The Death of Psychiatry

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More than 30 years ago, E. Fuller Torrey predicted psychiatry’s eventual demise on the basis that disorders of the brain would be subsumed under the specialty of neurology and problems of the mind would be taken over by the psychology professions.

I am presently working with a bright young woman who wishes to be a clinical psychologist. She came to see me as the result of a misdiagnosis, seen as having a more severe psychopathology than is present. This is not uncommon as  psychiatric diagnostic validity is pretty much limited anyway and should be replaced with the biopsychosocial formulation.

Psychiatric classification depends on symptom clusters; there are no signs, no lab tests and no scans that do anything other than rule out an underlying medical problem. They do not rule in anything.

I am encouraging her interest in psychology as I believe psychiatry to be a dead-end medical speciality.  It  has I think no more than 25 years of life left at the current rate of neuroscience progress. The major disorders will eventually be confirmed to be the result of faulty wiring or neurochemistry and be looked after by neurologists, which is where it all started in 1880 or so. Everybody else will be cared for by clinical psychologists and social workers.

Anywhere I have worked, if you saw a psychiatrist there was a 99% chance of receiving a prescription for something. None of the psychiatrists in my present community do psychotherapy, which at one time was the cornerstone of the field. Without it I think, there is no professional identity.

I recently received a (new) referral from a GP: “19-year-old university student with depression with limited response to Welbutrin after prior failed trials of Prozac, Zoloft and Ciprolex”. These drugs failed because in my experience most 19-year-old students have depression based on psychodynamic or existential causation not “chemical imbalances”.

The diagnosis of psychiatric conditions is based almost exclusively on clinical observations. So, under the current system, a standard consultation goes something like this: the psychiatrist talks with a patient about his or her problems and then uses the substance of that verbal exchange to identify the underlying cause of the patient’s mental illness.

Then, in order to prescribe treatment, the symptoms exhibited by the patient are matched to a set of pre-determined psychiatric labels, for example depression or conduct disorder and medication is dispensed accordingly.

Of course this is about as accurate as hunting 20 different species of ducks with a 12 gauge: “I don’t know what it is but I will get it”. And so the young woman above now has intractable depression and maybe ECT should be next. I will be able to make a more informed judgment after her  visit.

Psychopharmacology training only takes 6 months and writing prescriptions is easy, and it pays well. There are big pharma perks: free pens and paper weights or trips to conferences in Florida. In my younger days I admit that I was seduced by the dark side of these capitalistic forces.

There is a nationwide shortage of psychiatrists, so in rural areas they are using tele-health tied into urban mental health centres. This venue is fine for dermatology, but many schizophrenics already receive messages and hear voices from TV sets. People with depression or panic anxiety engage better with a living being in the same room. And you can’t shake hands through a screen, Videodrome not withstanding.

Fewer med students are choosing psychiatry these days, because insurance companies and government reimbursement have turned psychiatrists into pill-pushers instead of psychotherapists. The psychiatrists in my community only see patients for ‘med visits’ of 15 to 30 minutes once a month or less. This is what has been called ‘in and out burger psychiatry’—an assembly line.

Psychiatry should be put out to pasture. It’s a trap for medical students who could have a much better career removing gall bladders. Society seems to have concluded that mental illness is equally well treated by pastoral services. Research has shown that may indeed be true as the non specific factors in therapy such as empathy, persuasion and support are as important as technique.

It is obvious to me that those who are attracted to psychiatry in the hopes of genuinely helping others, could be put off because the current perception that this  part of the medical field clearly only stands  to support the pharmaceutical industry. I know that medications are often necessary, but there are other times where all it takes is some good conversation and talk therapy to get someone back to the point of feeling normal. But when your patients are hounding you for meds after watching a Cymbalta ad, it is hard to convenience them there is a pharmacy free alternative.

My ongoing patient above was put on Zoloft and then Effexor which were ineffective. I have had good success with her using CBT and mindfulness meditation. I will of course continue to support  her pursuit of a PhD in psychology.

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4 Responses to “The Death of Psychiatry”

  1. kristina nadreau says:

    agree with your assessments

  2. Amy says:

    Love your articles! Have been very lucky to have worked with some wonderful psychiatrists in my 25+ years as a social worker in Corrections. They were/are important members of our team.

  3. Carole Kocian says:

    Well, that peeled back the onion a good bit for me! So who is going to be the expert witness in head case trials in the future?

    • Allan Seltzer MD says:

      Back in the day I was a big fan of something called a bifurcated trial.This means that in part 1 there is a determination of guilt. Did the perp commit the crime or not? This eliminates debates around so called psychiatric defences. After that in part 2 we deal with sentencing. A balance of public protection, rehabilitation and deterrence.A clinical psychologist is quite capable of responding to to this.

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