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.
Second, the Kirsch study looked only at antidepressant trials in the FDA database done before 1999—an analysis of more recent trials might have produced different results. More subtle questions are raised by this study, relating to placebo responders. For example, placebo response rates have actually been rising in recent years, perhaps in part because of recruitment of less severely ill subjects for study. The less ill the subjects, the more likely a “sugar pill” is going to work for them.6 The unimpressive results of the Kirsch findings may, to some degree, reflect this confounding factor. Since the Kirsch study, another meta-analysis by Fournier et al7 has reached similar conclusions. My editorial in the April 2010 issue of the Journal of Clinical Psychopharmacology offers a detailed analysis.
Indeed, clinicians who have treated many severely depressed patients know that with sufficient time and effort, the majority can experience remission—if not necessarily full recovery. This was certainly my experience when I was seeing so-called treatment-refractory depressed patients (many of whom proved to have undiagnosed bipolar spectrum disorder8). Eventual success with antidepressants, even in refractory cases, is supported by a recent series of carefully controlled, multistage studies known as STAR*D, sponsored by the NIMH. STAR*D looked at remission rates in patients with treatment-resistant major depression. These patients had gone through several levels of intensive antidepressant treatment, without full recovery. By the time the subjects had jumped through the fourth and final “hoop,” the cumulative rate of remission (few or no depressive symptoms) was about 67%.9
The nature of the STAR*D study precluded use of a placebo group. However, the cumulative remission rate of 67% is certainly much higher than generally reported rates of remission with placebo, which average around 30%. I would venture to suggest that if a cancer chemotherapy regimen produced remission in 67% of patients with previously refractory disease, it would be hailed as a therapeutic breakthrough!
The bottom line: if you stick to it long enough, and make the right pharmacological “moves,” antidepressant treatment works.
Another underappreciated—and underutilized—treatment in psychiatry is lithium. This agent is not heavily promoted by “Big Pharma,” and it costs only a few pennies per tablet. As my colleague, Seyyed Nassir Ghaemi, MD, has observed:
Lithium has been shown to be effective in over 20 randomized clinical trials of prophylaxis, most of which are 1 year or longer, some of which last up to 3 years. Although some of these studies are small and use research designs that are not optimal . . . the replicability and consistency of these results greatly strengthens proof of lithium’s efficacy. . . . There is also increasing evidence that lithium prevents suicide, reduces lifetime mortality, and lengthens life span in bipolar disorder. . . . Lithium has also been shown to improve neuronal viability in animals and enhance in vitro the effect of neuroprotective factors, and this effect in humans also appears to prevent or reduce long-term hippocampal atrophy and cognitive decline in bipolar disorder.10
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 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.
by Ronald Pies, MD
I’ve set aside
my prescription pad
and analytic calm—
dropped all pretense
it’s you and me now,
against death’s ribs.
what tricks I know
to keep you living
through another bony night,
of final phone calls.
And you, as always, refuting life:
denaturing love, companions, sex.
Well, you leave my office alive.
That’s as close
as our work gets.
References1. Pies R. The “McDonaldization” of psychiatry: psychiatric knowledge is not the equivalent of “fast food.” May 2009. http://psychiatrictimes.blogspot.com/2009/05/mcdonaldization-of-psychiatry.html. Accessed January 4, 2010.