Does Psychiatry Work?–With Acknowledgements to Dr. Steve Balt, MD

I just read an article in Psychiatric Times about the burning question these days about whether psychiatric drugs work. The curt reply seems to be “yes, they do work, damn it; next question.” Are we ready for the next question, which is probably more important to the public’s perception of Psychiatry as a subspecialty of medicine: does psychiatry work? The review cited in the Psychiatric Times article was by Leucht and colleagues, who listed effect sizes of various psychiatric drugs squarely into the range one finds for a good number of general medicine medications. What you do don’t get in the abstract is the long list of pharmaceutical companies with which Dr. Leucht has been involved (Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses). Many are psychiatric drug companies, which might lead to a long yawn about the trustworthiness of the review (“pay no attention to that man behind the curtain”). In this context, Dr. Leucht’s own comment sounds ironic, “There is a deep mistrust of psychiatry, fostered by reports suggesting that the efficacy of psychiatric drugs is very small. Psychiatrists, patients, carers, and the media are often unsettled by these findings, and some may think that psychiatric medication is not worth the bother.”

Unfortunately, the list of potential conflicts of interests might overshadow a very important finding from this review, which is that psychiatric medications are a very effective component of a comprehensive, patient-centered, team-based psychiatric treatment plan with accountable stakeholders including psychiatrists, primary care providers, clinical pharmacists, psychotherapists, families and others.

In my opinion, there is a deep mistrust of psychiatry because of the many signs tending to imply its practitioners are in the hip pocket of the pharmaceutical industry. Of course, the article also reminded us of the recent 60 Minutes segment about psychologist Dr. Irving Kirsch’s pronouncement of antidepressants efficacy being not much above that of placebo followed by the defensive flurry of the American Psychiatric Association (APA) leadership. You can see my post about this at Black and White Thinking in Living Color: The Placebo Antidepressant Controversy « The Practical Psychosomaticist: James Amos, M.D. I thought the whole flap revealed a great deal more about  psychiatry’s identity crisis than with the efficacy of antidepressants.

In line with this is Dr. Steve Balt’s recent post, Did The APA Miss A Defining Moment? « Thought Broadcast. I think Steve is right. The APA seems to be defending psychiatric medications rather than a profession dedicated to helping patients recover from mental illness. Steve has a lot of constructive, practical and common-sense views about what is both right and wrong with psychiatry, and you can read more about them at his blog, Thought Broadcast.

Does psychiatry work? Yes it does, to the extent that individual, rank and file psychiatrists somehow recover both the humility and the courage to keep the well-being and recovery of persons with mental illness at the forefront of any definition of who we are and what we do.

1. Kaplan, A. (2012). On the Efficacy of Psychiatric Drugs. Psychiatric Times, UBM Medica XXIX.

2. Leucht, S., S. Hierl, et al. (2012). “Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses.” The British Journal of Psychiatry 200(2): 97-106.

Background:The efficacy of psychopharmacological treatments has been called into question. Psychiatrists are unfamiliar with the effectiveness of common medical drugs. Aims: To put the efficacy of psychiatric drugs into the perspective of that of major medical drugs. Method: We searched Medline and the Cochrane Library for systematic reviews on the efficacy of drugs compared with placebo for common medical and psychiatric disorders, and systematically presented the effect sizes for primary efficacy outcomes.Results: We included 94 meta-analyses (48 drugs in 20 medical diseases, 16 drugs in 8 psychiatric disorders). There were some general medical drugs with clearly higher effect sizes than the psychotropic agents, but the psychiatric drugs were not generally less efficacious than other drugs. Conclusions:Any comparison of different outcomes in different diseases can only serve the purpose of a qualitative perspective. The increment of improvement by drug over placebo must be viewed in the context of the disease’s seriousness, suffering induced, natural course, duration, outcomes, adverse events and societal values.

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