David Baxter PhD
Late Founder
Psychotherapy in the Age of Biological Psychiatry
Joel Paris, MD
Professor of Psychiatry McGill University, Montreal, Canada
Psychiatry Weekly, Volume 4, Issue 24
November 2, 2009
The past 50 years of developments in psychiatry demonstrate a marked movement toward evidence-based, more targeted, treatments. Receiving treatment for mental illness is more acceptable in society than ever before, and access continues to improve. But another evident and?according to Dr. Joel Paris?troublesome shift is the waning emphasis on psychotherapy as antidepressant prescriptions continue to increase dramatically (Olfson et al, 2009).
In his book, Prescriptions For the Mind: A Critical View of Contemporary Psychiatry, Dr. Paris, who has a sub-specialty in borderline personality disorder, weighs in on the tendency of some psychiatrists to ?prescribe too much and not attend to larger issues.?
Psychiatry Then and Now
?Psychiatry seems, in many ways, to have shifted from one extreme to another,? says Dr. Paris. ?The psychiatry of 50 years ago was dominated by psychoanalytic thinking, was certainly not very scientific, and did not offer evidence-based care. The psychiatry of today is much more evidence-based, but very narrow. Narrow in the sense that, when patients don?t get better, the tendency is to try another pill, the second pill, the third pill. What I find difficult is that clinicians don?t always ask the question, ?What?s going on in this person?s life? What is their history, and why do they have these problems??
?I am not one of those crotchety old clinicians who thinks you should just talk to everybody and that nobody needs drugs,? continues Dr. Paris. ?I was very critical of that view when I trained for psychiatry?I thought it was ridiculous and harmful. But it is equally harmful to believe that you should prescribe for everyone and that nobody needs psychotherapy.?
Factors Behind Shifting Principles
In addition to the push to make psychiatry more scientifically objective, psychiatric training and cost are two other important factors that have contributed to a de-emphasis of evidence-based psychotherapy.
?Psychiatrists know about the latest drug trials, but they don?t always know about the latest clinical trials of psychotherapy,? says Dr. Paris. ?Some of that literature is published in psychiatric journals, but you have to go to the psychology journals for most of it.
?As for cost, it is probably cheaper in the short term to prescribe a drug,? continues Dr. Paris. ?Whether it?s cheaper in the long run is a different question. If the drug works and the patient gets better?great. If not?not so great. There is quite a bit of evidence that psychotherapy does well in cost-benefit analyses, because when patients are offered talk therapy they are less likely to visit general practitioners with complaints and get expensive CAT scans, MRIs, and blood tests.?
What?s the Alternative?
Dr. Paris advocates a forward-facing path, eschewing nostalgia, and emphasizing the solidarity of mental health professionals in both training and practice.
?Psychiatrists should not be treating people with mild problems who could be treated by less-specialized therapists,? he says. ?That is not where psychiatrists should be doing psychotherapy. I think that psychiatrists should be farming out most of the psychotherapy to other people in the way that orthopedists send you to physiotherapy. But this doesn?t really happen, and the resources are not always available. Secondly, psychiatrists need to know enough about psychotherapy to know when it?s indicated, and that is a training issue. Finally, I advocate getting out of office practice, which I think is completely anachronistic. Psychiatrists should work in multi-disciplinary teams with other professionals, which is the best way to deliver our services.?
Conclusion
?Neuroscience has certainly made tremendous progress, but there has been very little practical application of these findings for psychiatry, so far,? says Dr. Paris. Diagnosing and prescribing under an assumption that psychiatric disorders are completely molecular or brain-based is not based on science.
Dr. Paris says that the reaction from peers to the arguments he posited in his book is often, ?You?re right, but what?s the alternative?? He admits that the healthcare system would need to be radically changed to encourage a different type of practice.
?Psychiatrists are not going to be able to do this themselves, and need to work closely with family doctors and psychologists.?
Joel Paris, MD
Professor of Psychiatry McGill University, Montreal, Canada
Psychiatry Weekly, Volume 4, Issue 24
November 2, 2009
The past 50 years of developments in psychiatry demonstrate a marked movement toward evidence-based, more targeted, treatments. Receiving treatment for mental illness is more acceptable in society than ever before, and access continues to improve. But another evident and?according to Dr. Joel Paris?troublesome shift is the waning emphasis on psychotherapy as antidepressant prescriptions continue to increase dramatically (Olfson et al, 2009).
In his book, Prescriptions For the Mind: A Critical View of Contemporary Psychiatry, Dr. Paris, who has a sub-specialty in borderline personality disorder, weighs in on the tendency of some psychiatrists to ?prescribe too much and not attend to larger issues.?
Psychiatry Then and Now
?Psychiatry seems, in many ways, to have shifted from one extreme to another,? says Dr. Paris. ?The psychiatry of 50 years ago was dominated by psychoanalytic thinking, was certainly not very scientific, and did not offer evidence-based care. The psychiatry of today is much more evidence-based, but very narrow. Narrow in the sense that, when patients don?t get better, the tendency is to try another pill, the second pill, the third pill. What I find difficult is that clinicians don?t always ask the question, ?What?s going on in this person?s life? What is their history, and why do they have these problems??
?I am not one of those crotchety old clinicians who thinks you should just talk to everybody and that nobody needs drugs,? continues Dr. Paris. ?I was very critical of that view when I trained for psychiatry?I thought it was ridiculous and harmful. But it is equally harmful to believe that you should prescribe for everyone and that nobody needs psychotherapy.?
Factors Behind Shifting Principles
In addition to the push to make psychiatry more scientifically objective, psychiatric training and cost are two other important factors that have contributed to a de-emphasis of evidence-based psychotherapy.
?Psychiatrists know about the latest drug trials, but they don?t always know about the latest clinical trials of psychotherapy,? says Dr. Paris. ?Some of that literature is published in psychiatric journals, but you have to go to the psychology journals for most of it.
?As for cost, it is probably cheaper in the short term to prescribe a drug,? continues Dr. Paris. ?Whether it?s cheaper in the long run is a different question. If the drug works and the patient gets better?great. If not?not so great. There is quite a bit of evidence that psychotherapy does well in cost-benefit analyses, because when patients are offered talk therapy they are less likely to visit general practitioners with complaints and get expensive CAT scans, MRIs, and blood tests.?
What?s the Alternative?
Dr. Paris advocates a forward-facing path, eschewing nostalgia, and emphasizing the solidarity of mental health professionals in both training and practice.
?Psychiatrists should not be treating people with mild problems who could be treated by less-specialized therapists,? he says. ?That is not where psychiatrists should be doing psychotherapy. I think that psychiatrists should be farming out most of the psychotherapy to other people in the way that orthopedists send you to physiotherapy. But this doesn?t really happen, and the resources are not always available. Secondly, psychiatrists need to know enough about psychotherapy to know when it?s indicated, and that is a training issue. Finally, I advocate getting out of office practice, which I think is completely anachronistic. Psychiatrists should work in multi-disciplinary teams with other professionals, which is the best way to deliver our services.?
Conclusion
?Neuroscience has certainly made tremendous progress, but there has been very little practical application of these findings for psychiatry, so far,? says Dr. Paris. Diagnosing and prescribing under an assumption that psychiatric disorders are completely molecular or brain-based is not based on science.
Dr. Paris says that the reaction from peers to the arguments he posited in his book is often, ?You?re right, but what?s the alternative?? He admits that the healthcare system would need to be radically changed to encourage a different type of practice.
?Psychiatrists are not going to be able to do this themselves, and need to work closely with family doctors and psychologists.?
