Psychiatry in 1984 vs. now: Has progress come at a cost?

This essay is part satire. The trouble is, I don’t know which part.

As far as I know, time travel is fodder for science fiction thrillers and movies. It doesn’t actually exist on Earth. However, I can time travel in my mind, and I do it frequently, reminiscing about the 40 years between the time I completed my psychiatric residency (in 1984) and now. What has changed in my specialty in that interval?

Mainly, there are fewer psychiatrists practicing psychotherapy – less than half, to be exact. They have become psychopharmacologists, content to let the drugs do all the work while referring patients to “therapists” of all ilk to handle the complex psychodynamics underpinning mental illnesses. For mental health issues related to “problems in living” – relationship problems, financial hardship, job stress, and other difficulties people may experience in managing or coping with various aspects of their daily lives – psychiatrists suggest consulting a social worker.

While the drugs are altering synaptic connections, possibly permanently altering the brain’s structure, the communication between the psychiatrist and the therapist is virtually nil. So-called “split therapy” divides the patient in half, as if the biological half and the psychological half were separate and distinct entities to be dealt with by two different professionals. However, in the event of a crisis or bad outcome, the psychiatrist winds up on the hot seat – they’re the ones least familiar with the patient, yet they have the deepest pockets accessible to malpractice lawyers.

During my residency, tricyclic antidepressants and first-generation antipsychotics predominated. They have given way to SSRIs/SNRIs and other “novel” antidepressants and second-generation antipsychotic drugs. Do they have fewer side effects? Not necessarily. Sometimes it’s just a trade-off: diarrhea for constipation. Have we seen better efficacy with newer drugs? It’s not definitively proven. Where are all the head-to-head studies that demonstrate the superiority of newer, more costly agents, over established ones?

Well, that brings us to the pharmaceutical industry, a much more complicated and regulated enterprise than it was in 1984. Indications for a drug’s use must be specified, and manufacturers are required to contain “fair balance” in their advertising. I used to think “fair balance” meant that companies should compare the merits of their drugs to another company’s drugs. I was wrong. Fair balance means that powerful drugs should be “balanced” by their side effects when promoting them, especially when advertised directly to consumers on television. But who can understand all that medical terminology? I can’t, and I’m a doctor, for God’s sake!

Why are companies loath to design clinical trials that compare their products? I would think the public would want to know which drugs are the best and which ones have the least side effects. It turns out that manufacturers are too scared to compete, afraid that their drugs will be the ones that come in second (or third). Because there is too much at stake when undertaking comparative clinical trials, pharma designs “non-inferiority” trials, hoping their product will perform “as good” – but certainly no worse – than their competitors.

The feds sometimes undertake research comparing the effectiveness of same- or similar-class drugs in what they term “real-world” clinical trials. However, these types of trials, with a broad representation of patients, contain a lot of noise (uncontrolled variables). The results are often ambiguous and difficult to interpret. What a waste of taxpayers’ dollars!

I was involved in a non-inferiority clinical trial 20 years ago. The trial was sponsored by the pharmaceutical company I worked for. There were several atypical antipsychotic drugs on the market at the time. The trial showed that all three drugs demonstrated comparable effectiveness in patients experiencing their first episode of psychosis. There were no winners or losers.

Some critics viewed the study as a marketing ploy by my employer to “rescue their baby” from a poor showing in an earlier study. Many publications ensued based on secondary analyses of the data. Investigators were able to pad their CVs with unimaginative publications. Worse yet, two patients died by suicide during the trial. Both of them were taking the agent manufactured by my employer.

But I digress. What else has changed in psychiatry since 1984? How about the Diagnostic and Statistical Manual of Mental Disorders – the DSM? I hit the ground running with the DSM-III in 1980, as a PGY-I resident. Newly revised in 1980, the DSM-III was hailed as a major advancement in psychiatric nosology compared to the DSM-II. And it was a huge improvement, with more evidenced-based diagnoses, a “multiaxial” diagnostic system, and a general assessment of patient functioning (GAF).

Today, we no longer employ multiaxial diagnoses or assess patients’ general functioning – what a shame! The diagnostic categories and number of diagnoses have mushroomed to the point where it has been argued that everyone – I mean everyone – can be labeled with some type of psychiatric disorder using the DSM-5, or at least placed on a “spectrum” of mental illness.

The number of psychiatric subspecialties has increased over the past 40 years. I’m particularly fond of “interventional” psychiatry. While not recognized yet by the American Board of Medical Specialties, academic fellowships exist in this field.

Interventional psychiatrists use various forms of neuromodulation, like electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), vagal nerve stimulation (VNS), and ketamine infusion to treat mental health disorders. These interventions are typically used when traditional psychiatric treatments, such as medication and psychotherapy, have not been effective. Interventional psychiatry requires a deep understanding of both the biological basis of psychiatric disorders and the technical skills necessary to perform these procedures. An understanding of psychological theories of human behavior is optional.

It seems that psychiatrists have finally succeeded in joining the ranks of procedurally-based physicians – ka-ching, ka-ching! Now we’re in business and cooking with gas; perhaps psychiatrists are no longer considered second class. Efficiency and science now drive psychiatric therapy. It’s no different than the type of assembly line medicine practiced everywhere else. But will insurance companies cover these procedures?

Judging by the fallout over expensive biologics, psychiatrists will likely be required to jump through hoops to get these procedures authorized by insurance companies. Psychiatrists, please do not advise your patients that they will qualify for these procedures, or that they should contact drug manufacturers for rebates or acceptance into indigent care programs – they won’t be eligible.

Also, prepare yourself and your staff to spend an average of 14 hours each week completing prior authorizations, a process that has devolved into a time-consuming system of hurdles for health care professionals and that delays access to effective treatments for patients.

The fact is that business models have not caught up with scientific models. Even if it were so, “fail-first” policies instituted by health insurance companies require prolonged patient suffering before their services can be authorized. There must be a CPT code for this type of craziness.

As a society, we have not moved beyond Orwell’s dystopian 1984, the symbol of a civilization under complete surveillance and control by a totalitarian government.

I knew there was no such thing as time travel. It’s still 1984, by my measure.

Arthur Lazarus is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia, PA. He is the author of Every Story Counts: Exploring Contemporary Practice Through Narrative Medicine and Medicine on Fire: A Narrative Travelogue.

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