The Troubled History of Psychiatry
newyorker.com
newyorker.com
I'm not sure if it's in the book, but part of the zeal for a biological and medication-based approach is the number of players who really want it to be true. Talk therapy is inefficient, expensive, and difficult. Good psychotherapy is not "rent-a-friend." Insurance companies, (many) patients, and pharmaceutical companies all really really want the answer to come in the form of a pill.
The problem is, wanting it doesn't make it so. There's a relatively small subset of problems walking into my office that medications can fix. Occasionally, medications are the only reasonable tool for the job, period. Even in those cases, they should ideally almost always be combined with non-pharmacologic interventions.
Another little-discussed part of this picture is that there is a booming number of mid-level practitioners such as nurse practitioners who are providing psychiatric care unsupervised. Their training is far shorter and includes much less psychotherapy, and there are fewer restrictions are their interactions with pharmaceutical companies. The results are predictable. Troublingly, I have seen dozens to hundreds of patients who have previously seen nurse practitioners, and have yet to meet one who knew that they were seeing a nurse practitioner rather than a physician psychiatrist.
Edit to add: It's not as though many in psychiatry haven't identified this issue. Here's one recent publication highlighting the problem - https://www.annualreviews.org/doi/abs/10.1146/annurev-clinps...
In particular we regularly have disaster after disaster caused by psychiatry, psychology, and related fields. Consider the excesses of frontal lobotomies in the 1950s, electroshock therapy in the 60s and 70s, and false memory syndrome in the 80s and 90s. It makes me wonder, what disasters are we creating now?
In the case of lobotomy, we now use stereotactic guided procedures to precisely ablate small parts of the brain, mainly for the treatment of severe OCD and treatment-resistant depression. In the case of ECT, we perform the procedure under full sedation and use EEG monitoring to deliver the minimum possible energy. Both treatments still carry a substantial burden of side-effects, but they work when nothing else does.
The uncomfortable reality is that a lot of people have debilitating, life-threatening mental health problems that don't always respond to medication or psychotherapy. Most of us don't want to think about what very severe mental illness really looks like - the person who is too depressed to sit up in bed, the person with OCD who picks at their wounds until they hit bone, the person with mania who is keen to test their belief that they're immortal. If you were treating a patient with that level of disability, what would you do?
The real disaster of psychiatry isn't the failed attempts, but all the stuff that we don't yet know how to treat or don't have the resources to treat. Mental illnesses are the single biggest cause of disability in the developed world. There's so much we could be doing, so much we should be doing, but we're not spending nearly enough on research or treatment. We're watching helplessly as people live short, miserable lives because of diseases that are treatable or potentially treatable.
As a teenage child he went from someone considered gifted (very high grades), to someone who could not tie his own shoes. Extreme cognitive impairment which his parents noticed and objected to during the ongoing treatment. In contrast, with modern psychology he would likely had gotten a diagnose of ADHD or autism because of his temper tantrums, and treatment outcome would look very different.
We have to consider that cultural environment of the 60s and early 70s. A lot of society, especially education, demanded a military style discipline. A student who did not obey got literally beaten until they did, breaking people physically and mentally until they would fit the mold. Electroshock therapy in that culture worked very effectively in doing so.
I'm also aware that electroshock therapy has real uses. However the widespread use of it with little cause has gone the way of the dodo for good reasons. But a lot of people suffered before psychiatry stopped using it as a routine treatment to use as a first resort for a wide variety of conditions.
All surgery is barbaric in those terms. You're knocking people out and cutting them apart, it's never going to be pretty. It's only actually barbaric if you're doing it for no good reason. Lobotomy was crude and error-prone, but it was a lifesaving intervention for a substantial proportion of patients. Although some patients were probably needlessly subjected to a lobotomy, the absolute number of patients treated represented a very small proportion of the overall population living with severe and enduring mental illness.
We didn't abandon lobotomy because we realised it was barbaric, we abandoned it because we discovered tricyclic antidepressants, antipsychotics and lithium. The discovery of those drugs was also the fundamental reason for de-institutionalisation in the 1960s and 70s - to a great extent the asylums emptied themselves, because enormous numbers of patients were now capable of independence.
The fundamental lesson of the past isn't "psychiatry is terrible and we should be afraid of it", but "terrible things happen when you have desperately ill people and no good treatments". The solution is not a crusade against psychiatry, but a massive investment in developing new treatments and actually using the treatments we already have.
Exactly the problem, right there.
Many thousands of people were lobotomized not because they had severe, untreatable illnesses, but just because they were inconvenient. In only slightly more barbaric times and places they would be slaughtered or starved, as happened quite recently in China, Russia, Cambodia, Mozambique, Guatemala, Germany, ...
But was that actually living and not just torture to please other people?
My issue with psychiatry is that psychiatrists can force these things onto people. And when confronted about some of the terrible things done through that the answer is "but we are trying to help."
People are fearful and suspicious of psychiatry because psychiatrists can basically imprison you and you have fewer rights than actual convicted prisoners. On top of that, if they get it wrong then there's no real accountability. While you're imprisoned, they can force you into many types of dangerous treatments and you have to obey.
Cases like Gustl Mollath are reason enough to be afraid of psychiatry. Terrible things happen when there are systems in society that can easily be abused while having little oversight and accountability.
Wait till you hear about slashing the body with knives and cutting parts off then!
That's not to write it off completely; there have been adaptions of CBT and DBT into text and electronically-mediated forms that show promise among subclinical populations or as an adjunct to conventional therapy, but by and large a human is going to be necessary for a long, long time.
If I go to a therapist, and they put time in to help me get better, my stress response decreases, and I feel better.
Completely made up, in case that wasn't obvious. But that's my guess.
If you are truly interested, try reading Trauma and Recovery by Judith Herman. Dense scientific book on just this type of thing.
That is to say, it appears to me that even "dense scientific books" are either sharing opinionated descriptive analyses or just making this shit up.
While I can appreciate you trying to defend a field of research, I am also OK with keeping my own mental model of operation.
On the topic of placebo, I found Irving Kirsch's talk about anti-depressants vs placebo in depression [1] very interesting.
But that's the least creative possible solution. I think there are all kinds of behavioral interventions that are difficult or impossible for a human to do that we haven't tried yet. Almost certainly there are lots of them that would work well and would be better delivered by a bot.
I can't help but feel something like talk therapy is only going to work with all or almost nothing. You either have a full person that can actually empathize, or an AI of equivalent ability (so, true AGI). Or you become a mirror and let the patient fill in for that capability, like with ELIZA.
Was Sapolsky playing fast and loose, or are the multiple components of depression widely appreciated in the field now?
Sapolsky's perspective is somewhat fringe, mostly because he's a neuroendocrinologist rather than a psychiatrist. His perspective reflects his research interests rather than a broader clinical perspective. I can't say that I'm hugely familiar with his work, but I'm not sure how much of it is actually clinically relevant.
This problem makes it near impossible to apply generic "gold standard" double-blind trials to psychoactive medications, because those depend implicitly on accurate diagnoses. If your target sample group has six different maladies all labeled "depression", you will never get a clear signal, even if the medication you are testing 100% cures the one-in-six of them that actually have the problem it fixes.
This guy does some great work on the topic: https://eiko-fried.com/the-replication-crisis-hits-psychiatr...
Personally, I'm very excited about direct neuromodulation technologies such as transcranial magnetic stimulation. These tools not only allow us to manipulate neural circuits, but to also test experimentally whether certain circuits causally contribute to a psychiatric phenotype of interest.
As a treatment modality, they're incredibly safe and virtually have no side effects. Given that chemical receptors on neurons are so widely distributed, I doubt that a chemical substance can ever alter neural circuitry precisely enough to cure certain kinds of circuit dysfunctions.
There's also starting to be exciting studies using brain imaging (e.g. fMRI) to tease apart the heterogeneity within conventional diagnostic categories and devise the inklings of biologically-based dimensional criteria.
But neuromodulation acts to mildly strengthen or weaken existing synapses within a brain region or circuit. The patient is awake and usually watching TV or something during the procedure. So I wouldn’t call that akin rebooting.
As a layperson who is suspicious of Big Pharma, I'd be interested to hear other perspectives from those more knowledgable (the book admittedly reinforces my pre-existing opinion!). But however many people are genuinely better off through the use of pharmaceuticals (and I'm sure there are many), I don't think it's controversial to claim that such drugs are often over-prescribed, compared to less profitable solutions (CBT, group therapy, or even basic things like sunshine, movement, and diet).
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(Generalist) MD: Ok so I'll see you back in 4 weeks to check up on your high blood pressure. Oh um.. you seem a little down today, are you depressed?
Patient: Yes, doctor, I've been feeling pretty depressed lately, I ...
MD: Ok would you like to try something for that?
Patient: Uh ok, sure.. I guess
MD: Alright I just wrote you for an anti-depressant, I think that will help.
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That's definitely not an interaction that would happen with a psychiatrist.
It is true that psych drugs can cause harm, or do nothing. But I've also seen very dramatic improvements in people's lives from psych drugs, and I think its the fact that enough practitioners see enough of these amazing transformations that it seems like its worth it for some subset of people, and justifies the enterprise.
Probably the majority of depression and anxiety we see in modern society is the byproduct of...modern society. Lack of meaningful work and relationships, high work stress, poor physical health and diet, etc. Some of these are the same cause of many cases of high blood pressure and diabetes, but just like with high blood pressure and diabetes, many of those patients just do not have the motivation or desire or ability to make the changes in their lives to improve their physical and mental health. So they want a pill.
However, if you go to an inpatient psych hospital, those are mostly people are seriously impaired. Not all of them will benefit from medications, but many will. A bipolar patient may totally throw her life off the rails during a manic episode but can live mania free if on medications.
It's just a very messy business. I have seen lots of patients who go from being so impaired they cannot lead a normal life to being fairly function on medications. But also many who get no benefit after many med trials. And others who are possibly worsened by meds.
Nonetheless, we're starting to see studies showing that we can predict, based on biological markers, which patients will likely respond to particular treatments. See for example the http://williamspanlab.com/ at Stanford. There they are piloting a study where patients receive a number of biological and symptom-based diagnostic tests, analyzed by predictive algorithms and this analysis is given to the treating physician to help guide treatment. Despite the unsavory history, I really think things are looking up for psychiatry as a field. But surely change will be slow.