Barry Blackwell and David Paul Goldberg: Sir Aubrey Lewis and psychopharmacology
Barry Blackwell’s reply to Edward Shorter’s comments
It was encouraging and delightful to read Edward (“Ned”) Shorter’s endorsement of the need for critical thinking and the manner in which its absence in contemporary practice and educational programs has become the norm. Below is what I hope is a timely example, offered as counterpoint.
Treating the Mind
I hope NIMH members will have read my review of Daniel Carlat’s book Unhinged and my commentary that was posted to inhn.org on June 27, 2019. It documents the pronounced change in clinical practice and training in psychiatry between the mid-1970s and the mid-1990s. In just two decades America went from ubiquitous psychoanalytic formulations and treatment in which medication was disparaged and discouraged to the contemporary practice confined primarily to med-checks minus therapy which, if indicated, is farmed out to other mental health providers.
An historical re-capitulation of four factors leading to the contemporary “medicalization” of society may be timely.
1. A draught of innovative discoveries and lack of novel insights into brain mechanisms from the late 1970s to the present has led the pharmaceutical industry to abandon its search and instead focus its resources on strenuous and seductive advertising of “me-too” products generating vast profits that fund extensive lobbying of Congress, extend patents and incentivize the FDA to approve its efforts by inflating its budget (Blackwell 2016).
2. The industry goals are aided by a diagnostic system (DSM) based on symptoms derived from clinical consensus rather than classical nosology or epidemiology. The symptoms of depressive- and anxiety-based disorders have become codified as “medical disorders” sometimes matching a specific drug to a particular “disorder.”
3. Persuaded by ingenious advertising and backed by complicit well-payed medical opinion leaders (e.g., “key opinion leaders” [KOL]) anxiety and depression have become parsed as exclusively medical disorders requiring drugs as the inevitable first choice treatment, enhanced by the training and practice of psychiatry becoming reduced to “med checks” divorced from verbal therapy. The main prescribers of psychotropic drugs are primary care physicians, often misled by KOL “educational” sessions, who find it difficult to make diagnostic or therapy referrals due to the increasing shortage of mental health professionals and long waiting times, coupled with insurance coverage that favors medication management over talk therapy, despite evidence that dealing with mental health issues produces significant reductions in the cost of co-morbid medical care - the medical offset.
4. The least discussed and most insidious aspect of this contemporary medicalization is an absence of any encouragement to view the onset of physical and emotional symptoms as a failure to acknowledge anxiety as an anticipatory response to everyday existential challenges, just as depression is a retrospective rumination on the failure to achieve a desired outcome. Of course, people differ in their responses. For some anxiety is a spur to further effort and depression a lesson learned from an unwise effort. Some folks have heightened awareness of physical sensations (symptom sensitivity, unkindly hypochondriasis) while others, deprived of affection in early life, lack an emotional vocabulary (alexithymia) and communicate in body language.
Whatever benefits contemporary psychotropic medications bestow, perhaps limited to a diminished placebo response, will evaporate on discontinuation, leaving no new behaviors to cope with re-emerging life predicaments. Relapse and return to the same or a new drug establishes dependency with a conviction that weaning or doing without medication is impossible. This is a recipe for despair, perhaps even suicidal ideation. Increasing rates of drug dependency, failure of weaning and increasing suicide rates are features of the current situation..
There is no better example of “throwing out the baby with the bath water” than the segregation of talk from medication management in affective disorders. (Blackwell 2017)
The psychiatric profession is suffering along with its patients. The diagnostic quagmire that is now psychiatry is worsened by a severe shortage of psychiatrists and long waiting times to see one. A discipline that is mindless, unscientific and overworked is hardly the intriguing career it used to be in the first half of the 20th century.
Perhaps Ned Shorter, a distinguished historian, can comment on whether this commentary is valid criticism or the curmudgeonly musings of an 85-year-old psychopharmacologist!
References:
Blackwell B. Corporate corruption in the psychopharmaceutical industry. inhn.org.controversies. September 1, 2016.
Blackwell B. The baby and the bathwater. inhn.org.controversies. June 22, 2017.
Carlat JD. (Au) Unhinged New York, Free Press . 2010.
October 24, 2019