Joel Paris, MD, is a Professor in the McGill University Department o Psychiatry, and is Editor-in-Chief of the Canadian Journal of Psychiatry. His new book, Prescriptions for The Mind: A Critical View of Contemporary Psychiatry provides a “state-of-the-field” assessment focusing on the diverging roles of psychopharmacology and psychotherapy in contemporary practice. In the excerpt below Paris considers the limitations of psychopharmacology.
Within one generation, advances in drug therapy changed the way psychiatrists practice, and then the rate of progress slowed down. We would be shocked if internists treated every disease with an arsenal as limited as the one we have. In fact, most of the choices that psychiatrists have when they write prescriptions lie between standard agents and copycat drugs that the pharmaceutical industry is promoting to break into a lucrative market. Although some newer drugs are safer, we are still working with the same basic groups we had 30 years ago. Unfortunately, there is no reason to believe that psychiatrists are that much better at treating mental illness than they were then. Moreover, they are prescribing drugs far beyond what the evidence shows are their indications.
For as long as I can remember, our specialty has gone from one extreme to another. Forty years ago, psychiatrists who ‘‘believed’’ in psychotherapy made insufficient use of drugs—to the detriment of their patients. Today drugs are almost the only treatment psychiatrists offer, and they are prescribed routinely. A balanced view would at least try to differentiate between situations where drugs are essential and where they are optional (or unnecessary).
Prescribing drugs runs parallel to reducing the use of psychotherapy, even though the evidence for the effectiveness of talk therapies in milder or moderate forms of depression is just as strong as it is for the effectiveness of medications. When drugs and brief therapies are compared directly, they work equally well for many people. Moreover, a combination of medication and therapy has been shown to be more effective than either treatment alone. Drugs are most necessary when patients suffer from illnesses of greater severity.
We have known for many years that patients with depression are more likely to recover when offered a combination of drugs and psychotherapy (as opposed to either alone) (Klerman et al., 1974). Prescribing both forms of treatment ‘‘covers’’ both patients who mainly respond to medication and those who respond best to talk therapy. At the same time, the two modes of treatment have synergistic effects, targeting different aspects of depression (e.g., physical symptoms versus depressed thinking).
Drugs are most necessary when patients suffer from illnesses that are more severe. Yet research has shown that even in the treatment of those illnesses that absolutely require drugs (schizophrenia and bipolar disorder), cognitive-behavioral therapy offers added value for rehabilitation). Nevertheless, very few patients with psychotic disorders receive this or any other psychotherapy—the human resources are almost always lacking.
Given the scientific evidence, why do so many patients receive only drugs? Why do psychiatrists not even think of prescribing psychotherapy when patients fail to respond to medication or when the addition of psychotherapy is known to effectively augment a medical regimen?
… At least part of the answer lies in reductionist thinking about mental illness—and in the field’s hope that psychiatry, like other areas of medicine, will define specific diseases with unique responses to treatment, much as infections respond to specific antibiotics. Thus, the belief that, say, major depression is a unique disease supports the practice of giving antidepressants to any patient who meets criteria for that disorder—in spite of the evidence discussed above that results are not consistent.
Another part of the answer lies in the limitations of time and money, and in the human resources problem. It takes only a few minutes to write a prescription (although making sure the patient actually fills it and takes it might require a little more time), whereas psychotherapy, even the evidence-based brief therapies, take more time, a very scarce resource for psychiatrists and patients.
Most of all, it is the pharmaceutical industry that drives the practice of over-prescription. In their advertising, the companies always claim greater efficacy for newer drugs, pitching them to physicians who worry about being out of date. Yet many drugs whose patents have long since expired are excellent if used properly (for example, typical neuroleptics and tricyclic antidepressants).