Reaction to "Mind Over Meds"

On April 19, 2010, the New York Times published an article by a psychiatrist named Daniel Carlat called Mind Over Meds. The article featured Carlat arriving at the possibility that "It may be time to consider whether the term 'psychopharmacologist' is actually doing damage to the field of psychiatry." (In this case, jumping on board later is better than never, I suppose.) While I fully appreciate his general attempt to portray contemporary psychiatry as incomplete in terms of reaching a limit with medications, the article is a perfect illustration of the philosophical naïveté of psychiatrists today.

The meat of the article begins with Carlat giving his question a foundation, by producing evidence to suggest that psychotherapy is decreasing in the perceived effectiveness at aiding the individual's so-called "recovery," and that the perceived efficiency of taking a pill is preferred over the trials and tribulations of the psychotherapeutic process:

"...the percentage of visits to psychiatrists that included psychotherapy dropped to 29 percent in 2004-5 from 44 percent in 1996-97. And the percentage of psychiatrists who provided psychotherapy at every patient visit decreased to 11 percent from 19 percent."

Carlat blames the psychiatrist's "not having enough time" as the reason why psychiatrists are increasingly untrained in psychotherapy, and states that once the psychiatrist reflects on the situation of the patient and not only concentrates on the assumed "biological deficiencies" the patient may have, they reach a tantalizing limit. He claims that once he began probing his patients, he realized he did not know them at all.

In addition, Carlat implicitly explains that the pharmaceutical companies have more interest in the individual's cost-efficacy, rather than their recovery:

"Oddly, managed-care companies discourage us from doing psychotherapy, arguing that it is cheaper to have psychiatrists do 20-minute medication visits every three months and to hire a lower paid non-M.D. for more frequent therapy visits."

"...the overall amount of money paid out by insurance companies is actually less than when the treatment is split between psychiatrists and psychotherapists. When patients see only one provider, they require fewer visits overall. "

Finally, Carlat states that these quick-fixes that the pharmaceutical companies are oppressing humanity with (my words, not his) are not the only effective means to treating patients, but psychotherapy and cognitive behavior therapy are sometimes needed to escape the limits of psychiatry. (Which also leaves the possibility of other therapies being equally - if not more - effective.) In addition, Carlat also states that three quarters of placebo trials prove to be just as effective as the medications they are a placebo for. This leads to Carlat giving an example of a patient that was in need of more than just a pill, and concluding that "She needed someone who could expertly probe her thought process, in order to understand the fateful logic that led her to conclude that the only solution was to end her own life. She needed treatment that was intensive and exquisitely coordinated."

If that "someone" that his patient needed doesn't sound like a philosopher, I don't know what would. Which leads me to my main criticism of the article:

Carlat also states that "Clearly, mental illness is a brain disease, though we are still far from working out the details. But just as clearly, these problems in neurobiology can respond to what have traditionally been considered 'nonbiological' treatments, like psychotherapy. The split between mind and body may be a fallacy, but the split between those who practice psychopharmacology and those specializing in therapy remains all too real." Fundamentally, he realizes the philosophical issue that he is dealing with. At the level of analysis, however, he still remains trapped by his reductionist account of "mental illness," without truly understanding the complexity of such a position. (He also refers to psychologists and social-workers as professional "lowers" in the "mental-health hierarchy.")

So, we have two issues with psychiatry today, as outlined by a professional psychiatrist:

1) The pharmaceutical and insurance companies have too much leeway when it comes to treating patients. A 20-minute medication-related visit is more cost-effective, and skills that may help in the progression of the patient are discouraged.

2) Due to the psychiatrist's knowledge being limited to a set of structured categories, and pills to attribute to each one of those categories, the patient becomes dehumanized and is treated in generally the same way a malfunctioning machine may be treated, despite possible unique properties and features that may be contributing to their "illness." This also leads to subsequent limits in the psychiatrist's ability to treat their patients.

All of the philosophical problems with all of the implications that can be drawn from this article (and psychiatry in general) would take too long to look at in a single blog post, and will be saved for a future date. However, as you are reading the article, I urge you to think of some of those problems and possible solutions. And of course, spread the word.