I recently attended a fascinating lecture by Eric Plakun, MD, entitled “Psychiatry’s False Assumptions (And The Price We Pay For Them)”. It was refreshing to hear a medical doctor point out some of the bias and distortion that takes place in the world of psychiatry and mental health, and I wanted to share his perspective. (As someone who has seen far too many tragically overmedicated and undertreated clients, this issue is very personal for me, and I think points to major flaws in how we as a society think about mental illness.)
Plakun is a psychiatrist who steeps himself in research into the most effective methods for treating mental illness; much of this research focuses on PTSD, depression, anxiety and schizophrenia (each of which is either widespread or stubbornly resistant to treatment.) He is Chair of the American Psychological Association’s Psychotherapy Caucus and Associate Medical Director at the Austen Riggs Center, one of the best mental health treatment centers in the country. In short, he knows what he’s talking about.
He says that the established thinking in psychiatry makes 3 false assumptions. They are:
Genes directly cause disease and are much more important than environment in causing mental disorders;
Patients present with single disorders that respond to single evidence-based treatments; and
The best treatments are pills.
Taking these assumptions one by one, we can see that they are false:
No underlying genetic cause has been identified for depression or schizophrenia. This doesn’t mean genes don’t play a role. Some genetic factors – “vulnerability genes” – mean that some individuals are more responsive than others to both positive and negative environmental experiences. A more familiar way of describing someone like that may be moody: they may be more easily affected by events than most, but they just as easily bounce back.
Environment, as it turns out, probably plays a much bigger role than most psychiatrists acknowledge. Maternal anxiety, for example, has been shown in studies to be transmitted through environmental and not genetic factors. Even sperm and egg cells can be effected by adversity in the previous generation, which helps explain the intergenerational transmission of trauma.
So, while no so-called "biomarkers" have been found for mental illness, many enviromarkers have been identified. Experiencing childhood sexual abuse, for example, doubles the risk of developing one or more mental disorders.
Let’s look at the second assumption – that patients present with single disorders that respond to single evidence-based treatments. One reason why medication has been promoted for treating mental illness (beyond the purported financial savings, which is in itself a false assumption) is because drugs are tested for efficacy through clinical trials, and clinical trials have what are called "exclusion criteria". This means that certain people are not allowed to participate in the trials, and this is problematic when the way the study’s results are interpreted fails to account for this.
Take this example: 78% of depressed patients originally considered for one study had comorbid disorders, meaning they had another mental disorder along with their depression. Because studies are designed to measure the effectiveness of one treatment on one disorder, those 78% were excluded from the study. That means that the medications were not tested on them. This is problematic, because people who come for psychiatric treatment have a 4 of 5 chance of having a comorbid disorder for which the drugs they are prescribed are not intended to treat.
Basically, this means that most people who need mental health treatment are getting drugs that will not work particularly well for them, because their overall mental health picture is much more complex.
No let’s look at the third assumption, that the best treatment for mental disorders is pills.
The exclusion criteria issue discussed above means that most psychiatric drugs work only for a minority of patients who seek help. Meanwhile, meta-analyses of hundreds of studies have shown that:
(a) we have overestimated the efficacy of antidepressants by about a third;
(b) 75% of an antidepressant’s effect is placebo; and
(c) depressed adolescents did no better on drugs – in fact, they did worse.
So then, what works?
Drugs certainly have a role to play, but that role is dramatically overestimated. Meta-analyses of studies show that the average patient receiving long-term psychodynamic therapy is 96% more likely to benefit from it than from drugs alone. In another study on trauma patients, therapy alone was more effective than drugs and nearly as effective as a combination of drugs and therapy.
Part of the reason for this, Plakun argued, is that psychodynamic therapy is a systems theory that incorporates multiple perspectives and fields of knowledge; it addresses the complexity of human lives, development, motivation, biology and relationships, and is therefore better equipped to provide meaningful intervention.
Despite this, the percentage of psychiatrists who practice therapy has declined: In 1996 44% of office visits involved therapy, and in 2004-2005 it was 29%.
I am optimistic that continued research into psychotherapy will demonstrate how, in most cases, it is the better first-line treatment for mental disorders. The truth tends to win out – eventually.