Consciousness and how it got to be that way

Sunday, November 3, 2019

Editorial Clickbait about Psychiatry in the New England Journal of Medicine

I'm really disappointed in NEJM for publishing this piece by Gardner and Kleinman (G&K.) Overall this article is not helpful or useful. There is a cottage industry of psychiatrists writing hit pieces on our own specialty, and often they make coherent and actionable points that improve the specialty and ultimately patient outcomes. But of many valid criticisms of psychiatry, this article bizarrely focuses on two problems that pervade most of medicine, and implies that they are uniquely problems for psychiatry. The thesis seems to be that psychiatry has been damaged by reliance on a biological approach, which has stunted its ability to treat patients, and damaged our interactions with them by decreasing the quantity and quality of our interaction.

First: these two have apparently not been talking to many of their colleagues, inside and outside of psychiatry. How many physicians do you know, especially in cognitive specialties with lots of patient contact, who say "No, I don't have inappropriate time pressures on my patient interactions, and what pressures there are, are not worse than they were thirty years ago"? Most psychiatrists would love to spend more time with patients. When we don't, it's not because we've already gone through the checklist so we don't want to waste time forming rapport - it's due to the moral hazard introduced by the financial and administrative structure of modern medicine. The same argument obviously applies to many specialties outside of psychiatry.

The second part of their argument is that over-reliance on a biological approach is what has distorted psychiatry and prevented us from adequately treating patients. In case they haven't noticed, we do have psychiatric medications which work, that we didn't have a few decades ago. (They somehow fail to comment on the existence of SSRIs and second-generation antipsychotics, for example.) How is this the failure of a biological approach? It is trivially true that biological approaches to psychiatry have not yet been as fruitful as we would all like. The genomics revolution (for example) has also not benefited most branches of medicine to the degree hyped - yet. It's a bit premature to say that therefore, biological approaches like genomics have not yet benefited psychiatry and therefore will never benefit psychiatry. They have essentially not benefited any other branch of clinical medicine besides hem/onc - because it's easier to kill or poison certain cells (especially ones that are suspended structurelessly in fluid, rather than connected in a specific network, neural or otherwise) than it is to make them work better. We should expect that oncology would have been the first to benefit. In this G&K are rather like engineers in 1900 saying "we haven't achieved powered flight yet, therefore it can't be achieved ever." (Which, by the way, some engineers at the time did.)

It's unclear what G&K's solution is. Perhaps most tellingly, the voices I've seen online defending this article seem to have great difficulty understanding the definition of "syndrome", or the idea of treating empirically before the biology of a specific case or even the disease itself is clear is quite often the best approach (and again, this is not specific to psychiatry.) For instance, many psychotherapies have an impressive evidence base at this point, and if we don't understand psychopharmacology as well as we would like at the biological level, we certainly don't have anything like a fully articulated biological theory of psychotherapy either. If you have a treatments that can help - pharmacologically or otherwise - it's immoral to withhold it just because the science behind the treatment mechanism or pathophysiology is not settled. And as near as I can tell, that's exactly what G&K are proposing.

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