Do we have to believe psychiatry concerns itself with "diseased brains" to be a relevant medical specialty?

[splik]

In the moral injury thread, the claim was made that psychiatry must concern itself with "diseased brains" and biomedical interventions to maintain its moral authority as a medical specialty. The implication was that wider social and psychological forces that shape our patient's experience were of peripheral concern to psychiatry and psychiatrists. The claim was also that that the power, privilege, and even "prestige" that psychiatrists might enjoy was dependent on viewing mental illness as the product of disease brains. I would like to rebuff these claims.

The idea that psychiatry should focus on biomedical activities such as diagnoses and pharmacological and somatic treatments is not new. In the 1970s, the Neo-Kraepelinian school of psychiatry emerged as a direct response to the perceived existential threat posed to the profession by psychologists and social workers. Up until the 60s, psychotherapy and psychoanalysis in particular, was largely seen as a medical activity, exclusively practiced by psychiatrists with some notable exceptions. In fact, it was not until the late 1980s, following an anti-trust suit that non-physicians were routinely admitted to psychoanalytic institutes. The Neo-Kraepelian school held that psychiatry should abandon psychodynamic thinking and focus on making rigorous diagnoses, see more patients for shorter visits less frequently in line with our medical colleagues, and focus on psychopharmacological and somatic interventions. Diagnosis making and prescribing were seen as solely in the province of psychiatry, and promised to make psychiatry more respectable and immune from "threats" posed to its survival from other mental health professionals. Only they didn't.

In the intervening years, the popularity of psychiatry as a medical specialty plummeted with psychiatric residencies contracting and closing in droves. The subsistence of the profession became heavily reliant on international medical graduates. A whole generation of psychiatrists barely learned psychotherapy with many questioning whether psychiatrists still knew how to talk to patients. While the advent of SSRIs and atypical antipsychotics no doubt changed psychiatric practice, there have been no major advances in the efficacy of psychopharmacological agents since the 1950s. The Neo-Kraeplinian model aligned itself well with both the rise of managed care and the Regan era. Managed care saw psychiatrists as an expensive commodity who had no business providing psychotherapy and the "15 minute med check was born" while inpatient units, residential programs, and specialized psychotherapy oriented programs closed down. The Reagan administration found it politically expedient to support biological research into mental disorders and defunded any social and economic research that would reveal the human costs of monetarism.

The 90s was heralded as the "decade of the brain" and also launched the human genome project. Both promised to shine light on the dark secrets of mental illness and afford new hope in diagnosis and treatment. These promises too, failed. At the same time, psychiatry became wedded to the pharmaceutical industry and in the minds of both the public and congress, psychiatrists were seen as having been corrupted by big pharma. By the early 2000s, despite the widespread closure of psychiatric residency positions, recruitment into available positions was in dire straights and the public perception of the field was low. Even the then APA President Steven Sharfstein wondered aloud whether psychiatry had replaced the biopsychosocial model for the "bio-bio-bio model".

Meanwhile, psychiatrists were no longer the only ones who could diagnose - psychologists, social workers, masters' levels therapists, PAs, NPs, and nurses were all making DSM-based diagnoses as well. Even prescription privileges expanded to psychologists in some states and jurisdictions, with PAs and NPs in particular buoyed by the dearth of available psychiatrists. Psychiatrist reimbursement from insurance companies was in freefall, and without any semblance of mental health parity, denials for both inpatient and other levels of care became increasingly common. In aligning with the Neo-Kraepelinian approach, psychiatry had authored its own suicide note.

What relevance does this recent history lesson have for us today? Well, psychiatry is at its least compelling and popular when it narrowly focuses on biomedical aspects of what it means to suffer. Both medical students choosing a career and public at large don't buy it. The problems that psychiatry deals with are too expansive and varied and suffering too complex to be understood as merely the product of a diseased brain. In fact, the golden age of psychiatry (both in public perception and in terms of recruitment) was in the post-war period when psychiatry was heavily influenced by psychoanalysis. Basic psychoanalytically-informed therapies were seen as effective for the war neuroses of returning servicemen as well as holding allure for the Hollywood elite and intelligentsia. We are arguably experiencing a second "golden age" for psychiatry. It is an increasingly popular choice for medical students and the public and our elected officials have embraced the importance of mental health treatment. Five factors seem particularly relevant.

Firstly, the great recession created the economic conditions that increased the prevalence of mental illness. This also provided the impetus for the passage of mental health parity, and wider healthcare reform. The significant increase in the number of individuals with health insurance with mental health benefits, increased demand for psychiatric services. Secondly, the recession exacerbated existing inequalities, with white individuals without college degrees facing the brunt of the economic downturn, leading to a rise in "deaths of despair" such as opiate overdoses, alcohol-related deaths, and gun suicides. This change in demographics led to increased funding for addiction services and wider recognition of the intersection between mental illness and substance abuse. Thirdly, with limited advancements in psychiatric drug development and saturation in the pharmaceutical market, the industry significantly reduced its investments in psychiatric research. This led psychiatry to do some soul searching. Partly in response to the blowing cultural winds, the ACGME emphasized that training in certain psychotherapeutic modalities was core to our professional identity. Finally, the COVID-19 pandemic presented both challenges and opportunities in the realm of mental health. The pandemic caused widespread uncertainty and confinement, leading to an increase in mental health issues. However, telehealth became increasingly prevalent, providing greater access to treatment for those in need. In short, a narrowly remedicalized psychiatry that took hold in the 1980s almost killed the profession. In contrast, embracing mental health problems as influenced by social, political, and economic factors with multimodal interventions including but not limited to medications, created the conditions for psychiatry to thrive.

On a personal note, my non-psychiatric colleagues appreciate me most not because of my medical or psychiatric input but because of my expertise in psychosocial medicine. In my previous job I had numerous discussions and attended many meetings about complex patients to which I was invited because I could explain the puzzling behaviors in their patients in a way that made sense, validated the teams most primitive feelings, and led to concrete action. I was also frequently sought out to consult on complex ethical and risk management dilemmas. There will always be a place for physicians who understand and integrate the biomedical, psychological, sociocultural, ethical and medicolegal dimensions of care. Psychiatrists can fill that role. Or we can attempt to be a simulacrum of a stereotypical physician and condemn the field to obsolescence.

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[vespers]

Really nice write-up; thanks, splik.

In my previous job I had numerous discussions and attended many meetings about complex patients to which I was invited because I could explain the puzzling behaviors in their patients in a way that made sense, validated the teams most primitive feelings, and led to concrete action. I was also frequently sought out to consult on complex ethical and risk management dilemmas.

Can you give a detailed example, even a hypothetical, of what this looks like?

 

[annoyedpsychiatrist]

I hate the medical school taught concept that depression is due to low serotonin when in reality the etiology of depression is complex and multifactorial. I would argue that even most cases of TRD aren't a result of being on the wrong med/needing a particular new med, but a result of complex personality disorders, significant life stressors, maladaptive coping skills, comorbid substance use, etc. In residency I resisted learning therapy because I wanted to focus on pharmacology when in reality I figured out that focusing just on medications would result in patients being treated with only one part of the equation (other parts often being lifestyle changes, therapy, etc). I try to frequently add in CBT components when I can and really hammer exacerbating factors to someones depression/anxiety. One patient who was fairly young, was depressed 2/2 to bad credit which limited her housing oppurtunities/ability to get a decent car loan/etc. I simply explained to her how credit works, simple methods to raise your credit score, etc. She was able to take better control over life through simple interventions.

Good psychiatrists understand, bad psychiatrists just focus on "is the med working?"

 

[TheRightMedication]

I hold out hope that someday, neurology, computer science, and other disciplines will be able to describe consciousness in precise detail. I also hope that we'll all be smart enough to develop usable heuristics to actually interact with that knowledge to solve practical problems of the sort we deal with in psychiatry.

However, for the foreseeable future, we have very complex phenomenon to deal with, about which much is known but not nearly enough to produce good theories. Our DSM is, as it states, valid (constructs are consistent-ish when used in the real world.) but not reliable (we don't claim its real).

So, for the foreseeable future, there's a whole category of human suffering that requires expertise in hard science (neuro looks like a hard science to me), soft science (psychology, sociology and similar) and in my opinion a bit of philosophy and ethics.

That's us! It's a valuable service. There is an interpretation of what a disease is and what a doctor is that excludes us from being "real" doctors.

Yet people come to us, witch doctors or no, in their hundreds of thousands, for a kind of help they can't get elsewhere.

Edit- For example,

Is your son's trouble at school an adaptation for hunting? A brain disease? A social need for him to sit still at a desk under flourescent lights all day? And what should we actually do about all this?

Very important questions, with very consequenctial answers, and psychiatry done well can do these families a great service.

 

[smalltownpsych]

On a personal note, my non-psychiatric colleagues appreciate me most not because of my medical or psychiatric input but because of my expertise in psychosocial medicine. In my previous job I had numerous discussions and attended many meetings about complex patients to which I was invited because I could explain the puzzling behaviors in their patients in a way that made sense, validated the teams most primitive feelings, and led to concrete action. I was also frequently sought out to consult on complex ethical and risk management dilemmas. There will always be a place for physicians who understand and integrate the biomedical, psychological, sociocultural, ethical and medicolegal dimensions of care. Psychiatrists can fill that role. Or we can attempt to be a simulacrum of a stereotypical physician and condemn the field to obsolescence.

Hey that’s my job! lol Actually, this is such a truth and I have interacted with many medical doctors who frequently said that psychiatrists weren’t really needed because the medicine and psychopharmacology wasn’t that complex ( I know thats not really true, just a common misconception by other providers), but they really appreciated me explaining and treating all of the other factors involved. It makes total sense that they would really appreciate and even prefer a psychiatrist who could do that. I have met a few who can and they are typically well-respected by all.

Also, wanted to add that psychotherapy is indeed a powerful intervention and although people tend to think anyone can do it, the truth is that when the case is tough, people are desperate for and even recognize the need for people with real expertise with delivering this treatment. in my exclusive cash only practice, most of my patients have been treated prior by any of this seeming multitude of newly minted poorly trained midlevel therapists that don’t even really know what psychotherapy is and are often just replicating the same unhealthy patterns that led to or exacerbated the problem in the first place. Along those lines, just knowing what initials of treatment goes with which diagnosis doesn’t help much.

 

[SmallBird]

In the moral injury thread, the claim was made that psychiatry must concern itself with "diseased brains" and biomedical interventions to maintain its moral authority as a medical specialty. The implication was that wider social and psychological forces that shape our patient's experience were of peripheral concern to psychiatry and psychiatrists. The claim was also that that the power, privilege, and even "prestige" that psychiatrists might enjoy was dependent on viewing mental illness as the product of disease brains. I would like to rebuff these claims.

The idea that psychiatry should focus on biomedical activities such as diagnoses and pharmacological and somatic treatments is not new. In the 1970s, the Neo-Kraepelinian school of psychiatry emerged as a direct response to the perceived existential threat posed to the profession by psychologists and social workers. Up until the 60s, psychotherapy and psychoanalysis in particular, was largely seen as a medical activity, exclusively practiced by psychiatrists with some notable exceptions. In fact, it was not until the late 1980s, following an anti-trust suit that non-physicians were routinely admitted to psychoanalytic institutes. The Neo-Kraepelian school held that psychiatry should abandon psychodynamic thinking and focus on making rigorous diagnoses, see more patients for shorter visits less frequently in line with our medical colleagues, and focus on psychopharmacological and somatic interventions. Diagnosis making and prescribing were seen as solely in the province of psychiatry, and promised to make psychiatry more respectable and immune from "threats" posed to its survival from other mental health professionals. Only they didn't.

In the intervening years, the popularity of psychiatry as a medical specialty plummeted with psychiatric residencies contracting and closing in droves. The subsistence of the profession became heavily reliant on international medical graduates. A whole generation of psychiatrists barely learned psychotherapy with many questioning whether psychiatrists still knew how to talk to patients. While the advent of SSRIs and atypical antipsychotics no doubt changed psychiatric practice, there have been no major advances in the efficacy of psychopharmacological agents since the 1950s. The Neo-Kraeplinian model aligned itself well with both the rise of managed care and the Regan era. Managed care saw psychiatrists as an expensive commodity who had no business providing psychotherapy and the "15 minute med check was born" while inpatient units, residential programs, and specialized psychotherapy oriented programs closed down. The Reagan administration found it politically expedient to support biological research into mental disorders and defunded any social and economic research that would reveal the human costs of monetarism.

The 90s was heralded as the "decade of the brain" and also launched the human genome project. Both promised to shine light on the dark secrets of mental illness and afford new hope in diagnosis and treatment. These promises too, failed. At the same time, psychiatry became wedded to the pharmaceutical industry and in the minds of both the public and congress, psychiatrists were seen as having been corrupted by big pharma. By the early 2000s, despite the widespread closure of psychiatric residency positions, recruitment into available positions was in dire straights and the public perception of the field was low. Even the then APA President Steven Sharfstein wondered aloud whether psychiatry had replaced the biopsychosocial model for the "bio-bio-bio model".

Meanwhile, psychiatrists were no longer the only ones who could diagnose - psychologists, social workers, masters' levels therapists, PAs, NPs, and nurses were all making DSM-based diagnoses as well. Even prescription privileges expanded to psychologists in some states and jurisdictions, with PAs and NPs in particular buoyed by the dearth of available psychiatrists. Psychiatrist reimbursement from insurance companies was in freefall, and without any semblance of mental health parity, denials for both inpatient and other levels of care became increasingly common. In aligning with the Neo-Kraepelinian approach, psychiatry had authored its own suicide note.

What relevance does this recent history lesson have for us today? Well, psychiatry is at its least compelling and popular when it narrowly focuses on biomedical aspects of what it means to suffer. Both medical students choosing a career and public at large don't buy it. The problems that psychiatry deals with are too expansive and varied and suffering too complex to be understood as merely the product of a diseased brain. In fact, the golden age of psychiatry (both in public perception and in terms of recruitment) was in the post-war period when psychiatry was heavily influenced by psychoanalysis. Basic psychoanalytically-informed therapies were seen as effective for the war neuroses of returning servicemen as well as holding allure for the Hollywood elite and intelligentsia. We are arguably experiencing a second "golden age" for psychiatry. It is an increasingly popular choice for medical students and the public and our elected officials have embraced the importance of mental health treatment. Five factors seem particularly relevant.

Firstly, the great recession created the economic conditions that increased the prevalence of mental illness. This also provided the impetus for the passage of mental health parity, and wider healthcare reform. The significant increase in the number of individuals with health insurance with mental health benefits, increased demand for psychiatric services. Secondly, the recession exacerbated existing inequalities, with white individuals without college degrees facing the brunt of the economic downturn, leading to a rise in "deaths of despair" such as opiate overdoses, alcohol-related deaths, and gun suicides. This change in demographics led to increased funding for addiction services and wider recognition of the intersection between mental illness and substance abuse. Thirdly, with limited advancements in psychiatric drug development and saturation in the pharmaceutical market, the industry significantly reduced its investments in psychiatric research. This led psychiatry to do some soul searching. Partly in response to the blowing cultural winds, the ACGME emphasized that training in certain psychotherapeutic modalities was core to our professional identity. Finally, the COVID-19 pandemic presented both challenges and opportunities in the realm of mental health. The pandemic caused widespread uncertainty and confinement, leading to an increase in mental health issues. However, telehealth became increasingly prevalent, providing greater access to treatment for those in need. In short, a narrowly remedicalized psychiatry that took hold in the 1980s almost killed the profession. In contrast, embracing mental health problems as influenced by social, political, and economic factors with multimodal interventions including but not limited to medications, created the conditions for psychiatry to thrive.

On a personal note, my non-psychiatric colleagues appreciate me most not because of my medical or psychiatric input but because of my expertise in psychosocial medicine. In my previous job I had numerous discussions and attended many meetings about complex patients to which I was invited because I could explain the puzzling behaviors in their patients in a way that made sense, validated the teams most primitive feelings, and led to concrete action. I was also frequently sought out to consult on complex ethical and risk management dilemmas. There will always be a place for physicians who understand and integrate the biomedical, psychological, sociocultural, ethical and medicolegal dimensions of care. Psychiatrists can fill that role. Or we can attempt to be a simulacrum of a stereotypical physician and condemn the field to obsolescence.

Fantastic. And to consider then, what are the barriers to a full-throated embrace of the broad practice style which is so critical to clinical success and a validation of our need for such extensive training? Well, systems are one thing, but we must take some of the blame ourselves. Doing this type of work takes more time, but I would argue that there are many systems that don't force anyone to go along with the model of the '15 minute med check'. Between the doctor who rounds on 20 patients in 3 hours to make $1 million, and the 2 year long inpatient stays at the Austen Riggs Center, there is the possibility to maybe only rounding on 10 patients and contributing to the psychosocial aspects of their care in the way you so clearly did at your prior institution. I also think that there are opportunities to articulate clearer standards of care that both expand the scope of interventions we should be applying while narrowing the expectations for what they will do.

 

[G Sheb]

There may be a day when say, someone is feeling down and we can intervene by changing a brain circuit or something like flipping a switch. That sort of expertise may require a lot of technical and specialized understanding.
We are not there. Or anywhere near, and unlikely to be anywhere near this for at least half a century or something.
Even then, the social and the personal would always be prominent in our mental experiences. Can you actually address depression without talking, empathizing and understanding? Can you address trauma without looking at the broader social context?

I agree, I think our position at the intersection of all those three is what makes the field even more relevant. Pigeonholing ourselves is not going to make the field more 'prestigious'.

N=1, but I recently went out with someone who disdainfully called his psychiatrist the "pill lady", because she just wanted to write a script.

I have interacted with many medical doctors who frequently said that psychiatrists weren’t really needed because the medicine and psychopharmacology wasn’t that complex ( I know thats not really true, just a common misconception by other providers),

It is probably true though. It is far less complex than say pharmacological management in heme-onc.
We kinda had this discussion before, but it's definitely not the so-called 'technical aspects' that make psychiatry challenging.

 

[dl2dp2]

In the moral injury thread, the claim was made that psychiatry must concern itself with "diseased brains" and biomedical interventions to maintain its moral authority as a medical specialty. The implication was that wider social and psychological forces that shape our patient's experience were of peripheral concern to psychiatry and psychiatrists. The claim was also that that the power, privilege, and even "prestige" that psychiatrists might enjoy was dependent on viewing mental illness as the product of disease brains. I would like to rebuff these claims.

This is a straw man. There's a bidirectional relationship between prestige and its associates and economic value by definition. You can't really rebuff either a logical tautology or you are simply saying that you *wish* it wasn't true. Whether mental illness is a "brain disease" is a secondary post hoc discussion specific to somatic treatments. One can say [some part of] psychiatry is a subspecialty of "supratentorial neurology" which certain meds you prescribe affect...and physician in that subsection of psychiatry commands greater prestige...etc. this is all a shell game. You are arguing against semantics. I hope my point is clear on this. Viewing [some] mental illness as a brain disease is a global "theory" or "hypothesis" to create a context whereby some progress can be made in some specific ways. This can't be false by definition or your interpretation is too broad.

Secondly, the link between sentences 1 and 2 are not logical, e.g.:
1. mental health can be brain diseases
2. treatment can yet be psychological, social, etc. as long as they are subjected to rigorous scientific testing

This is an argument that "antipsychiatry" philosophy doesn't really appreciate and err on. Like the claim is that the necessary implication that the only solution to brain diseases is med or medical procedure. This completely contradicts the prevailing knowledge about every single other specialty of medicine. The beef isn't the treatment isn't med or procedure, it's that 1. subjected to rigorous testing, and in fact it's "not testable"-- though that is even somewhat a secondary concern, as many procedures aren't rigorously tested (i.e. surgery); 2. there's no special expertise required to deliver the psychological, social interventions, or the expertise can be gained with less training.

On a personal note, my non-psychiatric colleagues appreciate me most not because of my medical or psychiatric input but because of my expertise in psychosocial medicine. In my previous job I had numerous discussions and attended many meetings about complex patients to which I was invited because I could explain the puzzling behaviors in their patients in a way that made sense, validated the teams most primitive feelings, and led to concrete action. I was also frequently sought out to consult on complex ethical and risk management dilemmas. There will always be a place for physicians who understand and integrate the biomedical, psychological, sociocultural, ethical and medicolegal dimensions of care. Psychiatrists can fill that role. Or we can attempt to be a simulacrum of a stereotypical physician and condemn the field to obsolescence.

I'm not saying you are wrong. I'm saying that no institutional player will pay you [well enough for you to not burn out on the aggregate] to fill that role, unless you make yourself somehow ultra-specialized enough to create a certificate program for "psychological, sociocultural, ethical and medicolegal dimensions of care" that requires MD level training.

Some subspecialties of psychiatry have that flavor. For example, forensic psychiatry is not biomedical at all. Yet it commands great pay and prestige because it has substantial technical expertise in "socialcultural, ethical and mediocolegal" dimensions.

Labels aren't that interesting in that way. You can look like a "physician" and quack like a "physician", but at the end of the day it's the specialized nature of your knowledge base that really matters for "prestige". Radiologists don't look like "physicians". Physician executives don't look like "physicians". Typically this doesn't drive the field into "prestige" vis-a-vis "obsolescence". Things that don't move forward drive a field into obsolescence. The problem with psychosocial interventions is that they aren't moving forward very much. Sometimes it's because it's not tested or tested correctly. Often it's political (the proverbial psychiatrists don't write enough grants). They aren't perceived as attractive and innovative and they don't require significant training for greater feasibility and efficacy. It's not that they don't work, or that they make you look "less like a physician". These are related issues, but ultimately they are symptoms rather than the cause. It's more about the barrier of entry is not high enough. If you can create a regulatory barrier and reimbursement framework that would pay for a stipulated set of complex psychosocial interventions that only MDs can deliver, it will immediately become less "obsolete" and more "prestigious". But, as I said before, very few psychiatrists are interested in THAT kind of work. They wish someone else did that work for them and just give them the prestige free of charge.

I'm just the messenger who's telling you that you are SOL if you have the delusion that this will happen automatically.

I hold out hope that someday, neurology, computer science, and other disciplines will be able to describe consciousness in precise detail. I also hope that we'll all be smart enough to develop usable heuristics to actually interact with that knowledge to solve practical problems of the sort we deal with in psychiatry.

However, for the foreseeable future, we have very complex phenomenon to deal with, about which much is known but not nearly enough to produce good theories. Our DSM is, as it states, valid (constructs are consistent-ish when used in the real world.) but not reliable (we don't claim its real).

So, for the foreseeable future, there's a whole category of human suffering that requires expertise in hard science (neuro looks like a hard science to me), soft science (psychology, sociology and similar) and in my opinion a bit of philosophy and ethics.

That's us! It's a valuable service. There is an interpretation of what a disease is and what a doctor is that excludes us from being "real" doctors.

Yet people come to us, witch doctors or no, in their hundreds of thousands, for a kind of help they can't get elsewhere.

Edit- For example,

Is your son's trouble at school an adaptation for hunting? A brain disease? A social need for him to sit still at a desk under flourescent lights all day? And what should we actually do about all this?

Very important questions, with very consequenctial answers, and psychiatry done well can do these families a great service.

Yes, and this is technical. Technical need not be "hard science", and that in itself is poorly defined. Corporate lawyers get paid great and have great prestige, but they don't have any training in hard science. The problem I see is when psychiatrists go out of their way to say oh your son's problem is some part of the "broader" social ill that we can't do anything ABOUT in our role as MDs, EXCEPT some mass political action that happens at an uncertain timeline. Whenever this kind of thinking happens, it inevitably leads to burnout. And worse. Much MUCH worse. I don't like speculations, but to me I think this kind of thinking ACTUALLY leads to various problems "antipsychiatrists" indicate, like overstepping our role in social problems, medicalizing everything, giving us a "bad reputation", and will eventually lead to "obsolescence" etc. etc. because then what would differentiate between a psychiatrist from a garden variety political activist of any other cause? Professions that couple their welfare with political actions do NOT do well in general, and especially not in the USA. Many many examples which I won't enumerate here to create more controversy but I think everyone knows what I'm talking about.

 

[Merovinge]

It is probably true though. It is far less complex than say pharmacological management in heme-onc.
We kinda had this discussion before, but it's definitely not the so-called 'technical aspects' that make psychiatry challenging.

I think good pharmacologic management is actually much more difficult than the overwhelming majority of other specialties. Much of IM is done via algorithm, whereas I have to make decisions on a daily basis about which medication with roughly equivalent research findings make the most amount of sense. The mechanisms of action can be very diverse for treating the same problem - anxiety being impacted by 5HT reuptake, binding at specific 5HT subreceptors, GABA agonism (hopefully very rarely), Ca channel changes, heart rate/blood pressure modifiers and also making sure the patient's psychotherapy is being done appropriately, their sleep is good, and they have a form of exercise that fits their life.

It might be because I have spent much of my career taking care of a sicker population, but if your BP does not come down after 2 agents, it is quite easy to figure out the next step. When your anxiety does not come down after 2 different well trialed SSRIs, it is not nearly as straightforward.

When my partner prescribes medication to patients it's typically try this med, does it work? If not maybe we have one other med. If that doesn't work you suck it up or you get surgery. For me at least, the impetus is to keep trying every 1st, 2nd, 3rd and 4th line med possible and you only rarely stop with that unless its clear there are other reasons for medication to not be effective.

 

[Merovinge]

The problem I see is when psychiatrists go out of their way to say oh your son's problem is some part of the "broader" social ill that we can't do anything ABOUT in our role as MDs, EXCEPT some mass political action that happens at an uncertain timeline. Whenever this kind of thinking happens, it inevitably leads to burnout. And worse. Much MUCH worse. I don't like speculations, but to me I think this kind of thinking ACTUALLY leads to various problems "antipsychiatrists" indicate, like overstepping our role in social problems, medicalizing everything, giving us a "bad reputation", and will eventually lead to "obsolescence" etc. etc. because then what would differentiate between a psychiatrist from a garden variety political activist of any other cause? Professions that couple their welfare with political actions do NOT do well in general, and especially not in the USA. Many many examples which I won't enumerate here to create more controversy but I think everyone knows what I'm talking about.

I know dozens of CAP and have never heard a single one say anything like this. We may say "statistically the is the single hardest time in modern human history to be an adolescent" (which it is), but this is always followed by "be that as it may, this is the how the cards have been dealt so we are going to do XYZ about it".

You can both be aware that having 95% pure THC being used every day in school and mixing that with the envy laden social comparison of Tictoc is really tough on an adolescent brain and still address the problems without getting into legislative actions against the cannabis industry targeting teens or big tech.

 

[Dantes]

On a personal note, my non-psychiatric colleagues appreciate me most not because of my medical or psychiatric input but because of my expertise in psychosocial medicine. In my previous job I had numerous discussions and attended many meetings about complex patients to which I was invited because I could explain the puzzling behaviors in their patients in a way that made sense, validated the teams most primitive feelings, and led to concrete action. I was also frequently sought out to consult on complex ethical and risk management dilemmas. There will always be a place for physicians who understand and integrate the biomedical, psychological, sociocultural, ethical and medicolegal dimensions of care. Psychiatrists can fill that role. Or we can attempt to be a simulacrum of a stereotypical physician and condemn the field to obsolescence.

Interesting read. Do you feel that this skill is unique to psychiatry? Could clinical psychologists also fill this role, for a cheaper price from the perspective of the MBAs upstairs? Genuine question coming from an outsider. A common opinion I see is that what sets psychiatry apart is the diagnosing and prescribing in the context of other medical issues, with the rest being handled by psychology and social work.

 

[dl2dp2]

We may say "statistically the is the single hardest time in modern human history to be an adolescent" (which it is), but this is always followed by "be that as it may, this is the how the cards have been dealt so we are going to do XYZ about it".

Is it really tho? Abraham Lincoln had 4 sons and 3 died in childhood or adolescence. These statements are a problem when they are thrown out willy-nilly as if we psychiatrists are pushing against some broad social collapse when in reality the statements are just rapport-building window-dressing. Embedded goals of treatment become politics-laden. You make the assumption that there's a "right way" and a "wrong way", and the right way is less cannabis and less Tiktok. Are you sure? Is this backed by technical knowledge or is this heresy? And is your treatment really effective for whatever social ill you claim is causing how "difficult" a time adolescents are having?

If all your value as a pediatric psychopharmacologist is to treat the problem of cannabis and tiktok, why not just have a peer counselor do your work? No-- your value is diagnosing autism and adhd (really making a high-impact *judgment call* because these criteria are rough sketches), prescribing very carefully meds that have substantial side effects and discussing very complex risks and benefits, and designing a highly complex, comprehensive psychosocial interventions that most peer counselors don't have a clue how to do. I don't know of a single CAP who has a case that's not a complete trainwreck for a non-specialist. Do you? All of this would be impossible to do regardless of the existence of cannabis and Tiktok.

Your value isn't your recognition that there are psychosocial environmental contributions to psychopathology. Every soccer parent can speculate about that and make their opinion known. Your value is the technical specialization that allows you to deal with complex cases and the certification that allows you to declare your expertise in a credible way --- vis-a-vis a broad, perhaps "incorrect" way to define "prestige".

Think about this for one more second. If your logic holds any water, in a jurisdiction where cannabis and Tiktok are banned, the pediatric psychopharmacologist would be out of a job? Do you REALLY want that world? And yet many of our colleagues bend over backward to convince themselves and others that HAD the social problems been SOLVED, their jobs would be "SO much easier" (you know exactly what I'm talking about). They say it say it ("so many people I see don't really need a psychiatrist, they need housing and support", blah blah) and everyone else nods along in groupthink, except that this damages our field in the long run. LOL No this has little to do with petitioning the legislature.

 

[SmallBird]

Interesting read. Do you feel that this skill is unique to psychiatry? Could clinical psychologists also fill this role, for a cheaper price from the perspective of the MBAs upstairs? Genuine question coming from an outsider. A common opinion I see is that what sets psychiatry apart is the diagnosing and prescribing in the context of other medical issues, with the rest being handled by psychology and social work.

I just don't think that's how it works. When I have participated in situations like this, the ability to understand the biomedical aspects of the case combined with having a framework for making sense of the patients behavior has been of value. This comes up a lot with capacity evaluations where an ability to understand the importance and invasiveness of the intervention influences the assessment. But psychologists can contribute in unique ways as well. I have worked in several systems and the approach to hiring has recognized the value of a mix of people with various levels of training and expertise, with an overall trend towards trying to hire less expensive people, but I've never seen it micromanaged to the extent that an 'MBA upstairs' is saying that a psychiatrist shouldn't be participate in complex care discussions.

 

[comp1]

Unfortunately I get a kind of navel gazing vibe from this thread's line of thought. The good news for anyone interested in the specialty is that this sort of thing is rarely an issue day to day in psych...

 

[SmallBird]

Unfortunately I get a kind of navel gazing vibe from this thread's line of thought. The good news for anyone interested in the specialty is that this sort of thing is rarely an issue day to day in psych...

The practical translation is questions of what your scope of engagement should be with a patient, how many tasks you should try accomplish, how much time you need to spend, to what extent you will consider things other than their dose and response to medication... it feels central.

 

[Sushirolls]

Good psychiatrists understand, bad psychiatrists just focus on "is the med working?"

Not gonna lie. Too much writing in this thread. Didn't read much of anything.

Psychiatry really is simple - function. It is the core of the diagnostic criteria's, impaired function. Are people not functioning as well?

We strive to assist people in functioning better/more. Or we point people to options that might. I don't get bogged down by the heady, philosophical weeds anymore with which to shine a magnifying glass on the roles of our field. Our field, our role, is relevant. We help people function better/more. That's how I explain what I do to my young child.

 

[vespers]

Unfortunately I get a kind of navel gazing vibe from this thread's line of thought. The good news for anyone interested in the specialty is that this sort of thing is rarely an issue day to day in psych...

Disagree with handwaving these things with the “navel gazing” descriptor. They’re deep questions worth contemplating, and where you land on some of this stuff will shape your practice and teaching.

For what it’s worth, dl2, I feel that you’ve made some good and interesting points between these two threads despite your bizarre and kinda aggressive energy and your refusal to write coherently.

 

[Merovinge]

Is it really tho? Abraham Lincoln had 4 sons and 3 died in childhood or adolescence. These statements are a problem when they are thrown out willy-nilly as if we psychiatrists are pushing against some broad social collapse when in reality the statements are just rapport-building window-dressing. Embedded goals of treatment become politics-laden. You make the assumption that there's a "right way" and a "wrong way", and the right way is less cannabis and less Tiktok. Are you sure? Is this backed by technical knowledge or is this heresy? And is your treatment really effective for whatever social ill you claim is causing how "difficult" a time adolescents are having?

If all your value as a pediatric psychopharmacologist is to treat the problem of cannabis and tiktok, why not just have a peer counselor do your work? No-- your value is diagnosing autism and adhd (really making a high-impact *judgment call* because these criteria are rough sketches), prescribing very carefully meds that have substantial side effects and discussing very complex risks and benefits, and designing a highly complex, comprehensive psychosocial interventions that most peer counselors don't have a clue how to do. I don't know of a single CAP who has a case that's not a complete trainwreck for a non-specialist. Do you? All of this would be impossible to do regardless of the existence of cannabis and Tiktok.

Your value isn't your recognition that there are psychosocial environmental contributions to psychopathology. Every soccer parent can speculate about that and make their opinion known. Your value is the technical specialization that allows you to deal with complex cases and the certification that allows you to declare your expertise in a credible way --- vis-a-vis a broad, perhaps "incorrect" way to define "prestige".

Think about this for one more second. If your logic holds any water, in a jurisdiction where cannabis and Tiktok are banned, the pediatric psychopharmacologist would be out of a job? Do you REALLY want that world? And yet many of our colleagues bend over backward to convince themselves and others that HAD the social problems been SOLVED, their jobs would be "SO much easier" (you know exactly what I'm talking about). They say it say it ("so many people I see don't really need a psychiatrist, they need housing and support", blah blah) and everyone else nods along in groupthink, except that this damages our field in the long run. LOL No this has little to do with petitioning the legislature.

Firstly, modern era I use interchangeably with post industrial era. Honest Abe's children's struggles notwithstanding. Clearly for 99.9999% of human history there was more death and disability among adolescents (although likely mental health itself was better). I think overall human kind has done a pretty remarkable job.

Second, yes I am confident to a reasonable degree of medical certainty that the longitudinal data on the detriments of THC use in adolescence is overwhelming, unless you would also like to argue that smoking cigarettes doesn't cause lung cancer. Of course my job would not go away if these two things changed, the fact that you can write that much about two specific stressors and somehow think that is the entirety of the argument is a bit baffling/reductive.

Third, I actually want to see youth live good lives. It core to my beliefs as a person and what I have dedicated by life's work towards. I know that happening to the point of putting my out of a job is not actually going to happen, but it doesn't mean that I wouldn't like to see progress in that domain.

Forth, my value as a person is that I actually help make children's life demonstrably better with less impairment in function. People will always pay for that, and unlike most of what people pay for to try and juice the system for their kids, we have science and data to back up things that work.

 

[whopper]

the claim was made that psychiatry must concern itself with "diseased brains" and biomedical interventions to maintain its moral authority as a medical specialty.

If someone wants to make this claim and make it a philosophical pillar in our field, I'd tell them show me the evidence. No ego, I want evidence. Otherwise your opinion is like your anus. I know you got one but you don't necessarily have to show it to me.

 

[G Sheb]

I think good pharmacologic management is actually much more difficult than the overwhelming majority of other specialties. Much of IM is done via algorithm, whereas I have to make decisions on a daily basis about which medication with roughly equivalent research findings make the most amount of sense. The mechanisms of action can be very diverse for treating the same problem - anxiety being impacted by 5HT reuptake, binding at specific 5HT subreceptors, GABA agonism (hopefully very rarely), Ca channel changes, heart rate/blood pressure modifiers and also making sure the patient's psychotherapy is being done appropriately, their sleep is good, and they have a form of exercise that fits their life.

It might be because I have spent much of my career taking care of a sicker population, but if your BP does not come down after 2 agents, it is quite easy to figure out the next step. When your anxiety does not come down after 2 different well trialed SSRIs, it is not nearly as straightforward.

When my partner prescribes medication to patients it's typically try this med, does it work? If not maybe we have one other med. If that doesn't work you suck it up or you get surgery. For me at least, the impetus is to keep trying every 1st, 2nd, 3rd and 4th line med possible and you only rarely stop with that unless its clear there are other reasons for medication to not be effective.

But this is actually why I think psychopharmacology is less challenging in the technical and medical sense.
Becuase the algorithms are non-existent and almost 'anything goes', and basically everyone makes up their own interpretation of the data and their 'experience' prescribing x or y.
Algorithms may be mechanical, but they can also be extremely complex, and make diagnosis even more imperative. To come up with algorithms you also need a strong evidence base and lots of research.
For example, if we have actual criteria why we should prescribe zyprexa rather than abilify for someone with schizophrenia, then you would argue the technical complexity increases.
Not saying the field of completely devoid of this, but the technical aspects aren't as rigorous.

 

[G Sheb]

Is it really tho? Abraham Lincoln had 4 sons and 3 died in childhood or adolescence. These statements are a problem when they are thrown out willy-nilly as if we psychiatrists are pushing against some broad social collapse when in reality the statements are just rapport-building window-dressing. Embedded goals of treatment become politics-laden. You make the assumption that there's a "right way" and a "wrong way", and the right way is less cannabis and less Tiktok. Are you sure? Is this backed by technical knowledge or is this heresy? And is your treatment really effective for whatever social ill you claim is causing how "difficult" a time adolescents are having?

If all your value as a pediatric psychopharmacologist is to treat the problem of cannabis and tiktok, why not just have a peer counselor do your work? No-- your value is diagnosing autism and adhd (really making a high-impact *judgment call* because these criteria are rough sketches), prescribing very carefully meds that have substantial side effects and discussing very complex risks and benefits, and designing a highly complex, comprehensive psychosocial interventions that most peer counselors don't have a clue how to do. I don't know of a single CAP who has a case that's not a complete trainwreck for a non-specialist. Do you? All of this would be impossible to do regardless of the existence of cannabis and Tiktok.

Your value isn't your recognition that there are psychosocial environmental contributions to psychopathology. Every soccer parent can speculate about that and make their opinion known. Your value is the technical specialization that allows you to deal with complex cases and the certification that allows you to declare your expertise in a credible way --- vis-a-vis a broad, perhaps "incorrect" way to define "prestige".

Think about this for one more second. If your logic holds any water, in a jurisdiction where cannabis and Tiktok are banned, the pediatric psychopharmacologist would be out of a job? Do you REALLY want that world? And yet many of our colleagues bend over backward to convince themselves and others that HAD the social problems been SOLVED, their jobs would be "SO much easier" (you know exactly what I'm talking about). They say it say it ("so many people I see don't really need a psychiatrist, they need housing and support", blah blah) and everyone else nods along in groupthink, except that this damages our field in the long run. LOL No this has little to do with petitioning the legislature.

But aren't you contradicting yourself right there?
If you think part of his expertise is designing 'highly complex psychosocial interventions', then why would you want to limit his role to the biological aspects?

The problem with your argument is not the focus on the biological per se but:
- it's not clear that this focus will make the field more technical. After 30 years of intensive biological psychiatry research, there's barely anything to show for it. You can keep pinning your hopes on this, but the reality is that the field is NOT there yet and will not be in the near future. The brain is simply too complex. You're just selling a pipe dream and ironically most of the time when the field oversells 'technical aspects', it's usually based on shoddy science. (psychoanalysis, 'chemical imbalance', bla bla). Now unless you're also advocating selling snake oil, but that;s a different story.

- a singular focus on the biological will not address mental illness optimally and may paradoxically lead to invalidating the specialty. I think that's the core of the argument that splik is making. Psychiatry, pretty much by definition, cannot restrict itself to the 'diseased brain', or it becomes neurology.


I remember I had a case as a PGY-4. I was actually working under the supervision of a very renowned physician scientist in biological psychiatry. The pt had a gambling disorder and bipolar, and the team had given up any hope of him taking medications though he says he's willing to engage in supportive therapy.
After 5/6 months of working with that guy, I was very careful not to push medications. I used the skills I learned in my therapy training. How to maintain a holding environment, how to make someone feel heard and validated.
By the end of the year, the guy agreed to start an antipsychotic.
If I didn't have that 'other' training, the work simply could not have succeeded.

 

[Candidate2017]

Our power and curse is too much introspection and navel gazing. Do endocrinologists bemoan that insulin is useless because all their patients have sugars in the 600s? Do ID doctors bemoan there are no real advances since PCN, and all they have are Vanco and Zosyn? Do cardiologists bemoan the NNT for statins is quite high?

The fact is our meds, by themselves, work quite well for psychosis and mania. Somewhat less well for depression and anxiety, but a much lower NNT than other meds. I am happy at what I can accomplish by meds alone or meds plus therapy. Some patients get much better, some improve, some merely stabilize, some settle into a chronic slow decline, some precipitously crash and die. That is all of medicine. I accept my job is not to solve free will, poverty, homelessness, shootings, crime, stupidity, humans being humans, etc.

Anyway, our specialty was born in the asylum. A protective place with work, exercise, nature, medications, paternalism. Those things worked well, so well that society started to drop everyone into the asylum and destroyed it with overcrowding. Psychiatry works less well when it expands outside the asylum into society, or when society intrudes into the asylum.

 

[clausewitz2]

But this is actually why I think psychopharmacology is less challenging in the technical and medical sense.
Becuase the algorithms are non-existent and almost 'anything goes', and basically everyone makes up their own interpretation of the data and their 'experience' prescribing x or y.

I don't think this follows it all. If "technical" is defined strictly as memorizing a fixed body of knowledge or a logical-deductive system, then yes, psychopharmacology is not super technical.

If we get back to techne, the sort of knowledge that a craftsperson has about their art, psychopharmacology is this in spades. Lack of obvious and context-independent correct answers does not make something less complicated or challenging.

Cf. a prototypical craft, like, say, blacksmithing. It is the case that if you want to know how to make, say, a steel helmet, you can look up a number of steps that have to be done to transform impure iron ore into the finished product you can attach a chinstrap to. You can find illustrated guides to this allowing you to better visualize these steps, and there is certainly a body of knowledge about what sorts of conditions and approaches tend to work out the best. You could study up on all of this and have the relevant details memorized in a a day or two, tops.

This does not actually make you a master blacksmith.

There are so, so, so many decisions and nuances and frankly unarticulated hard-won experience that shape how you will do this if you plan to do it well. If we are talking about the difficulty of transmitting and acquiring the relevant knowledge, it is dramatically more complex than an explicit algorithm. If you are making decisions by flipping a coin or via throwing darts at a formulary, sure, much less challenging.

Rigor is in many instances an attempt to make something clearer and simpler in a useful way, and so rigor can definitely have the effect of making things less complex if in its absence you really do have to take a much bigger plethora of variables into account.

 

[FlowRate]

This is a straw man. There's a bidirectional relationship between prestige and its associates and economic value by definition. You can't really rebuff either a logical tautology or you are simply saying that you *wish* it wasn't true. Whether mental illness is a "brain disease" is a secondary post hoc discussion specific to somatic treatments. One can say [some part of] psychiatry is a subspecialty of "supratentorial neurology" which certain meds you prescribe affect...and physician in that subsection of psychiatry commands greater prestige...etc. this is all a shell game. You are arguing against semantics. I hope my point is clear on this. Viewing [some] mental illness as a brain disease is a global "theory" or "hypothesis" to create a context whereby some progress can be made in some specific ways. This can't be false by definition or your interpretation is too broad.

Secondly, the link between sentences 1 and 2 are not logical, e.g.:
1. mental health can be brain diseases
2. treatment can yet be psychological, social, etc. as long as they are subjected to rigorous scientific testing

This is an argument that "antipsychiatry" philosophy doesn't really appreciate and err on. Like the claim is that the necessary implication that the only solution to brain diseases is med or medical procedure. This completely contradicts the prevailing knowledge about every single other specialty of medicine. The beef isn't the treatment isn't med or procedure, it's that 1. subjected to rigorous testing, and in fact it's "not testable"-- though that is even somewhat a secondary concern, as many procedures aren't rigorously tested (i.e. surgery); 2. there's no special expertise required to deliver the psychological, social interventions, or the expertise can be gained with less training.




I'm not saying you are wrong. I'm saying that no institutional player will pay you [well enough for you to not burn out on the aggregate] to fill that role, unless you make yourself somehow ultra-specialized enough to create a certificate program for "psychological, sociocultural, ethical and medicolegal dimensions of care" that requires MD level training.

Some subspecialties of psychiatry have that flavor. For example, forensic psychiatry is not biomedical at all. Yet it commands great pay and prestige because it has substantial technical expertise in "socialcultural, ethical and mediocolegal" dimensions.

Labels aren't that interesting in that way. You can look like a "physician" and quack like a "physician", but at the end of the day it's the specialized nature of your knowledge base that really matters for "prestige". Radiologists don't look like "physicians". Physician executives don't look like "physicians". Typically this doesn't drive the field into "prestige" vis-a-vis "obsolescence". Things that don't move forward drive a field into obsolescence. The problem with psychosocial interventions is that they aren't moving forward very much. Sometimes it's because it's not tested or tested correctly. Often it's political (the proverbial psychiatrists don't write enough grants). They aren't perceived as attractive and innovative and they don't require significant training for greater feasibility and efficacy. It's not that they don't work, or that they make you look "less like a physician". These are related issues, but ultimately they are symptoms rather than the cause. It's more about the barrier of entry is not high enough. If you can create a regulatory barrier and reimbursement framework that would pay for a stipulated set of complex psychosocial interventions that only MDs can deliver, it will immediately become less "obsolete" and more "prestigious". But, as I said before, very few psychiatrists are interested in THAT kind of work. They wish someone else did that work for them and just give them the prestige free of charge.

I'm just the messenger who's telling you that you are SOL if you have the delusion that this will happen automatically.




Yes, and this is technical. Technical need not be "hard science", and that in itself is poorly defined. Corporate lawyers get paid great and have great prestige, but they don't have any training in hard science. The problem I see is when psychiatrists go out of their way to say oh your son's problem is some part of the "broader" social ill that we can't do anything ABOUT in our role as MDs, EXCEPT some mass political action that happens at an uncertain timeline. Whenever this kind of thinking happens, it inevitably leads to burnout. And worse. Much MUCH worse. I don't like speculations, but to me I think this kind of thinking ACTUALLY leads to various problems "antipsychiatrists" indicate, like overstepping our role in social problems, medicalizing everything, giving us a "bad reputation", and will eventually lead to "obsolescence" etc. etc. because then what would differentiate between a psychiatrist from a garden variety political activist of any other cause? Professions that couple their welfare with political actions do NOT do well in general, and especially not in the USA. Many many examples which I won't enumerate here to create more controversy but I think everyone knows what I'm talking about.

Please correct me if I'm putting words in your mouth but, trying to simplify and strongman your position, I think you're laying out something like:

1. Reimbursement (whether direct or via an employer/institution) is driven, in some large part, by "prestige" which is a term you're using slightly idiosyncratically to mean some combination of, but not limited to: demand, public perception, capability, credential, effectiveness, uniqueness.
2. There are aspects of psychiatric practice which can be handled by more focused/less-trained (duration of training)/more available (number of people) professionals
3. Therefore, incentives are aligned such that psychiatrists should define/master/emphasize the unique capabilities of the psychiatric profession, especially capabilities with proven (rigorously/scientifically) effectiveness, if they want to maximize prestige (reimbursement/demand/reason for existing separate from other professions)

Then, based on that line of logic, there are aspects of psychiatric work, as it exists today, that you suspect will/should/are falling out of the domain of psychiatry. This loops way back to your comment about seeing the field split into at least two camps, one more "biological" and another more "sociocultural" (I do not think I'm precisely recalling the exact split you enumerated/terms you used and I'm also not sufficiently motivated to go look that post back up at the moment with just a few minutes before my next patient.)

--

And that's where some of us disagree, at least to a point. People who are able to integrate knowledge/skill/expertise from multiple domains are often highly valued (prestigious). This can range from how having very solid therapy skills/foundation/understanding can help you better direct your patients to relevant therapies/therapists to splik's example of how part of the value of C/L is precisely that C/L docs are physicians first and not psychologists. (Have the core knowledge to significantly/fully grasp the medical situation.) Sometimes this is seen in VC, consulting, and business in general where having several different domains of expertise helps with creatively solving problems, evaluating technical feasibility of new startup technologies, etc.

 

[Merovinge]

And that's where some of us disagree, at least to a point. People who are able to integrate knowledge/skill/expertise from multiple domains are often highly valued (prestigious). This can range from how having very solid therapy skills/foundation/understanding can help you better direct your patients to relevant therapies/therapists to splik's example of how part of the value of C/L is precisely that C/L docs are physicians first and not psychologists. (Have the core knowledge to significantly/fully grasp the medical situation.) Sometimes this is seen in VC, consulting, and business in general where having several different domains of expertise helps with creatively solving problems, evaluating technical feasibility of new startup technologies, etc.

That's an excellent point, there are so many examples of extremely famous people who are that way because they were able to cross the chasm and wield multiple different areas of expertise. Danny Kahneman is a great example of a psychologist who ended up winning the Nobel prize in economics. Steve Jobs background in fonts of all things he highly credited to the success of Apple. The podcast People I Mostly Admire (my vote for best podcast) by Steven Levitt recurrently focuses on the split between generalists and specialists and often argues in favor of generalists when speaking to real thought leaders across disciplines.

 

[G Sheb]

I don't think this follows it all. If "technical" is defined strictly as memorizing a fixed body of knowledge or a logical-deductive system, then yes, psychopharmacology is not super technical.

If we get back to techne, the sort of knowledge that a craftsperson has about their art, psychopharmacology is this in spades. Lack of obvious and context-independent correct answers does not make something less complicated or challenging.

Cf. a prototypical craft, like, say, blacksmithing. It is the case that if you want to know how to make, say, a steel helmet, you can look up a number of steps that have to be done to transform impure iron ore into the finished product you can attach a chinstrap to. You can find illustrated guides to this allowing you to better visualize these steps, and there is certainly a body of knowledge about what sorts of conditions and approaches tend to work out the best. You could study up on all of this and have the relevant details memorized in a a day or two, tops.

This does not actually make you a master blacksmith.

There are so, so, so many decisions and nuances and frankly unarticulated hard-won experience that shape how you will do this if you plan to do it well. If we are talking about the difficulty of transmitting and acquiring the relevant knowledge, it is dramatically more complex than an explicit algorithm. If you are making decisions by flipping a coin or via throwing darts at a formulary, sure, much less challenging.

Rigor is in many instances an attempt to make something clearer and simpler in a useful way, and so rigor can definitely have the effect of making things less complex if in its absence you really do have to take a much bigger plethora of variables into account.

Yes, in any technical field, there's always room for individual judgement and variation.

But my point is different. I am pointing out almost relative lack of guidelines. That is not a point in favor of the 'technical' qualities of psychopharmacology. In the 21st century, one would have to strongly correlate technical with scientific. Lack of consensus points out to poor scientific validity. See the thread on TRD.

 

[clausewitz2]

Yes, in any technical field, there's always room for individual judgement and variation.

But my point is different. I am pointing out almost relative lack of guidelines. That is not a point in favor of the 'technical' qualities of psychopharmacology.

And my point is that lack of guidelines actually makes it harder to do well and requiring more learning of things that are very difficult to operationalize to the extent of being able to be put in an algorithm. We deal in the idiographic.

 

[dl2dp2]

Unfortunately I get a kind of navel gazing vibe from this thread's line of thought. The good news for anyone interested in the specialty is that this sort of thing is rarely an issue day to day in psych...

There is some utility, on a day-to-day basis, in marketing when your thoughts are clearer. Like, when people ask questions like why is your practice unique, that sort of thing. Why should I pay you for psychotherapy for $500 an hour when I can pay a PhD therapist for $200 and a social worker for $80. If your thoughts are unclear, you can't defend yourself convincingly. It's not because "there aren't enough social workers" and "if there were my job would be so much easier!" And it's not because "I think about getting people housing" or "kids these days have it so tough with Tiktok and cannabis". Dear god no. Do you understand now?

This kind of thing permeates a bit in salary negotiations, insurance contract negotiations, getting the right payer mix, getting the right patient assignment, getting rid of scut, dealing effectively with admin. All kinds of things are not medicine but is practiced about medicine.

I see people every day getting screwed because some random admin person be like "oh you know these people really just need better housing and social support... the meds are so straightforward anyway...maybe let's just get an NP to *help* you..." and you know where that goes. "Oh, we have psychologists here to do therapy ... and they are better trained in therapy than you!" etc etc.

You need to build this natural intellectual association between MD training - prestige - exclusivity - case complexity/technical demand - high economic value. This can mean hundreds of thousands of dollars in your career, and THEN some (power, leadership, lifestyle, flexibility).

Please correct me if I'm putting words in your mouth but, trying to simplify and strongman your position, I think you're laying out something like:

Then, based on that line of logic, there are aspects of psychiatric work, as it exists today, that you suspect will/should/are falling out of the domain of psychiatry. This loops way back to your comment about seeing the field split into at least two camps, one more "biological" and another more "sociocultural" (I do not think I'm precisely recalling the exact split you enumerated/terms you used and I'm also not sufficiently motivated to go look that post back up at the moment with just a few minutes before my next patient.)

--

And that's where some of us disagree, at least to a point. People who are able to integrate knowledge/skill/expertise from multiple domains are often highly valued (prestigious). This can range from how having very solid therapy skills/foundation/understanding can help you better direct your patients to relevant therapies/therapists to splik's example of how part of the value of C/L is precisely that C/L docs are physicians first and not psychologists. (Have the core knowledge to significantly/fully grasp the medical situation.) Sometimes this is seen in VC, consulting, and business in general where having several different domains of expertise helps with creatively solving problems, evaluating technical feasibility of new startup technologies, etc.

I don't think the way you describe is a useful way to split, and that's not what I proposed. It's more useful to split along services that actually correlate to your customer. I.e. a child psychiatrist who can see children and prescribe medication and has special training in pediatric psychotherapy would be in demand and prestigious because their particular combination of technical skills is especially useful for a particular high-demand customer base. It's less useful to get trained as a psychiatrist, but then get trained also as an insurance navigator and try to help your patients deal with insurance problems, even though the latter is very much a social-cultural issue that affects access.

In terms of public psychiatry, which was originally what initiated this whole conversation, you could train public psychiatrists to get people housing. You *could* do that. In fact, people have been doing that. But the irony of all irony is that when you do that, people "burn out". I wonder why this is? I don't think this is the way to go. I think public psychiatrists should be getting mini-MBAs and managing NPs. That's really their value-add. And in fact most public psychiatry "fellowships" are exactly like that, and if you get hired as a public psychiatry "medical director", all of a sudden you gain $, flexibility, prestige, etc.

As I said, forensic psychiatrists can charge $1000 an hour. They do little med management. Why IS that? You are missing the forest ("prestige") for the trees ("biological psychiatry"). Biology is ONE simplistic way to gain some aspect of prestige. It's not the only way. It may not even be the best way, but the goal, if you want to make psychiatry one of the best specialties well into the future ("avoid obsolescence"), is to focus on THAT which gives the semblance of prestige. To me this means technical hyperspecialization, attention to detail, and identifying seemingly boutiquey things that a lot of people really care about. It's definitely NOT trying to ameliorate poorly defined consequences of well known social ills. Whether we are talking about techniques in terms of biological psychiatry is less material to me.

Forth, my value as a person is that I actually help make children's life demonstrably better with less impairment in function. People will always pay for that, and unlike most of what people pay for to try and juice the system for their kids, we have science and data to back up things that work.

Sure, but why are you paid way more than, say, a good teacher? People are paying for expertise and exclusivity.

And my point is that lack of guidelines actually makes it harder to do well and requiring more learning of things that are very difficult to operationalize to the extent of being able to be put in an algorithm. We deal in the idiographic.

There are some algorithms, but the technical aspect is the technical aspect of complex discussions on topical areas that are tangentially affected by the science. E.g., being able to talk to parents well about meds is highly *technical*. It takes a lot of practice. It's not a science. It may never become a science. But it's still highly technical.

 

[FlowRate]

if you want to make psychiatry the best specialty well into the future ("avoid oblescence"), is to focus on THAT which gives the semblance of prestige. To me this means technical hyperspecialization.

Although I explicitly stated that I wasn't certain I recalled your suggested split and rather tried to describe the concepts you laid out more abstractly at first, with the split part clearly being just an example means of splitting the field, it looks like you took issue only with that part of my post. You might see how your first post in that thread seemed to indicate that was part of your argument:

Disagree. The reason that psychiatry pivoted to biological is that psychosocial interventions had been "trialed" for many hundreds of years. In fact, you can plausibly argue that psychosocial interventions are not scientific. Luminaries in the field are trying to make it more scientific, so to speak, but this is not a clean process at all. The only intervention that reliably reduces psychosis is antipsychotic medications/ECT, and you know how effective they are on average. In specific, incidental cases, they can be life-changing.

Psychosocial interventions are low prestige and low effect size. This is generally true throughout all medicine. You can say okay CBT works better than antidepressant meds for X. Sure. But really what it says is that CBT is equally INEFFECTIVE as meds are for X. Compared to large effect size interventions (i.e. clozapine, ECT, addiction meds, ADHD meds), therapy is at best adjunctive, and often do nothing (several large trials show this type of results).

If we had no meds and other somatic treatments, you'd get paid less, the residency programs won't be that competitive. Cash practices won't be nearly as widespread (demand won't be there), and the practice would be much more usurped by "mid-levels". So you can't really complain about both (low-prestige/mid-level penetrance and lack of access/indigent patients being aggressive) at the same time. If you want to be high prestige you need to be scientific, technical, exclusive (small number of physicians capable of delivery), and (hopefully) large effect size. I can't think of a single high-prestige effort in medicine that isn't like this.

I think psychiatry needs to split more (and this is indeed the tendency here in the real world). More "procedural"/"medical"/"specialized" subspecialties (child/addiction/"interventional", etc.) will be much more focused. Training on TMS, stellate ganglion, ketamine, other psychedelics, other somatics (obesity meds, hormone) will become more widespread. Psychotherapy-focused specialists would have their own subspecialty for "cosmetic/existential psychiatry", as most analytic institutes shut down and only the highest prestige ones remain and only take a handful of MDs a year. General psychiatry/public health-focused portions will include more management/business school curricula on training "mid-levels" on the delivery and budgeting of psychosocial interventions effectively. These pathways will become more formalized, even though as is they kind of already are (i.e. people who want to practice "cosmetic" need to match into a handful of programs that have analytic institutes, a wealthy patient base, etc). The future of psychiatry is that if it really wants to be "the new derm" it needs to act more like it.

And I think I recalled pretty well because you do state that at least one type of psychosocial intervention (elite branded psychoanalysis) can be high prestige and move toward the hyperspecialization point, if somewhat indirectly, by the very end of that post.

 

[dl2dp2]

Although I explicitly stated that I wasn't certain I recalled your suggested split and rather tried to describe the concepts you laid out more abstractly at first, with the split part clearly being just an example means of splitting the field, it looks like you took issue only with that part of my post. You might see how your first post in that thread seemed to indicate that was part of your argument:


And I think I recalled pretty well because you do state that at least one type of psychosocial intervention (elite branded psychoanalysis) can be high prestige and move toward the hyperspecialization point, if somewhat indirectly, by the very end of that post.

Yes exactly, the issue is not this duality of biological vs. psychological psychiatry. This duality is used as a straw man argument a LOT. It's a simple straw man and people can pile on easily. Specific kinds of psychotherapy can be very technical and "high prestige" (i.e. psychoanalysis, complicated, specialized therapy for various specific indications), and certainly tailored therapy specifically to various sick populations that are already on meds, etc. But many kinds of psychosocial interventions are, let's be honest here, low prestige. And we should absolutely get rid of them in our practice.

 

[finalpsychyear]

Almost all medical professionals are only relevant because of the self inflicted wounds humans foolishly inflict upon themselves through poor nutrition, lack of exercise, poor sleep, addictions to phones/various substances/tv.

Diseases in nature vs diseases in the zoo can tell you we are only to blame for almost everything. The cause and the cure are sourced from within.

 

[clausewitz2]

Almost all medical professionals are only relevant because of the self inflicted wounds humans foolishly inflict upon themselves through poor nutrition, lack of exercise, poor sleep, addictions to phones/various substances/tv.

Diseases in nature vs diseases in the zoo can tell you we are only to blame for almost everything. The cause and the cure are sourced from within.

You could probably drastically reduce the incidence of all manner of lifestyle diseases by just abandoning agriculture and going back to hunter-gatherer-trapper type subsistence economies. We'd be so much healthier.

...or at least the median survivor would be, y'know, once the billions of people who could no longer be fed all starved to death.

 

[calvnandhobbs68]

Almost all medical professionals are only relevant because of the self inflicted wounds humans foolishly inflict upon themselves through poor nutrition, lack of exercise, poor sleep, addictions to phones/various substances/tv.

Diseases in nature vs diseases in the zoo can tell you we are only to blame for almost everything. The cause and the cure are sourced from within.

United States: child mortality rate 1800-2020 | Statista

The child mortality rate in the United States, for children under the age of five, was 462.9 deaths per thousand births in 1800.

www.statista.com

 

[G Sheb]

Yes exactly, the issue is not this duality of biological vs. psychological psychiatry. This duality is used as a straw man argument a LOT. It's a simple straw man and people can pile on easily.

Whether we are talking about techniques in terms of biological psychiatry is less material to me.

OK, it seems that your gripe here is specifically towards public advocacy and public funding.
I think that's what it is all about.

Where you stand on this is purely a matter of values and why you signed up for a career in psychiatry in the first place.

I would like to think that being passionately involved in the well being of our patients is how we fight burnout, and that includes public advocacy and these 'low prestige' interventions which could help our patients lead better lives. This has little to do with expertise though, as we're uniquely positioned as experts to address the biological, the subjective and the social.

I'm not really sure if running around, being all 'technical' trying to help a patient who's in and out of the hospital (because they can't get housing and they decompensate the moment they step out) is how you actually fight burnout.

 

[dl2dp2]

OK, it seems that your gripe here is specifically towards public advocacy and public funding.
I think that's what it is all about.

Where you stand on this is purely a matter of values and why you signed up for a career in psychiatry in the first place.

I would like to think that being passionately involved in the well being of our patients is how we fight burnout, and that includes public advocacy and these 'low prestige' interventions which could help our patients lead better lives. This has little to do with expertise though, as we're uniquely positioned as experts to address the biological, the subjective and the social.

I would remove "public". I care about private advocacy of private funding just as much if not more. It is definitely a matter of values. The career I personally value is one of the specialists who practice precise, high-quality, technical medicine and one that affords a good lifestyle, high pay, and good flexibility and ownership. I don't personally value a career that's involved at all in public (or private) advocacy of low-prestige interventions. This is why I think there should be a "split", and there is already a split at the fellowship level. Again, just because I don't want to do X, doesn't mean X isn't virtuous or valuable at large. I don't want to be a public school teacher, but public school teachers are obviously valuable.

One major reason that I don't personally value that track is that, ironically, in my experience, people who claim that they are "passionately involved" in this type of effort are the ones who burn out first. I'm sure some of you also have similar experiences. People aren't happy with facilities jobs, CHMC jobs, especially when they entered with idealism, etc.

 

[G Sheb]

And my point is that lack of guidelines actually makes it harder to do well and requiring more learning of things that are very difficult to operationalize to the extent of being able to be put in an algorithm. We deal in the idiographic.

It's 'harder' yes (as subjective as this is), but it's not more 'technical' imo if you can't back it up with science.
If a disproportionate number of decisions end up because you make it up on your own (i.e reading articles and coming to your own conclusion, without somehting of a scientific consensus even for basic questions (i.e what to do when you fail an SSRI) - or from 'experience', or 'learning' - whatever that means), it is not more 'technical' IMO, by 21st century standards. It's harder in the sense it's frustrating and probably fruitless IMO.

 

[G Sheb]

I would remove "public". I care about private advocacy of private funding just as much if not more. It is definitely a matter of values. The career I personally value is one of the specialists who practice precise, high-quality, technical medicine and one that affords a good lifestyle, high pay, and good flexibility and ownership. I don't personally value a career that's involved at all in public (or private) advocacy of low-prestige interventions. This is why I think there should be a "split", and there is already a split at the fellowship level. Again, just because I don't want to do X, doesn't mean X isn't virtuous or valuable at large. I don't want to be a public school teacher, but public school teachers are obviously valuable.

One major reason that I don't personally value that track is that, ironically, in my experience, people who claim that they are "passionately involved" in this type of effort are the ones who burn out first. I'm sure some of you also have similar experiences. People aren't happy with facilities jobs, CHMC jobs, especially when they entered with idealism, etc.

Yes, it's absolutely a matter of priorities.
It also depends on where you are in your career, and what works for it and what doesn't (not making judgements).
I do not think though these 'low prestige' interventions which are likely very efficacious are going to drop the salaries of psychiatrists employed in large systems, and I do think it will help them fight burnout.

 

[SmallBird]

I see people every day getting screwed because some random admin person be like "oh you know these people really just need better housing and social support... the meds are so straightforward anyway...maybe let's just get an NP to *help* you..." and you know where that goes. "Oh, we have psychologists here to do therapy ... and they are better trained in therapy than you!" etc etc.

In what setting do you have daily exposure to this phenomenon?

 

[smalltownpsych]

In what setting do you have daily exposure to this phenomenon?

I think he might be talking about the US healthcare system. 😉
I do think this has been a fruitful discussion and agree that formulating our value is essential and also how to best place our energies and skills. I agree with the contention that it is risky for either psychiatry or psychology as a field to get too involved in political advocacy. I think that’s how social work started and they ran like hell from that arena as soon as they realized treating patients paid better.

 

[clausewitz2]

It's 'harder' yes (as subjective as this is), but it's not more 'technical' imo if you can't back it up with science.
If a disproportionate number of decisions end up because you make it up on your own (i.e reading articles and coming to your own conclusion, without somehting of a scientific consensus even for basic questions (i.e what to do when you fail an SSRI) - or from 'experience', or 'learning' - whatever that means), it is not more 'technical' IMO, by 21st century standards. It's harder in the sense it's frustrating and probably fruitless IMO.

We'll have to agree to profoundly disagree. I think making decisions based on the sum total of the body of available knowledge, scientific literature, careful observation, well-developed intersubjective intuition, personal experience, and practical wisdom (phronesis for all you Aristotle fans out there) is more complex and difficult to pull off than 'read the algorithm do the algorithm.' You feel differently.

All I will say is that the reason orbital mechanics is capable of far more explicit numerical analysis than psychotherapy is not because asteroids are more complex than people.

 

[SeniorWrangler]

In my experience, prestige is directly related to money, and money is related mostly to how the health care system is designed.
Trying to overthink it is just going to get you confused and frustrated. A spine surgeon doing a useless three-level fusion on a 28 year old patient with generic back pain is going to make much, much more than a psychiatrist will for saving someone's life. It's just how it works. There is no judgement involved, nobody saying that psychiatrists aren't real doctors, in fact nobody gives psychiatrists much thought.

 

[Stagg737]

Five factors seem particularly relevant.

You only named 4... (curious if there was another you forgot)

On a personal note, my non-psychiatric colleagues appreciate me most not because of my medical or psychiatric input but because of my expertise in psychosocial medicine. In my previous job I had numerous discussions and attended many meetings about complex patients to which I was invited because I could explain the puzzling behaviors in their patients in a way that made sense, validated the teams most primitive feelings, and led to concrete action. I was also frequently sought out to consult on complex ethical and risk management dilemmas. There will always be a place for physicians who understand and integrate the biomedical, psychological, sociocultural, ethical and medicolegal dimensions of care. Psychiatrists can fill that role. Or we can attempt to be a simulacrum of a stereotypical physician and condemn the field to obsolescence.

I just don't think that's how it works. When I have participated in situations like this, the ability to understand the biomedical aspects of the case combined with having a framework for making sense of the patients behavior has been of value. This comes up a lot with capacity evaluations where an ability to understand the importance and invasiveness of the intervention influences the assessment. But psychologists can contribute in unique ways as well. I have worked in several systems and the approach to hiring has recognized the value of a mix of people with various levels of training and expertise, with an overall trend towards trying to hire less expensive people, but I've never seen it micromanaged to the extent that an 'MBA upstairs' is saying that a psychiatrist shouldn't be participate in complex care discussions.

It would be nice to work in a system like this. I've attended these meetings during residency and a couple times in my current position, I can say that psychiatrist involvement is frequently completely unnecessary and my role has largely been to reinforce common sense. For the truly complex ethical and risk associated cases, we have an excellent IM physician with a focus on ethics who fills this role very well and she writes some of the best notes for those cases that I've seen. I'm not sure what kind of "puzzling behaviors" would require psychiatry's involvement regarding complex care on a medical floor where a psychiatrist is uniquely positioned to address this, but I'd be interested in examples if you're willing to share. I have found that administration wants psych involved in these cases and certainly allows for shift of liability to a certain extent, but I also feel that the vast majority of the time our role here is unnecessary.

While the advent of SSRIs and atypical antipsychotics no doubt changed psychiatric practice, there have been no major advances in the efficacy of psychopharmacological agents since the 1950s.

Kind of? We can argue that there haven't been advances here, but I think it that this we miss the many advances we have made because once we gain a better understanding the conditions are treated by other specialties. Anti-NMDA receptor encephalitis is a modern example, we didn't even know it existed until around 2007 and now we diagnose several hundred cases per year (I saw 2 cases in 1 month in residency). Yes, we may still be the ones seeing the initial presentation, but once a diagnosis is made neuro or rheum or insert specialty here takes over and it's no longer psych. I've had the discussion with many colleagues, but how many different conditions do we call schizophrenia now that may one day have clear unique medical diagnoses and treatments?

I'd argue the biggest failing of the biological aspect of our field, and also what makes psych so interesting to me, is that there is still so much undiscovered overlap here and that we are so quick to hand these patients off to other physicians for management once a diagnosis is made. Ie, from a pharmacological standpoint we've pigeonholed ourselves to be limited to "psychopharmacology" and relinquished the medical side of our expertise too easily.

I hold out hope that someday, neurology, computer science, and other disciplines will be able to describe consciousness in precise detail.

There may be a day when say, someone is feeling down and we can intervene by changing a brain circuit or something like flipping a switch. That sort of expertise may require a lot of technical and specialized understanding.

While this would be nice, I think the nature of the human experience as a whole is far too complex for this to be understood anytime soon (I'm talking about centuries) and agree that an understanding of the complex interaction of multiple (physiologic) human systems is necessary to move forward. While I do think psychosocial perspectives do play a significant role with many patients, I think we also underestimate

It's 'harder' yes (as subjective as this is), but it's not more 'technical' imo if you can't back it up with science.
If a disproportionate number of decisions end up because you make it up on your own (i.e reading articles and coming to your own conclusion, without somehting of a scientific consensus even for basic questions (i.e what to do when you fail an SSRI) - or from 'experience', or 'learning' - whatever that means), it is not more 'technical' IMO, by 21st century standards. It's harder in the sense it's frustrating and probably fruitless IMO.

While I appreciate what you're saying, I agree with Clause here and would argue against the need for 'scientific consensus' to optimize treatment. We don't need scientific consensus of evidence for that evidence to be true, even if we want to debate interpretation. Imo, understanding the patient and the existing evidence and applying that knowledge to formulate the best treatment plan requires far more technical expertise than just diagnosing and following guidelines.

 

[G Sheb]

While I appreciate what you're saying, I agree with Clause here and would argue against the need for 'scientific consensus' to optimize treatment. We don't need scientific consensus of evidence for that evidence to be true, even if we want to debate interpretation. Imo, understanding the patient and the existing evidence and applying that knowledge to formulate the best treatment plan requires far more technical expertise than just diagnosing and following guidelines.

Medicine cannot progress scientifically without rigorous, actual, objective data.
Personalized medicine does not mean non-evidence based medicine, or one where you just omit the rigor part.
Of course no amount of research will answer every single question. And you will always involve judgement and how to apply the scientific knowledge to individual cases.
But if most of your decisions are not based on actual objective data then you're pretty much practicing quackery.

Frankly I see this attitude in our field and I believe it's a bane that we encourage it and tolerate it. The reality we just don't have the data and we need to deal with what we have, but it's not something that we should encourage. See the thread about mania.
If anyone suggests to use a medication that has no evidence vs one with evidence because 'in their experience it doesn't work', they would be roasted in every other field of medicine.

 

[MedMan80]

So i made the right choice in psych

 

[allantois]

In my experience, prestige is directly related to money, and money is related mostly to how the health care system is designed.
Trying to overthink it is just going to get you confused and frustrated. A spine surgeon doing a useless three-level fusion on a 28 year old patient with generic back pain is going to make much, much more than a psychiatrist will for saving someone's life. It's just how it works. There is no judgement involved, nobody saying that psychiatrists aren't real doctors, in fact nobody gives psychiatrists much thought.

That patient will then need lifelong mental health services for chronic pain and depression

 

[mistafab]

One thing Dr. McHugh outlines in his book The Perspectives of Psychiatry is that fundamentally all fields start with phenomenological explanations/organizing (DSM type) of disease. Inevitably, as things progress forward and more knowledge is had, things become more mechanistic.

What Dr. McHugh outlines, in addition, is that diagnosis alone can be a therapeutic intervention. What psychiatrists do to clamor for the "biomarker" that some feel we may never find, is forget that there is a lot of healing that can be had without the biomarker. Also, that biomarkers don't necessarily correlate with distress or severity.

Needless to say, I am in the camp that we don't need diseased brains to be a real field. People really suffer, and many really die. Being "real" medicine is a matter of perspective.

 

[futureapppsy2]

One important thing is that it's fundamentally and empirically incorrect to say that non-pharmological interventions don't impact physiology. There's been studies, for example, that show that excess amygdala size in patients with OCD decreases following ERP. Likewise, behavioral and environmental inputs can affect physiological responses, of course. So, are mental illnesses at some level caused by physiological changes? Of course--after all, thought in general is physiological if you drill down deep enough into it. But that doesn't mean the only or most effective ways to address those changes are inherently pharmocological.

 

[Stagg737]

Medicine cannot progress scientifically without rigorous, actual, objective data.
Personalized medicine does not mean non-evidence based medicine, or one where you just omit the rigor part.
Of course no amount of research will answer every single question. And you will always involve judgement and how to apply the scientific knowledge to individual cases.
But if most of your decisions are not based on actual objective data then you're pretty much practicing quackery.

I don't disagree with any of this, but it doesn't change that we work with what exists and that we shouldn't always wait for "scientific consensus" to provide treatments when the evidence is slapping you in the face. We just spent the last 3.5 years dealing with this with COVID, where national protocols were made based on limited data before "scientific consensus" was reached. I'm not arguing against EBM, I'm questioning what you're considering to be EBM vs quackery.

Frankly I see this attitude in our field and I believe it's a bane that we encourage it and tolerate it. The reality we just don't have the data and we need to deal with what we have, but it's not something that we should encourage. See the thread about mania.

Not sure what attitude you're referring to or what you're referring to in the mania thread.

If anyone suggests to use a medication that has no evidence vs one with evidence because 'in their experience it doesn't work', they would be roasted in every other field of medicine.

Idk that anyone here has implied that, I certainly didn't. However, there's plenty of areas of medicine where things like this happen and both sides roast each other because of the gray zones in the evidence. Look at controversial conditions like leaky gut syndrome, adrenal fatigue, POTS, etc as well as basically the entire field of integrative medicine and associated treatment recommendations.

This is all slightly off-topic from the question of do we need a "diseased-brain" model, but it gets at the point of what does "evidence" mean and how do we look at and address conditions within our field (and medicine as a whole) when our data is either minimal or just inadequate/too mixed to have a "consensus" (the lamotrigine thread is a better example of this).

I'd argue that from a biological standpoint, we have made more progress than this thread would convey and that there are aspects of psychiatry which we will have "hard" biological/physiological answers to. I also think there will be areas of our field which will continue to have softer evidence (depression, anxiety, and most personality traits being the best examples) where more psychosocial approaches will continue to be necessary. I think the best direction of the field moving forward from both a nosological and deontological perspective is continuing to gain better understanding of what psychiatric/psychologic conditions are d/t relatively straightforward physiological processes and which are hopelessly complex biologically (or just non-biological depending on where your beliefs on consciousness and human experience lie) and deciding whether we will mainly concern ourselves with the non-biological and hand off "medical" illnesses (like encephalitides) to other fields or if we will continue to be the experts of "behavioral" medicine.

 

[Dantes]

Kind of? We can argue that there haven't been advances here, but I think it that this we miss the many advances we have made because once we gain a better understanding the conditions are treated by other specialties. Anti-NMDA receptor encephalitis is a modern example, we didn't even know it existed until around 2007 and now we diagnose several hundred cases per year (I saw 2 cases in 1 month in residency). Yes, we may still be the ones seeing the initial presentation, but once a diagnosis is made neuro or rheum or insert specialty here takes over and it's no longer psych. I've had the discussion with many colleagues, but how many different conditions do we call schizophrenia now that may one day have clear unique medical diagnoses and treatments?

I'd argue the biggest failing of the biological aspect of our field, and also what makes psych so interesting to me, is that there is still so much undiscovered overlap here and that we are so quick to hand these patients off to other physicians for management once a diagnosis is made. Ie, from a pharmacological standpoint we've pigeonholed ourselves to be limited to "psychopharmacology" and relinquished the medical side of our expertise too easily.

Interesting point as anti-NMDA was pretty recent. Do you think this will change or does psychiatry inherently operate within a black box?

 

[Stagg737]

Interesting point as anti-NMDA was pretty recent. Do you think this will change or does psychiatry inherently operate within a black box?

I don't know, but I do think it needs to be looked at and addressed by our field as a whole. Are we going to be the people who purely manage "psychiatric" concerns who pass the patient off if something more concrete and "medical" like an autoimmune etiology is identified? Will we continue to remain heavily involved in the care of those patient's because their "psychosis" and behaviors are primary symptoms? Should we lean into a more med/psych role and be the primary doc managing these patients and work with other specialties?

We've had a few threads now where this debate has come to the forefront and it's been happening for decades. Even just figuring out what to call ourselves has been a debate (psychiatry department? Department of behavioral sciences? Department of mental health? etc) as different names imply different roles. I currently work in a "department of psychiatry and behavioral sciences" for what it's worth. I think some people have pretty clear visions of where they feel our field should head (see dl2's posts about a divergence of services) while others are either more fluid or unsure.

Personally, I think we need to remain heavily involved in the cases which become "medical" (like anti-NMDA) as we're trained first as physicians and our ability to be involved with the behavioral and psychological symptoms of "medical" patients is where we truly hold a niche that other fields just cannot fill adequately. I do think this is an area where we should stand our ground as experts, but I know many psychiatrists simply aren't interested in being the ones responsible for this type of care. I know others will disagree and say that we should lean in to the psychological and social aspects of our patients, but I just don't see that as an area we are uniquely aligned to address (which I admit may be the result of my training). I'm not arguing that we shouldn't be involved in those areas, but I do contend that there are others who may address many of these aspects as well, if not better, than we can.