Reflections on How We Think About Ourselves

October 2, 2020

A Psychiatrist Looks Back on His Career and Considers the Role of the Placebo Effect in Treatment.

MIND-BODY ALLIANCE

I passed the boards in 1985. That means I am grandfathered into a system that required you to pass the boards once and then never made you take them again. To those who chafe under Maintenance of Certification requirements, that may seem idyllic. But let me tell you, I am intensely aware of all that I have had to learn since residency.

Think for a moment about what residency was like in the early 1980s. Is it possible to imagine a psychiatric residency that existed before Prozac was invented? Along with my fellow trainees, I had no idea what a computerized tomography (CT) scan or magnetic resonance imaging (MRI) might be. Our residency director had to fight hard to incorporate the radical approach to therapy called cognitive behavioral therapy (CBT). As trainees, we were certainly expected to have read all 182 pages of the DSM-II (the DSM 5 comes to 816 pages without the glossary and tables in the back), and I recall I was the only member of the residency group who was not in psychoanalysis. Consider those facts for a moment, and you will have some idea of how psychiatry has changed since I entered the field and how much I have had to learn.

As a psychiatric grandfather, I am the product of sweeping advances, as well as some therapeutic catastrophes, that have happened over the lifetime of my generation. I was already in practice when posttraumatic stress disorder (PTSD) was rarely considered a psychiatric diagnosis, except in cases of military combat. Medical marijuana was considered an anarchist’s fantasy. The idea of multi-generational Satanic trauma was a common topic of academic study, and the services and institutions that had been established to treat the victims of that trauma collapsed under the weight of multiple lawsuits. I was only in mid-career when the American Psychiatric Association (APA) figured out that being gay was not a mental illness. The flowering of so-called second-generation antipsychotics started with risperidone, and I can remember when $7 a tablet seemed utterly beyond comprehension and forever out of reach of my patients on Medicaid. For four-fifths of my years as a psychiatrist, I was paid at 60% of the rate that primary care doctors received, because the idea of parity was considered impossibly idealistic. Even the insurance offered by the APA to its own members did not cover psychiatric services at parity, and when I wrote to the insurance manager to point that out, I was told that it was just impossible to imagine such a policy.

I learned some things about psychiatry almost as soon as I could walk. I have very clear childhood memories of walking past the units for disturbed males at Kalamazoo State Hospital. These 3-story buildings had open porches facing the road and behind each porch were dozens of mostly naked men groaning and shouting. I was 3 years old, holding on tightly to my mother’s hand as we walked to visit my grandmother who was, thankfully, usually on the quiet women’s unit. It was years before her life was changed by the miracle of Stellazine, but she never left the state hospital.

In parallel with sea changes within the discipline of psychiatry, my own life has been blessed with a career that spanned many different settings. In all these settings, I've been a front-line clinician, always loving the challenge of seeing patients myself but never interested in academic psychiatry or administration. Shortly out of residency, I served on the staff of a state hospital and briefly as medical director, and later as an international graduate trainee in the British Health System. I lived in a village in West Africa and organized a health program for all the villages in the district. I have been employed as a contract psychiatrist in a state prison system (see the columns “Working on the Inside” from that segment of my life) and been self-employed in solo office practice, specializing in trauma—ie the folks who other psychiatrists refused to see because they would not deal with self-injury. I have worked as an inpatient psychiatrist who was on call every third night and expected to make rounds 7 days a week. I carried a practice of several hundred adults with intellectual disabilities living in 16 bed community housing settings—about two-thirds of whom carried a second diagnosis of psychiatric disorder. For several years I managed dual diagnosis clients in a major substance abuse program. I was a contract psychiatrist for a residential program that housed persons with serious mental illness, folks who 3 generations previously would have been confined to the chronic ward of the state hospital where my grandmother had lived. These opportunities have been woven into my life, almost always alongside at least 1 contract as the psychiatrist for a community mental health agency.

I retired once when I was 55. It might be more accurate to say I was driven out by the heavy-handed ways that managed care constrained pharmacy costs. My retirement did not last, and I returned to work, even though I had had a brain bleed at age 64 and was still having visual hallucinations. I retired again when I was 70, but again I have been drawn back into psychiatry. I continue to work today, albeit mostly via telepsychiatry connections. The technology allows me to work despite the fact that the brain bleed left me with right hemianopsia, so I am not able to drive a car to the clinics where I work.

I am a person who is always curious, and for some reason a recent article on Placebo caught my attention.1 This New York Times Magazine article, reporting work done by the Harvard researcher Ted Kaptchuk, led me to reflect on all the ways that body and mind are linked.1 As psychiatrists, we often send our patients to practitioners of CBT, which is the disciplined evocation of mind-body connections. Our training prepares us to think in terms of the allopathic principles of scientific intervention and the mechanics of the brain. The stated purpose of our professional organization is to promote “scientific psychiatry” and it is eager to claim allopathic parity with the other “scientific” branches of medicine, such as cancer surgery or procedural radiology. Perhaps because of that interest in being recognized as fully allopathic, in our day-to-day work we mostly ignore all the ways we know mind and body are linked.

I am proposing to organize a series of columns that tracks the mind-body relationship. This reflection for me started with Ted Kaptchuk’s research on placebo effect.2 I have extended it in my own mind to think about how it is relevant in the way we conceptualize what is going on when thousands of people knowingly ingest fentanyl and similarly dangerous substances as part of their recreational choices. I believe we can also appropriate work of some cardiologists, who have begun to explore the implications of mind-body linkages.

As a way to begin the reflection, please consider with me the problem of high placebo rates in recent drug trials.3 Notwithstanding legitimate concerns that among paid trial participants, there may be some who were convincingly claiming illness as a ticket to get into the program, placebo rates of30 to 40%3 seem striking. Drug companies value these studies because they certify that their medication is worth hundreds of dollars a month, as opposed to self-healing, which would presumably cost the patient nothing. Among those who are considered by researchers to be “placebo responders,” there many who are really improved. They experienced good or great benefit from the treatment. The drug trial protocol will dismiss this placebo effect as a problem to overcome. Of course, the drug company wants to draw our focus to the benefit beyond the placebo effect, because they want to prove the effectiveness of their product in order to make a profit There would be no profit in proving that placebo effect works.

If we as a community of outpatient psychiatrists want to know how to get people who are disabled back on their feet and well again, should we not be very interested in something that works 50% of the time at a price the patient can afford? From my perspective that question holds a lot of interest. I hope you will join me in coming months as I pursue this and similar reflections on how we think about ourselves.

Dr Gilbert is a community psychiatrist contracting telepschiatry services to small community mental health centers in the rural area of his state. The author reports no conflicts of interest concerning the subject matter of this article.

References

1. Greenberg, G. What if the Placebo Effect Isn't a Trick? The New York Times Magazine. Nov 7, 2018: Page 50. Accessed 10/1/2020.

2. The Power of the Placebo Effect: Treating Yourself With Your Mind Is Possible, but There Is More to the Placebo Effect Than Positive Thinking. Harvard Health Publishing. May, 2017. Updated August 9, 2019. Accessed September 25, 2020.

3. Sonawalla SB, Rosenbaum JF. Placebo response in depression. Dialogues Clin Neurosci. 2002 Mar;4(1):105-13.