Turning back the clock to pre-Oslerian era

by Academy of Clinical Excellence on April 14, 2011

An article recently appeared on the front page of the New York Times: “Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy,” which was the most widely e-mailed article of the day (March 6, 2011). The article profiles Dr. Donald Levine, who personifies psychiatrists’ movement towards pharmacotherapy and away from psychotherapy. The author writes “The switch from talk therapy to medications has swept psychiatric practices and hospitals, leaving many older psychiatrists feeling unhappy and inadequate. A 2005 government survey found that just 11 percent of psychiatrists provided talk therapy to all patients, a share that had been falling for years and has most likely fallen more since. Psychiatric hospitals that once offered patients months of talk therapy now discharge them within days with only pills.” Although the article highlights an important and timely issue, it misses many key forces driving the change in U.S. psychiatric practice, including the wide availability and marketing of psychiatric medications.
A larger issue for psychiatry, not addressed in this article, is how the decision to practice either pharmacotherapy or psychotherapy turns back the clock for psychiatry and psychiatric patients. In this sense, the article unfortunately propagates an antiquated view of the practice of modern psychiatry. Modern psychiatry is best appreciated as a medical discipline which follows traditional medical approaches to evaluation, diagnosis, and treatment. This focus on practicing either pharmacotherapy or psychotherapy relegates our profession to the pre-Oslerian era, when evaluation and diagnosis of the patient were less relevant than the types of treatments that individual physicians had been trained to provide. If a psychiatrist’s practice (or any physician’s) is limited to one intervention, and is not derived by thorough evaluation and formulation of the individual patient, it negates what we’ve learned from Osler:
  • The conditions with which patients present to psychiatrists differ in their origin: not all psychiatric conditions are the same
  • A thorough evaluation is critical to differentiating these conditions along their distinct natures

 

  • Evidence should drive decision-making about which treatment(s) to prescribe for which condition

 

  • A systematic approach should be used to decide whether a patient is being helped by the treatment(s) prescribed

 

  • If a patient is not improving, diagnostic and treatment decisions should be revisited

 

William Osler had it right in so many ways when he said: "Listen to your patient.” We psychiatrists, as all physicians, do best for our patients when we listen to Osler…

 
With acknowledgment to Constantine G. Lyketsos for his thoughtful input on this post.
 
Margaret S. Chisolm, MD
Assistant Professor
Department of Psychiatry and Behavioral Sciences
Johns Hopkins University School of Medicine
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