Is Psychiatry Becoming Extinct?

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COMMENTARY

In contemporary psychiatry, there has been marked progress in neurobiological research to establish the causality of many mental disorders in brain pathology. I admire and support them in continuing these endeavors because I have the same hope. However, establishing psychiatry’s identity is missing in these endeavors.  

In a New York Times Op-Ed titled “Psychiatry’s Identity Crisis”¹ on July 17, 2015, author Richard A. Friedman, MD, warned against the modern clinical and research psychiatric practice primarily focusing on neurobiological treatments, mainly medications, and excluding psychotherapy, which carries its unique and irreplaceable position in treating psychological mental disorders. Friedman is a professor of clinical psychiatry and a psychopharmacologist at Weill Cornell Medical College.

A more recent article titled “Psychiatry’s Identity: Scope, Complexity, and Humility,”² published in the Journal of Academic Psychiatry on February 12, 2021, mainly supported the idea that psychotherapy is integral to psychiatry.

In “Comment on ‘Psychotherapy and the Professional Identity of Psychiatry in the Age of Neuroscience,’”³ author Aldis H. Petriceks wrote from the perspective of a medical student considering joining our field. His reflection on the necessity of psychotherapy to psychiatry speaks to the anxiety that he will join a profession in which something essential is “missing.” Seeing psychotherapy as “grounded in science and humanism,” the author considers it a bridge between different fields of study, as well as a means to learn about the mind, which must ultimately be engaged through subjective experience.

The same trend of ignoring psychotherapy continued, and now psychiatry faces extinction. In an article titled “Time for Brain Medicine”⁴ that was published in the April 6, 2023, issue of the Journal of Neuropsychiatry and Clinical Neuroscience, the authors (who include psychiatrists and neurologists) proposed to merge neurology and psychiatry and to create a new medical specialty called brain medicine because “unprecedented knowledge of the brain is inevitably contributing to the convergence of neurology and psychiatry.” They even pointed out that, historically, there has been a division of structure versus functional mental disorders etiologically—however, they still asserted that there is no distinction.

I will comment on this article first by pointing out that this premise is wrong because structural and functional cannot be the same. Is depression brought on by losing one’s job the same as a depressive episode in a patient with bipolar disorder?

Background

This unfortunate practice developed in 1980 when the third revision of the DSM was published. The revision included 2 significant changes. One change was not to consider the cause of mental disorders. The second was to remove the diagnostic entity neurosis, as neurosis is based on psychodynamic theory, and there are other theories regarding the cause of mental disorders other than psychodynamic (psychoanalytic) theory. The rationale given for the change was that it is difficult to understand and agree on the definition of neurosis. It is better when more psychiatrists agree on the same diagnosis; these revisions will help achieve this agreement. We now have the fifth edition of the DSM, but the same trends persist.

The DSM clearly stated that it is not a textbook because no causality and treatment approaches are included. However, most psychiatrists carried the DSM positions into their clinical practice to treat patients. In my opinion, the reason for this development is that many psychiatrists are taking the easy way out. Any psychiatrist who provides dynamic psychotherapy must invest 2 to 5 years of extra time for formal training, which includes personal analysis and taking on a financial burden. Once individuals are accustomed to the easy way, they will try to expand it. There have been endless efforts to expand neurobiological practice and research.

The most recent example is the attempt to use psychedelics to treat depression. It is hard to understand why these practitioners are against understanding human psychology and incorporating it into their treatment armamentarium.

The following 2 example cases show some of the serious flaws in our mental health care system.

Case 1

Recently, I received a call from a patient who needed to find a new psychiatrist to continue his medications because his psychiatrist had retired. His drugs include 2 for depression, 1 highly addictive anxiety medication (lorazepam), and 1 highly addictive medication for attention-deficit/hyperactivity disorder (dextroamphetamine-amphetamine). He has been taking these medicines for the past 20 years.

This patient started psychiatric treatment because he became anxious and depressed during a divorce. This clearly is a psychological or functional mental disorder. He also claims he has been getting psychotherapy for 20 years: a talk therapy called cognitive behavior therapy (CBT). In my opinion, he did not get appropriate treatment—dynamic psychotherapy—for his suffering mind but only received treatment for his symptoms. He became addicted to 2 of his medicines and was desperately looking for a new psychiatrist to support his addiction.

Case 2

A young man went to see a psychiatrist with complaints of anxiety, depression, and difficulty concentrating on his work. The psychiatrist prescribed him an antidepressant and amphetamine for his concentration problem. After taking the amphetamine, the patient became acutely psychotic and was involuntarily hospitalized twice with a diagnosis of acute psychosis. Upon discharge, his parents took him to see me for follow-up care.

The patient had drug-induced psychosis. His original problem was created by his psychological response to his family problems. After receiving dynamic psychotherapy for a few months, he got off his medications, restored his usual life, and began pursuing his career.

Discussion

As these cases exemplify, many modern psychiatrists consider all mental disorders as brain tissue problems and treat them as such, mostly with medications. If it works, there is no issue. However, the reality is that many patients with psychological problems take medicines for long periods of time and experience little or no improvement.

There is no question that all mental disorders are brain diseases. Still, unlike other medical diseases, mental disorders are divided into 2 depending on what precipitated the mental disorder: One originates in the brain cells and the other from the function of the brain. The former are organic mental disorders, and the latter are functional (psychological) mental disorders. When there is a genetic problem in the brain cells, for example, mental disorders like schizophrenia, bipolar disorder, and autism can develop; and when there is psychological trauma, depression, panic disorder, phobia, posttraumatic stress disorder, personality disorder, etc, may develop.

The appropriate and effective treatment is different depending on what caused the mental disorder. For organic mental disorders, neurobiological treatments such as medication are used and are primarily effective; for functional mental disorders, dynamic psychotherapy is used and effective. The salient elements of CBT are used early in the process of providing dynamic psychotherapy.

On August 28, 2023, Time published an article by Jamie Ducharme titled “America Hass Reached Peak Therapy. Why Is Our Mental Health Getting Worse?”⁵ For the article, Ducharme interviewed many leaders of psychiatry, including Thomas Insel, MD, the former director of the National Institute of Mental Health. In the article, it is noted that most of the psychiatrists are neurobiological- or organic-oriented and yet, they seem to agree medication alone is not sufficient. Still, none mentioned the identity of psychiatry: that there are 2 different types of mental disorders (organic and functional) and the treatment approaches for each are different. I sent this article to the editor for their reference to help obtain answers to their issues, but I have received no response.

Again, all mental disorders—both organic or functional—are brain diseases. Neurobiological changes should take place in both types. However, more research comparing changes in the types is needed. Many researchers and clinical practitioners move forward as if the 2 types have the same changes because they are both labeled as brain diseases; therefore, they provide neurobiological treatments that are appropriate for organic mental disorders. However, they ignore dynamic psychotherapy without any plausible explanation.

To date, there have been some neurobiological treatments, medications, and so on that are said to be effective for functional mental disorders—however, they are not as effective as dynamic psychotherapy.

There are many articles that discuss this topic. One such article that received particular worldwide acclaim for establishing psychodynamic therapy as an evidence-based treatment is “The Efficacy of Psychodynamic Psychotherapy,”⁶ which was published in the February-March 2010 issue of American Psychologist. In the article, author Jonathan Shedler, PhD, of the University of Colorado Denver School of Medicine presented the distinctive scientific features of psychodynamic psychotherapy and how it is misunderstood.

He compared many other forms of treatments including medications, CBT, and dialectical behavior therapy (DBT) and concluded that dynamic psychotherapy i superior in all respects except for the frequency of treatment. He wrote⁶:

“The scientific evidence tells a different story: Considerable research supports the efficacy and effectiveness of psychodynamic therapy. The discrepancy between perceptions and evidence may be due, in part, to biases in the dissemination of research findings. One potential source of bias is a lingering distaste in the mental health professions for past psychoanalytic arrogance and authority…Patients who receive psychodynamic therapy not only maintain therapeutic gains but continue to improve over time.”

Contemporary psychiatric practice requires drastic upgrading to improve treatment for psychologically triggered mental disorders for the general public and humanity. Mental disorders have spread uncontrollably and contributed to the unnecessary prolongation of suffering, as well as the increase of many social problems including homicides, mass shootings, sexual violence, and suicides. The identity of psychiatry must be restored and practiced. Treating brain cell problems and ignoring the invisible function of the mind is neurology, not psychiatry.

Concluding Thoughts

What I have presented in this article is only the tip of the iceberg. Numerous other problems stem from the efforts to justify the neurobiological approach alone as the most appropriate. But I will save it for another time and briefly propose some ways we can reverse this practice.

I advocate that neurobiological research should continue but include research for functional mental disorders. This may elucidate many human brain functions someday, although I do not believe we will ever discover all of those functions. I suggest expanding and strengthening psychodynamic psychotherapy training for all mental health clinicians to make psychiatry holistic. This will strengthen the identity of psychiatry, enrich psychiatric practice, increase the confidence of psychiatrists, and dramatically improve patient recovery. I also want to suggest paying attention to psychiatrists who also are psychoanalysts, for they may have broader view of mental health practice. 

It may take decades to achieve these goals, but it is possible with concerted effort and a will to improve.

Dr Kim is a clinical assistant professor at RWJ Rutgers University Medical College, a member of the senior faculty at the American Institute for Psychoanalysis, and author of Cherish the Invisible Mind.

References

1. Friedman RA. Psychiatry’s identity crisis. New York Times. July 17, 2015. Accessed March 15, 2024. https://www.nytimes.com/2015/07/19/opinion/psychiatrys-identity-crisis.html

2. Brenner AM, Coverdale J, Morreale MK, et al. Psychiatry's identity: scope, complexity, and humility. Acad Psychiatry. 2021;45(2):137-141.

3. Petriceks AH. Comment on “Psychotherapy and the professional identity of psychiatry in the age of neuroscience.” Acad Psychiatry. 2020;45:238-239.

4. Brown JC, Dainton-Howard H, Woodward J, et al. Time for brain medicine. J Neuropsychiatry Clin Neurosci. 2023;35(4):333-340.

5. Ducharme J. America has reached peak therapy. why is our mental health getting worse? Time. August 28, 2023. Accessed March 15, 2024. https://time.com/6308096/therapy-mental-health-worse-us/

6. Shedler J. The efficacy of psychodynamic psychotherapy. Am Psychol. 2010;65(2):98-109.