The Good Psychiatry Does: A Brief Review

Electroconvulsive therapy

Perhaps the most maligned and misunderstood treatment in all of psychiatry is electroconvulsive therapy (ECT). Jack Nicholson’s zombie-like performance in One Flew Over the Cuckoo’s Nest seems to have left an indelibly negative impression of ECT in the public mind, despite overwhelming evidence of ECT’s efficacy and safety. For example, a recent meta-analysis revealed “a significant superiority of ECT in all comparisons: ECT versus simulated ECT, ECT versus placebo, ECT versus antidepressants in general, ECT versus TCAs, and ECT versus MAOIs.”¹¹

ECT, overall, is a very safe procedure when used for appropriately selected patients and carried out using optimal techniques, such as unilateral, nondominant electrode placement. This is so, notwithstanding rare cases of significant and enduring memory impairment.¹² Recently, at the Annual Meeting of the Massachusetts Psychiatric Society, Mrs Kitty Dukakis pleaded with the audience to consider ECT early in the course of severe, refractory depression. For Mrs Dukakis, ECT was literally a lifesaving treatment and well worth the trade-off of some mild and isolated memory deficits.

Psychotherapy

Psychotherapy has also been given short shrift in most discussions of what psychiatry has to offer. Yes, I know: the use of psychotherapy has declined considerably in outpatient psychiatric practice in the past decade.¹³ But tens of thousands of psychiatrists still provide psychotherapy, and we have excellent evidence that all the major types of psychotherapy “work” for a variety of nonpsychotic disorders.¹⁴ We need to reinforce the importance of psychotherapy training, particularly in residency programs, as Dr Cynthia Geppert and I recently stated.¹⁵

Yet all these literature citations do not really capture the day-by-day, crisis-by-crisis accomplishments of psychiatrists and other mental health professionals. Flawed healers though we are, we try to do “good” each day simply by showing up and doing our best to help those who struggle with serious illness. I tried to capture this in a poem (please see below) about working with a severely disturbed patient with borderline personality disorder.¹⁶ I will let the poem speak for itself, and hope that it says something encouraging about the work we do.