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Psychiatrist: ‘We are not your adversary’ | READER COMMENTARY

Psychiatry has problems, but also many strengths

It is true that psychiatry has many problems, but lack of effective treatments is not the major one. Psychiatrists have much to offer patients nowadays, especially for depression.

Letter writer Ann Bracken recently complained about the imprecise nature of psychiatric treatment and theory, remarking that exercise might solve the problem for some with depression (”Forget ‘Field of Screams,’ psychiatry has more than an image problem,” Nov. 4). For some this is true, but regrettably, not for many. Depression is a catchword for the key symptom of what we suspect are many different types of illnesses; most likely with as many different causes. For a great many people, it is a chronic, recurring problem that is not solved by time alone or by “walking (or running) it off.”

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What we know about depression (and many other psychiatric illnesses) and the brain is just the tip of the iceberg, but our knowledge and treatment is growing and in keeping with other modern medical treatments. While we remain skeptical of any unproven specific theory of each illness, this does not prevent us from offering effective treatments. Gone are the days when people spend months or years in an asylum because they are depressed. Today’s treatments are mostly outpatient with occasional brief inpatient stays of days to weeks leading to a return to normal life and functioning.

While some serious psychiatric illnesses like tertiary syphilis are mostly eliminated by antibiotic cures and transferred to the care of infectious disease specialists, others like depression remain the purview of psychiatrists and even general practitioners. Our treatment armamentarium is multifaceted, and the vast majority of patients improve with treatment. Just because we know that up to 30% of people receiving a placebo (or sugar pill) for a problem, still respond to treatment, even when they are told upfront that they are getting a placebo, does not mean that we should give everyone placebos for their depression or other illnesses. Nor does this mean that the proven treatments we offer are not effective.

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What we are missing are the tests that would tell us which medicine will give an individual the best response. This is not a disabling problem, as we have many clues, including family history, which help us find treatments that are safe and effective for each person. The thoughtful practitioner keeps in mind the “natural course” of illness where some get better with time alone. Yet most do not, and should not, wait for time or exercise alone to heal them, as for some this can be fatal with this serious group of illnesses. As many as one of every five people has a mental health issue, with many never receiving treatment.

It is reasonable to hope that genetic and other research will eventually get us to that gold standard where we have tests that specify the exact problem and treatment, perhaps in the lifetime of those reading this for some psychiatric illnesses. Maybe we will even find the “silver bullet” to splice the defective gene(s) to effect a cure for some forms of depression. Until then, finding the best combination of treatments and managing side effects is an important part of the healing process; this is much improved since the introduction of the first antidepressant medication in the mid-1950s. This is always an important part of any treatment program for any illness.

Another problem of psychiatric illness and treatments, especially with depression, is that sometimes people do not understand the chronic nature of these conditions, partly due to some having a waxing and waning history on their own. A depression following a major loss may not re-occur, and might be considered “cured,” but most other chronic illness depressions, like diabetes and hypertension, require lifelong treatment for patients to remain at their best. Treatments may be stopped when someone gets better, often without any periodic monitoring, then in a few months, or years, a relapse occurs. It has not been unusual for me to see a person who said they got depressed when they lost their job, but upon teasing out the history we reveal that as depression gradually built up, they lost interest and concentration in their work, and as a result got fired, which made things even worse.

Modern treatments can include psychotherapy, cognitive behavioral therapy, exercise, diet, medication, occupational and recreational therapies and transcranial magnetic stimulation (TMS). But for those who need urgent improvement or have not responded to other methods, the gold standard for major depression remains electroconvulsive therapy (ECT). The standard of care is to explain the risks, benefits and alternatives to each treatment being offered in any setting. None of these treatments is a cure, so if some form of treatment is not continued, or if therapy is not maintained at some level to pick up and treat early symptoms of illness, relapses may occur. In treating patients for over 40 years, I have yet to see a patient with depression who I have not been able to help.

— Dr. Bruce T. Taylor, is a psychiatrist, former owner of Taylor Manor Hospital and health care advocate (www.HealthCare-Savings.com).

Letter citing my psychiatry work misleading

Ann Bracken, who cites some of my work, raises important issues regarding psychiatric treatments. Unfortunately, her letter unduly emphasizes side effects sometimes associated with psychiatric treatments and greatly understates the devastating effects of psychiatric illness. She also cites statistics from several studies without understanding their context or limitations. (“Forget ‘Field of Screams,’ psychiatry has more than an image problem,” Nov. 4.)

First, the so-called “chemical imbalance theory” of depression was largely the creation of pharmaceutical company advertising and has never been the official position of psychiatric organizations, academic psychiatrists or psychiatric textbooks. For over 40 years, psychiatrists have viewed mood disorders as the outcome of biological, psychological and social/environmental factors. And contrary to Ms. Bracken’s claim, antidepressants are not prescribed “to address a chemical imbalance theory”; rather, they are prescribed because they help seriously depressed patients recover.

Indeed, Ms. Bracken’s claim that “antidepressants only work for 15% of the people who take them” is misleading in several respects. First, it is based on a meta-analysis of clinical studies that looked at response to a single antidepressant prescribed for a short period of time — usually six to 12 weeks. The analysis found that antidepressant treatment was much more effective than a placebo in about 15 out of 100 patients.

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Now, imagine that you or a loved one had a life-threatening illness and knew there was a treatment that led to remission of the illness for 15 in 100 patients. Would you not take advantage of that treatment? To say that “only” 15 in 100 patients will have a robust response to an antidepressant completely ignores the debilitating and sometimes fatal effects (e.g., suicide) of severe depressive illness. Furthermore, in clinical practice, psychiatrists will often use several antidepressants in sequence, over many months, until the patient achieves remission. In my experience of over 25 years, remission is eventually achieved in well over 50% of antidepressant-treated patients. The addition of psychotherapy further boosts remission rates.

Ms. Bracken also cites a 2006 study that seems to show that 85% of depressed individuals who go without somatic treatment (such as medication or electroconvulsive therapy) spontaneously recover within one year. So, if most depressed people get better without medical treatment, why take an antidepressant? But subjects in this study were not seeking treatment for their depression; rather, they were “recruited” by the study authors, who point out that their results can’t be generalized to treatment-seeking depressed patients. Nor did the study examine the risk for recurrence of depression, which can be as high as 50% in the first year following recovery. The authors noted that “ … it is possible that patients whose depressive illness spontaneously remits might still benefit from [somatic treatment] as prophylaxis against future recurrences.”

Finally, Ms. Bracken’s remarks concerning electroconvulsive therapy (ECT) are also misleading. ECT is usually reserved for the most serious cases of major depression, and no psychiatrist simply “administers” ECT without a thorough process of informed consent, in which possible side effects are carefully discussed with the patient. Yes, some memory problems often follow ECT, but these usually improve significantly by six months, and treatment of the patient’s severe depression often leads to improved ability to plan, concentrate and attend to things. There is no credible evidence that modern ECT leads to brain “trauma” or damage, and a recent comprehensive review concluded that “ECT is a potentially lifesaving treatment for severe [major depressive episodes].”

In short, somatic treatments in psychiatry, while far from ideal or without some risk, are generally safe; well-tolerated, and effective. They should always be used conservatively, as part of a comprehensive “bio-psycho-social” approach.

Dr. Ronald W. Pies is professor emeritus of psychiatry at SUNY Upstate Medical University and a clinical professor of psychiatry at Tufts University School of Medicine.

Psychiatrists are people, too

Ann Bracken paints the entire field of psychiatry as unscientific, ineffectual and often harmful. This is a dangerous mischaracterization and could lead folks who are suffering to avoid getting necessary help.

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We psychiatrists are your daughters, sons, sisters, brothers and cousins. We decided to devote our lives to helping others. We studied chemistry and biology. We wanted to know as much as we could about the body, so we went to medical school. We trained for years after medical school in residency, caring for folks with severe mental illness.

We see folks who are suffering every day, try to understand their problems and help them. We work with primary care doctors, psychologists, social workers and other mental health providers. Of course we encourage healthy diets, exercise, good sleep and managing stress. We are physicians and know that a healthy body is important for a healthy mind.

We attend conferences, read journals, consult with colleagues, constantly trying to get better at what we do to help more of our patients. We know that there is much we do not know, that there are folks we are not yet able to help. But we know that there are countless folks whose lives we have improved, or even saved, as a result of our labors. We are human, and have also had loved ones suffer from mental illness. We are not your adversary; we are all in this together.

— Dr. Robert Herman has been practicing psychiatry since 1987 and based in Arnold for the past 22 years.


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