For the past two days, a superb article on American psychiatry has been the most-viewed article at the New York Times. "Talk Doesn't Pay, So Psychiatry Turns Instead to Drug Therapy," by health reporter Gardiner Harris, follows a working day in the lives of two experienced psychiatrists, Dr. Donald Levin and Dr. Louisa Lance, both based in Pennsylvania, who have quite different perspectives on their patients and professional roles.
The power of the article lies less in stating what's already well-known about American psychiatry—that it favors drug treatments over talk therapy, despite growing evidence that the latter strongly outweighs the former in terms of efficacy and freedom from side effects. The article's power lies instead in tracking the myriad decisions that Drs. Levin and Lance make on an ordinary day full of appointments with dozens of suffering Americans.
"In 1972," Harris notes, Dr. Levin "treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart."
What that entails—besides having a waiting room that, in Dr. Levin's words, more closely resembles "a bus station" than a place of "analytic calm"—is a constant struggle to stay on schedule, even or especially when that means avoiding discussion of the personal issues that presumably sent his clients into treatment in the first place.
The irony of this enforced wall between drug treatments, on the one hand, and knowledge about the patient's personal life, on the other, becomes increasingly glaring and disturbing as the article progresses. At one point, Dr. Levin feels obliged to tell one distraught patient, "Hold it. I'm not your therapist. I could adjust your medications, but I don't think that's appropriate." That's his response, by the way, to hearing that the man's newborn was having health problems, that his distraught wife was "screaming at him," and that he had started drinking again.
"I had to train myself not to get too interested in their problems," Dr. Levin explains, "and not to get sidetracked trying to be a semi-therapist." Sidetracked? Into hearing about his patient's problems when the man was describing them to his own psychiatrist?
"I miss the mystery and intrigue of psychotherapy," Dr. Levin later declares. "Now I feel like a good Volkswagen mechanic." Except that Volkswagen doesn't need to add black-box warnings to its cars, to warn that they could drive owners to suicide.
"In 15-minute consultations," we learn, "Dr. Levin asks for quick updates on sleep, mood, energy, concentration, appetite, irritability and problems like sexual dysfunction that can result from psychotropic medications." These updates are, the psychiatrist imagines, akin to a routine service or tune-up. When researching my book on American psychiatry and the DSM I ran into this fantasy all the time—the notion that the brain is normally a well-oiled machine, and meds are refined lubricants designed to return it to optimal performance.
That analogy stops short of much long-term interest into how the brain adjusts to—and rapidly overcompensates for—altered levels of serotonin, dopamine, and norepinephrine, as Robert Whitaker has demonstrated so ably in Anatomy of an Epidemic. Nor does it bother to ask, as Dr. Irving Kirsch fortunately has, whether meds aren't closer to being "the emperor's new clothes," with a reputation built more on myth and marketing than short-term placebo and dogged meta-analyses that present a quite different picture. Psychiatrists are still so enamored by "the myth of the chemical cure," British psychiatrist Joanna Moncrieff explains, they are wilfully ignoring reams of contrary evidence.
Then there's the risk of misdiagnosis from such absurdly short sessions, with one patient convincing himself (and almost Dr. Levin) that he suffers from ADHD, only to reveal, at the end of his session, that he has contemplated suicide. The revelation alters Dr. Levin's diagnosis to anxiety, and his prescription to an antidepressant. But what if the man hadn't made that revelation by the 13th or 14th minute of his session? Would he not, quite likely, have been sent home instead with a prescription for Adderall or Ritalin?
"People want to tell me about what's going on in their lives as far as stress," Dr. Levin is quoted as saying, "and I'm forced to keep saying: 'I'm not your therapist. I'm not here to help you figure out how to get along with your boss, what you do that's self-defeating, and what alternative choices you have.'"
Dr. Louisa Lance, a former colleague of Dr. Levin's, doesn't feel "forced" to adopt the same course. She apparently "treats fewer patients in a week than Dr. Levin treats in a day." She also earns a fair bit less than him. (While "Dr. Levin would not reveal his income," Harris reports, "in 2009, the median annual compensation for psychiatrists was about $191,000, according to surveys by a medical trade group.")
But Dr. Lance appears to have to held on to one piece of professional wisdom that Dr. Levin, with all his fears about being "sidetracked" from his frantic schedule, seems to have forgotten: "Medication is important," she said, "but it's the relationship that gets people better."
Harris, Gardiner. "Talk Doesn't Pay, So Psychiatry Turns Instead to Drug Therapy," New York Times March 5, 2011.