Here's a hit list of publications devoted to psychotherapy topics; to issues in genomic medicine; the impact of technology, and burnout on the practice of medicine; and to more traditional clinical articles addressing diagnosis and treatment of psychiatric disorders.
My selected articles this year were not limited to those appearing in psychiatric journals. One group of publications is devoted to psychotherapy topics, another to issues in genomic medicine and the impact of technology and burnout on the practice of medicine, and last, more traditional clinical articles addressing diagnosis and treatment of psychiatric disorders. This somewhat atypical selection was prompted by another writing assignment for The World Psychiatric Association-Lancet Psychiatry Commission on the Future of Psychiatry,1 in which my colleagues and I were asked to address clinical and technological issues potentially affecting the centrality of the doctor-patient relationship and therefore ultimately clinical care.
Included on my list, therefore, are tempered articles on the unrealized promises of genomics and the shortcomings of precision or personalized medicine. It was abundantly clear as I reviewed the literature, that to speak of precision psychiatry without acknowledging the severe limitations of its scientific foundation is quite risky. In psychiatry, we have had an unfortunate legacy of promising much more than we could ever deliver to our patients and the public. No one disagrees with advancing science and improving care. However, as an emeritus professor, now looking back on the grandiosity of the claims of psychoanalysis, psychopharmacology, diagnostic classification schemes, community mental health, the electronic medical record (EMR) and its inextricable relationship to physician burnout, and the reductionistic biomedical approaches to treatment that undercut the clinician’s ability to tolerate uncertainty and ambiguity, a slow medicine approach appears to be increasingly attractive to me.
Moreover, personalized psychiatry, if and when it becomes scientifically sound, must always be delivered within the context of the doctor-patient relationship. Computer-generated genomic analyses, neuromodulation, deep brain stimulation (DBS), new drug delivery mechanisms, and perhaps someday, stem cell therapy, to name but a few, all require the participation of a physician. (With respect to DBS and FDA scrutiny over rogue stem cell therapy clinics, initial excitement has given way to mixed findings and resultant physician ambivalence and caution lest we oversell this technique as well.)
Promises of scientific advances often appear to downplay the value of the psychiatrist’s subjective understanding of patients. And, of course, there is the yearly plethora of studies each of whose findings is so obvious that I refer to them as “duh” articles. For example, an endless number of studies each year substantiate the impact of bad things happening to good little people. Does any clinician doubt that maltreatment and other adverse childhood experiences produce psychological vulnerability? Does anyone not believe that a disorganized attachment style has a profound effect on development throughout the life cycle? Have we not accepted the concept of intergenerational transmission of unresolved trauma in mothers?
A final point to be made is the enduring dismissal of psychotherapy either as a monotherapy or in conjunction with medication. When will the field embrace this proven therapeutic intervention for the treatment of our patients? Can we stop the self-defeating infighting about efficacious psychotherapy treatments?
→ Roy-Byrne P, Dubovsky S, Yager J. When genetic testing is unproven: the case of depression treatments. NEJM J Watch. August 31, 2017. https://www.jwatch.org/na44895/2017/08/31/when-genetic-testing-unproven-case-depression-treatments. Accessed November 15, 2017.
This article highlights the myth of precision psychiatry, that, in my opinion, has insufficient scientific support at present. It alerts us to be cautious and thoughtful about jumping on a bandwagon that favors adopting approaches that are not ready for prime time.
→ Lebowitz MS, Ahn W-K. Testing positive for a genetic predisposition to depression magnifies retrospective memory for depressive symptoms. Consult Clin Psychol. 2017;85:1052-1063.
Given a strong reliance on self-report measures in assessing depression and other disorders, this creative investigation assessed the impact of feedback about genetic testing results on study participants’ memories about depressive symptoms. Retrospective falsification by patients through exaggerating symptoms as recorded by well-accepted symptom checklists, that are a component of many treatment outcomes and drug studies, is a vital finding. If future research supports the need for greater concern, clinicians must be sensitive to this effect on diagnosis and treatment.
→ Leichsenring F, Steinert C. Is cognitive behavioral therapy the gold standard for psychotherapy? The need for plurality in treatment and research. JAMA. 2017;318:1323-1324.
This is but the last in a long line of articles going back more than 50 years elucidating the value of psychodynamic psychotherapy and countering its alleged inferiority when compared with CBT. Those who follow the psychotherapy outcome literature know of Falk Leichsenring’s impressive meta-analyses explicating the efficacy of dynamic therapy in head to head comparison with other types of psychotherapy. Recent studies have verified that dramatically fewer psychiatrists now conduct psychotherapy with their patients. This alarming trend is irrespective of the fact that the Accreditation Council for Graduate Medical Education still mandates proficiency in dynamic therapy for our psychiatric residents because this approach provides an in-depth understanding of many psychological phenomena outside of awareness that compels patients to re-enact self-defeating and destructive behaviors. (More complete assessment of these issues can be found in my recent article.2)
→ Dunlop BW, Rajendra JK, Craignead WE, et al. Functional connectivity of the subcallosal cingulate cortex and differential outcomes to treatment with cognitive-behavioral therapy or antidepressant medication for major depressive disorder. Am J Psychiatry. 2017;174:533-545.
An article that supports the notion that imaging may someday enable the routine prediction of what type of treatment works for what kind of patient. However, this article also affirms the point that patient preferences for psychotherapy or medication are often related to treatment/study retention. Although there is some controversy surrounding this finding, nevertheless, it assists us in assessing the findings of some studies that pit medication against psychotherapy without permitting the option of patient preference.
→ Swift JK, Greenberg RP, Tompkins KA, Parkin SR. Treatment refusal and premature termination in psychotherapy, pharmacotherapy, and their combination: a meta-analysis of head-to-head comparisons. Psychother (Chic). 2017;54:47-57.
In support of one finding in the previously cited article by Dunlop and colleagues, this meta-analysis of 186 comparative studies showed that while the average refusal for treatment was over 8% for all treatment approaches, those assigned to pharmacotherapy were 1.76 times more likely to refuse help than those participants who were assigned to psychotherapy; this was particularly true for depressive (for which there is research support) and anxiety disorders. Dropout rates were 1.2 times higher in the pharmacotherapy group.
→ Tai-Seale M, Olson CW, Li J, et al. Electronic health record logs indicate that physicians split time evenly between seeing patients and desktop medicine. Health Affairs. 2017;36:655-662.
Concern is expressed once again about the intrusion of the EMR and its impact on patient care and, by extension, physician well-being as the following article indicates.
→ Sinsky CA, Dyrbye LN, West CP, et al. Professional satisfaction and the career plans of US physicians. Mayo Clinic Proc. 2017;92:1625-1635.
The findings from a large national AMA 2014 survey of more than 6600 physicians (550 or 8.3% of respondents were psychiatrists) revealed that 1 in 4 physicians is considering significant changes to his or her practice. Nearly 20% would move to part-time within the next year; more than 26% would change practices by retiring or find a new practice, move to the administrative side, or begin a new career outside of medicine.
Those aged between 50 and 59 years were more likely to leave medicine within the next 2 years. Burnout, dissatisfaction with lifestyle, and the EMR were all significant (P < .001) predictors of career change. Authors expressed concern with the potential impact on workforce through decreased continuity of care and medical accessibility for patients, as well as financial threats to health care organizations.
→ Khoury M. No shortcuts on the long road to evidence-based genomic medicine. JAMA. 2017;318:27-28.
This is a thoughtful piece from a CDC staff member in the Office of Public Health Genomics. Khoury argues for greater humility about the promises of genomic medicine, since analytic validity of genomic tests (are tests accurate?) and clinical validity (do they demonstrate an association with disease end points?) leave much to be desired in the prediction of improved health care.
→ Weber-Stadlabuer U. Epigenetic and translational mechanisms in infection-mediated neurodevelopmental disorders. Translat Psychiatry. 2017;7:e1113.
This is an in-depth review of the role of maternal inflammation in initiating prenatal immune responses that may contribute to the pathogenesis of psychiatric disorders. Another article published in 2017 showed higher levels of cytokines in mothers of offspring who developed significant childhood disorders.3 The possible role of chronic inflammation in conferring vulnerability to psychiatric disorders is receiving increasing scientific attention.
→ Fonagy P, Campbell C. Bad blood: 15 years on. Psychoanal Inquiry. 2017;37:281-283.
Although the tension between psychoanalytic thinkers and empiricists has lessened, the authors argue for recognition by neuroscientists and those providing CBT that much of psychopathology is better viewed in relational terms with increased sensitivity to social/cultural issues. Relational theory has supplanted insight with respect to change as in the traditional models of psychoanalytically oriented psychotherapy. Accordingly, a more socially based concept of the mind as manifested within interpersonal relationships could better accommodate both empiricism and more cognitive psychotherapies. Many clinician-educators feel the relational/interpersonal model is less theory bound with less jargon and therefore attractive to psychiatry trainees.
→ Carhart-Harris RL, Roseman L, Bolstridge M, et al. Psilocybin for treatment-resistant depression: fMRI-measured brain mechanisms. Sci Rep. 2017. https://www.nature.com/articles/s41598-017-13282-7. Accessed November 15, 2017.
This article is among a number of publications this year that address the possible role of hallucinogens in the treatment of psychiatric disorders. This, of course, is not a new line of investigation. MDMA and, I include, ketamine studies as well are representative of this line of inquiry. At this point, greater research is required and more restraint in using these compounds off label is warranted. Many in our field appropriately are critical of the mushrooming numbers of free-standing clinics (some managed by non-psychiatrists) that offer ketamine treatment to those with treatment-resistant depression.
→ Cabitza F, Rasoini R, Gensini GF. Unintended consequences of machine learning in medicine. JAMA. 2017;318:517-518.
Much has been made recently of the transformative powers of machine learning and its attractive potential for analyzing very large data sets that may better inform treatments. In this viewpoint article, authors detail pitfalls in wholesale adoption of machine learning with respect to promoting a less skillful clinician who may over rely on new treatment algorithms while denying the basic uncertainty in the practice of medicine. Vital research goals in the application of machine learning are presented as well.
Although neurobiological advances in our field are exciting and will one day undoubtedly be translated into marked change in the practice of psychiatry, the centrality of the doctor-patient relationship has been scientifically acknowledged and remains the cornerstone of all psychotherapeutic and somatic treatments. It behooves psychiatrists to moderate their enthusiasm for, and adoption of, novel but scientifically unsupported treatments. We owe this to our patients, their families, and the public at large.
Dr. Kay is Emeritus Professor, Deparment of Psychiatry, Boonshoft School of Medicine of Wright State University, Dayton, OH, and Clinical Professor of Psychiatry, Tulane University School of Medicine, New Orleans, LA.
1. Bhugra D, Tasman A, Kay J, et al. The WPA-Lancet Psychiatry Commission on the Future of Psychiatry. Lancet Psychiatry. 2017;4:775-818.
2. Kay J. Psychotherapy by psychiatrists: why choose a bugle when you can play the trumpet?Acad Psychiatry. 2017;41:24-29.
3. Jones KL, Croen LA, Yoshida CK, et al. Autism with intellectual disability is associated with increased levels of maternal cytokines and chemokines during gestation. Mol Psychiatry. 2017;22:273-279.