The Good Psychiatry Does: A Brief Review
The Good Psychiatry Does: A Brief Review
In 2 previous editorials—“The ‘McDonaldization’ of Psychiatry” and “Doctor, Are You ‘Drugging’ or Medicating Your Patients?”—I focused on some serious problems in current psychiatric practice and on various shortcomings in our treatments.1,2 Even though the latter essay also emphasized some positive aspects of psychotropic medication—for example, in promoting neuronal “connectivity” in the brain—I suspect that the overall tone of these essays may be perceived at best as cautionary, and at worst as a bit defensive. In the third “panel” of this editorial triptych, I want to take note of the considerable good that psychiatric treatment may bring to those who suffer with devastating illnesses.
One of the misconceptions about psychiatry and psychiatric disorders is that we have no effective treatments for serious illnesses such as schizophrenia, major depression, PTSD, and bipolar disorder. In fact, we do have good (albeit imperfect) treatments—and I am not just talking about medication. We also have psychotherapies that “work,” at least for major mood and anxiety disorders.
What is the evidence for these upbeat claims? Way back in 1993, the National Advisory Mental Health Council carefully studied psychiatric treatments and concluded that “millions of Americans and many policy makers are unaware that the efficacy of an extensive array of treatments for specific mental disorders has been systematically tested in controlled clinical trials; these studies demonstrate that mental disorders can now be diagnosed and treated as precisely and effectively as are other disorders in medicine.”3 In fact, the report found that the overall success rates for the treatment of several major psychiatric disorders (panic disorder, bipolar disorder, major depression, and schizophrenia) were all higher than for the treatments then available for several cardiovascular disorders. (You can find the statistics online.4)
The National Advisory Mental Health Council report pointed out that, unfortunately, many people who could benefit from psychiatric treatments do not have access to them, and this problem has not gotten better in the past 17 years. Nonetheless, the report left no doubt that psychiatric treatment is comparable in efficacy to several treatments commonly used in general medicine. I have seen no data that would lead me to believe that this finding has changed markedly in the past 17 years, even allowing for serious flaws and omissions in the database—most notoriously, the exclusion of unfavorable (“negative”) studies from some meta-analyses of antidepressant treatment.
More needs to be said regarding the efficacy of antidepressants. These medications took a serious knock when Kirsch and colleagues5 published a large meta-analysis that seemed to show—as the lay press predictably put it—that antidepressants are “no better than a sugar pill”! But this is not really what the Kirsch study showed, as I discuss in detail elsewhere.6 The Kirsch study lumped together results from 47 antidepressant trials (including unpublished ones) and found that the active drug showed a clinically significant “separation” from placebo only in the most severe cases of depression. The authors attributed the apparent benefit of antidepressants in the most severely ill patients to reduced responsiveness to placebo rather than to increased effectiveness of the drug. But there are problems in interpreting studies such as this.
First of all, the entire Kirsch study turns on whether a 2-point improvement in a single depression rating scale (the Hamilton Rating Scale for Depression, or HAM-D) amounts to a “clinically significant” (not just a statistically significant) change. That is, of course, a matter of judgment. Even on its own terms, the Kirsch study did not show that antidepressants “don’t work”—only that clinically significant effects do not become evident in mild to moderate cases of depression, using the specific yardstick of the 2-point change on the HAM-D.