. The treatment involved 'filling up the tank' by prescribing a medication like Zoloft, Celexa or Paxil."
Carlat never returns these psychiatric platitudes, which in the case of "low serotonin" has been dismissed so many times as a viable answer by so many experts that one wonders, with incredulity, how it could still circulate without irony in 2010. Of course, the patient's question about what is causing his anxiety sends Carlat onto a discussion of the mind, which alas he views as identical with the brain. Yet even in this self-reflective article on the deficiencies of his own psychiatric practice, there's no discussion of how Carlat picks one SSRI over another, whether the numerous side effects of psychotropic drugs outweigh their marginal benefit over placebo, and whether the diagnostic categories on which he still relies are quite as reliable as he seems to think they are.
When I was researching my book on the history of DSM-III and -IV, I asked Robert Spitzer, editor of the first of these editions, how he and his colleagues on the anxiety disorders subcommittee came to devise generalized anxiety disorder as a stand-alone illness. Renowned anxiety specialists such as Isaac Marks in London had warned strongly against the move, insisting that studies did not support it, and David Healy, in his book The Antidepressant Era, had called the process analogous to pulling things "out of the classificatory hat" (p. 236). With justification, it transpired.
"We came up with that name [GAD] after we had anxiety neurosis in DSM-II," Spitzer told me in February 2006, "and if you had panic then there had to be something that was left over. So that became Generalized Anxiety Disorder."
In short, the diagnosis that Dr. Carlat adopted for his patient J.J. was, for the architect of DSM-III, the "something that was left over" from panic. It didn't exactly sound evidence-based to me—and it still doesn't today.
At the end of his article, Carlat continues to insist that "mental illness is a brain disease," so reproducing the very thinking that helped to de-emphasize psychiatric attention to the mind in the first place. But he does usefully debunk the myth that psychotherapy is easier to learn and practice than biological psychiatry. "Psychopharmacology," he writes, "was infinitely easier to master than therapy, because it involved a teachable, systematic method. First, we memorized the DSM criteria for the major disorders, then we learned how to ask the patient the right questions, then we pieced together a diagnosis and finally we matched a medication with the symptoms."
While Carlat's efforts at incorporating "nonbiological" treatments into his practice are both notable and laudable, a recent article in American Psychologist on "The Efficacy of Psychodynamic Psychotherapy" powerfully underscores, with several large meta-analyses, that psychotherapy is routinely mischaracterized by psychopharmacologists and cognitive behavioral therapists as weak in getting results. Yet on the contrary, author and noted researcher Jonathan Shedler makes clear, in strict empirical terms psychotherapy is just as effective as "other therapies that have been actively promoted as ‘empirically supported' and ‘evidence based.'" "Empirical evidence supports the efficacy of psychodynamic therapy," he declares, based on meticulous meta-analyses involving thousands of patients. "The perception that psychodynamic approaches lack empirical support does not accord with available scientific evidence and may reflect selective dissemination of research findings."
The notion that psychotherapy is less effective than drug-related treatments and cognitive behavioral therapy "appears to have taken on a life of its own," Shedler concludes, no doubt owing to drug company advertising and the prejudice of so many leading psychiatrists, but it is not based on fact. One can only hope that Shedler's and Carlat's willingness to correct that misperception and speak out about the provable clinical benefits of psychotherapy will convince psychiatrists incurious about the mental lives of their patients that they need to rethink their approach, expand their treatment options, and listen to their patients in a radically new way.