Affirming Psychiatry - Episode 5
The truth: Psychiatric treatment works.
The shocking thing about psychiatric treatment is that it works. If you are a mental health professional, this “news” will not surprise you at all. But if you are someone outside our field, the news will come as a genuine revelation. And if you are a reader of periodicals such as The Wall Street Journal or The New York Times, you will be stunned to learn that the following assertion is true: Psychiatric treatments are comparable to those in other branches of medicine. By this I mean that we have mental health treatments that are generally equal to the rest of medicine in scientific support, efficacy, and safety. Are our treatments perfect? Hardly. But they are fully in line with the rest of medicine.
I do not blame laypeople for believing that our treatments are ineffective or dangerous. There is a steady stream of books proclaiming this to be true,1 along with prominent articles such as, “How Much Do Antidepressants Help, Really?”2 and “Doctors Gave her Antipsychotics. She Decided to Live With Her Voices.”3 And while media outlets such as The New York Times hardly represent antipsychiatry, they articulate a not-so-sneaking suspicion that there is something uniquely wrong with psychiatric treatments. Do they really work, really? Aren’t they dangerous and toxic in the end? Wouldn’t we be better off without them, coping for ourselves rather than depending on pills and therapists?
Even nonpsychiatric physicians, who understand the reality of mental illness quite well, seem to be sympathetically doubtful of our ability to help. I remember talking to a neurologist friend who declared that he could never be a psychiatrist because it was “too depressing to see people come back time after time with the same problems.”
“Wait a minute,” I replied. “Don’t neurologists mostly treat things like strokes, multiple sclerosis, migraines, and seizures? These do not just go away with treatment.” This prompted an explanation from him about how meaningful it was to work with patients over the long term and see improved adjustment and quality of life. “Yeah,” I said, “that’s what we do in psychiatry.” But I was wrong. We do so much more than that in psychiatry.
Let’s Compare Apples to Apples
The old argument is that we in psychiatry do not have cures for mental illnesses. And this is true. But it is also true of the other chronic illnesses that constitute our major public health problems in this country. Although we do have cures for many acute illnesses like appendicitis and otitis media, we lack these for most chronic illnesses. We cannot cure heart disease, and we cannot cure diabetes. We do not have cures for high blood pressure, strokes, or most kinds of cancer either. Why is no one in despair about this? Why do we not see regular articles like, “Doctors Gave Her Antihypertensives. But She Decided to Live with High Blood Pressure”? The reason is that we have good treatments for all these chronic health conditions, and using such treatments is not a matter of galvanizing public debate. Yet precisely the same thing applies to the major mental illnesses that—for no legitimate reason—remain a matter of galvanizing public debate. We generally do not cure psychiatric illnesses. But we have good treatments for them all, and no one should despair of getting help.
How do we know this? In 2012, Leucht and colleagues conducted a major meta-analysis for the purpose of comparing psychiatric medicines to medicines commonly used in primary care.4 They combined the results of 94 independently published meta-analyses on both types of medications. They compared effect sizes to evaluate the overall difference between psychiatric and other commonly prescribed medications. The meta-analyses included common general medical conditions such as asthma and type 2 diabetes, and common psychiatric conditions such as schizophrenia and major depression. In all, medications for 20 general medical diseases and 8 psychiatric disorders were compared.
The result: There was no statistically significant difference in effect sizes between the 2 groups. On average, psychiatric medications were moderately effective (with a mean effect size of 0.49), just as medicines for other common medical conditions were moderately effective (with a mean effect size of 0.45). In other words, the prescriptions that patients carry out of a psychiatrist’s office are, on average, just as likely to help them as the prescriptions they take out of their primary care offices.
What the Public Does Not Know
Psychiatric treatments work. Psychiatric medications work. And psychotherapy works as well. The past 30 years have seen an unheralded revolution in psychotherapy research. Commonly derided as unscientific “psychobabble” in the 1970s and 1980s, well-established forms of psychotherapy have now been scientifically validated in hundreds of published studies. Cognitive behavioral therapy (CBT),5 dialectical behavior therapy (DBT),6 and various forms of psychodynamic psychotherapy7 are well-substantiated as treatments of common mental illnesses. And there is evidence that the medications and psychotherapy work better in tandem than individually, at least in the case of major depression.8 Moreover, we have less prominent but nevertheless empirically supported treatments such as psychoeducation, mindfulness, exercise, and peer support groups.9 We mix and match these medically legitimate treatments to our patients’ needs and preferences. This, in reality, is what psychiatric treatment looks like.
Contrary to the assumptions of our public intellectuals and media thought leaders, there is no lack of proven treatments for psychiatric illnesses. We can offer an array of scientifically supported treatments for all the major mental illnesses. What we lack is not an effective set of treatments, but a cure for the hearsay that feeds the ignorance, anxiety, and irrational skepticism of our public. What can we do? Speak up. As the only group of individuals who deeply understand the efficacy of mental health treatment, it falls upon us to thoroughly educate ourselves, our patients, their families, our advocacy organizations, and our communities. As always, good news is hard to sell. But reality is on our side, and this should be enough.
Dr Morehead is a psychiatrist and director of training for the general psychiatry residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health and is author of Science Over Stigma: Education and Advocacy for Mental Health, published by the American Psychiatric Association. He can be reached at firstname.lastname@example.org.
1. Hari J. Lost Connections: Uncovering the Real Causes of Depression – and the Unexpected Solutions. Bloomsbury USA; 2018.
2. Moyer MW. How much do antidepressants help, really? The New York Times. April 21, 2022. Accessed June 22, 2022. https://www.nytimes.com/2022/04/21/well/antidepressants-ssri-effectiveness.html
3. Bergner D. Doctors gave her antipsychotics. She decided to live with her voices. The New York Times. May 17, 2022. Accessed June 22, 2022. https://www.nytimes.com/2022/05/17/magazine/antipsychotic-medications-mental-health.html#:~:text=Gave%20Her%20Antipsychotics.-,She%20Decided%20to%20Live%20With%20Her%20Voices.,medication%20and%20toward%20greater%20acceptance
4. Leucht S, Hierl S, Kissling W, et al. Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses. Br J Psychiatry. 2012;200(2):97-106.
5. Hofmann SG, Asnaani A, Vonk IJ, et al. The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognit Ther Res. 2012;36(5):427-440.
6. DeCou CR, Comtois KA, Landes SJ. Dialectical behavior therapy is effective for the treatment of suicidal behavior: a meta-analysis. Behav Ther. 2019;50(1):60-72.
7. Leichsenring F, Luyten P, Hilsenroth MJ, et al. Psychodynamic therapy meets evidence-based medicine: a systematic review using updated criteria. Lancet Psychiatry. 2015;2(7):648-660.
8. Cuijpers P, Noma H, Karyotaki E, et al. A network meta‐analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression. World Psychiatry. 2020;19(1):92-107.
9. Morehead DB. Science over Stigma: Education and Advocacy for Mental Health. American Psychiatric Association Publishing; 2021:151ff.