NEAL CONAN, HOST:
This is TALK OF THE NATION. I'm Neal Conan in Washington. Just about everyone's image of a psychiatrist's office includes a long couch, dim lights and a doctor with a notepad asking: And how did that make you feel? A stereotype, of course, and way out of date at that. Over the past 20 years, few professions have seen more change than psychiatry.
Weekly, 45-minute appointments are largely a thing of the past. Many psychiatrists see patients for 15 minutes, one after another. Instead of listening, they ask a series of questions, write out prescriptions, and refer their patients to a psychologist or to a social worker for therapy.
While some in mental health circles feel these changes are necessary, others worry they hurt both patients and doctors. We want to hear from psychiatrists in our audience today. How has your practice changed? Give us a call, 800-989-8255. Email us, firstname.lastname@example.org. You can also join the conversation by going on our website. That's at npr.org. Click on TALK OF THE NATION.
Later in the program, Chicago Tribune columnist Mary Schmich on the words that date us, but first the evolution of psychiatry. And we begin with Dr. Richard Friedman, a professor of psychiatry and director of the Psychopharmacology Clinic at Weill Cornell Medical College. He's in our bureau in New York. And it's good to have you back on TALK OF THE NATION.
RICHARD FRIEDMAN: Thank you, it's good to be here.
CONAN: And when you were trained, is psychopharmacology what you signed up for?
FRIEDMAN: Actually, in the days when I trained, which was in the '80s, we were generally trained to be broad-based clinicians, meaning we learned a lot about psychological theories, we learned a lot about dynamic psychiatry and the unconscious, and it was the beginning of psychopharmacology, you know, in its heyday, and the explosion of neuroscience that came in the decades after that.
CONAN: But you started out in practice in those 45-minute sessions?
FRIEDMAN: I did, and actually, all of my colleagues who trained with me were - had the experience of being patients themselves, because almost everybody who went and became a psychiatrist in those days actually underwent their own personal psychoanalysis.
CONAN: So you had to understand what it was like to go through it as well.
FRIEDMAN: Right, it was a good thing to have the understanding of what it was like to be a patient if you were going to treat people.
CONAN: And how has it changed?
FRIEDMAN: I would say one of the biggest changes in the field is the way that we train young psychiatrists these days, and the emphasis is, you know, and we can argue about whether it's desirable or not, is more along the lines of understanding how the brain works, neuroscience, neurobiology and the use of medication to treat various mental disorders.
And what's been de-emphasized is psychology, understanding the, you know, sort of individual patient and training young psychiatrists to actually be practitioners of psychotherapy. That's unusual these days.
CONAN: And how much of that change is due to breakthroughs in pharmacology, and how much is it due to changes in the way insurance is administered?
FRIEDMAN: I think probably market forces drive it, but it's helped by the fact that there's an explosion in neuroscience and the understanding about basic mechanisms of brain functioning and, you know, the role of, you know, circuitry and understanding psychiatric disorders. But I think largely it's driven by market forces.
I mean after all, there are only, what, about 45 or 50 thousand psychiatrists in the United States. So they must have a small impact in terms of population base.
CONAN: So to maximize the number of patients, you have shorter sessions and talk a lot more than you used to.
FRIEDMAN: Well, I don't, actually. My practice has not changed all that much over these years because clinical practice is just a small part of what I actually do. But if I were in private practice, and I look at my colleagues who are out in private practice, I think that that is true.
CONAN: And when you are teaching people who are entering the field today, is that what they now expect to do?
FRIEDMAN: You know, it's a very interesting - it's a very regional effect. You know, I am here at Cornell Medical Center in New York City, and if you happen to be learning to be a psychiatrist in New York City, you're going to learn and be trained in a different way than you would, let's say, if you were in St. Louis or if you were in Kansas.
CONAN: Why is that?
FRIEDMAN: Well because there are - there's an emphasis, which is geographically particular. You know, psychotherapy is still very big and important in major cities like Boston and New York and probably San Francisco and Chicago and de-emphasized in other areas of the country. I mean in some ways that's a very odd thing to say about a medical sub-specialty.
I mean if you had hypertension, you know, your treatment would relatively be the same whether you were treated in Kalamazoo or you were treated in New York City.
CONAN: And is there any practical difference in terms of the well-being of the patient whether the talk therapy part of this is conducted by a psychiatrist or by a psychologist or a social worker?
FRIEDMAN: You know, it's actually very hard to show that there's any difference in terms of outcome in psychotherapy regardless whether it's delivered by a psychiatrist, an MD, a psychologist, a Ph.D. or a social worker. I mean, what really matters to the outcome of psychotherapy is feeling understood by your therapist, knowing that the person really understands your story.
It's the non-specific alliance that really determines the outcome in psychotherapy.
CONAN: So - and plus, you're getting the benefit of these modern medications.
FRIEDMAN: Yes. You know, for some people who have very complex psychiatric problems, there's a benefit by receiving all your treatment from one person and not having a split treatment, so to speak, where you get your medicine from a psychiatrist and you get your psychotherapy from, you know, a non-psychiatric practitioner who presumably has got an alliance and is talking to your psychiatrist.
CONAN: And is it always the case, or how often is it not the case - let me put it that way - that someone will go to a psychiatrist to get their meds and then not go to a psychologist or a social worker for talk therapy?
FRIEDMAN: I think it's very frequent, basically - not necessarily because it's ideal or desirable but because there are economic reasons why somebody may be able to afford medication but not psychotherapy. Third parties...
CONAN: Insurance, in a word.
FRIEDMAN: Absolutely. You know, they would much rather pay for a pill than a psychotherapist.
CONAN: Let's bring another voice into the conversation. Dr. Steve Balt, who got his training in psychiatry more recently, at a time when antidepressants were in wide use, and psychiatric training was beginning to reflect that. Dr. Balt now in private practice in the San Francisco Bay Area, editor-in-chief of the Carlat Psychiatry Report and runs the Thought Broadcast blog, and he joins us from member station KQED. Good to have you with us today.
STEVE BALT: Thank you, Neal, thanks for having me.
CONAN: And I wonder, can you support that regional difference that Dr. Friedman was talking about?
BALT: Well, not directly. I have to say that I was trained in New York City myself and had my further training in the San Francisco Bay area. So I've not been trained in the hinterland of the U.S., so I can't speak for how psychiatry is practiced there.
But I can say that my own training, my own trajectory, has been one of wanting to enter this field initially because I've just been fascinated by human thought and behavior. I studied a lot of psychology in my undergraduate years and thought cognitive psychology was extraordinarily fascinating, learning how people think, how people make decisions, what causes and what triggers emotions and behaviors, and I wanted to combine that with a medical science.
But what I found in the late '90s when I entered my medical training was that there was such a tremendous emphasis on novel medications, the new antipsychotics, certainly the antidepressants which had taken hold through the '80s and '90s, and of course it was the decade of the brain, so there was tremendous enthusiasm for neuroscience and what neuroscience could tell us about human behavior and thought and emotion.
And it's very seductive, in a way, to think that a particular neurotransmitter, a particular molecule, a pathway in the brain, a receptor, could explain something complicated like happiness or depression or anxiety. And so it becomes very appealing to think about medications as one-stop solutions for a number of complaints, any number of complaints that a person might bring to our offices.
Now, when I entered practice in the mid-2000s, I was surprised to find that there were few opportunities to provide therapy. In fact, most of my sessions were 15 or 20-minute sessions, particularly when I worked in a public community health clinic where I had very little time to ask anything other than how the medications are working, what symptoms is this person experiencing, rushing to a diagnosis in order to get paid for the visit, and sending them off with a prescription for a medication.
And I found that very unsatisfying because I lost sight of the human being in that whole process.
CONAN: Very unsatisfying, so - but is it unsatisfying to you? Is it worse for the patient?
BALT: Well, that's a great question. Surprisingly enough, about a year and a half ago, you may recall the New York Times had a story about Dr. Donald Levin, a psychiatrist in Pennsylvania. Nothing special about Donald. I think he reflected the state of the field. He had chosen not to do psychotherapy simply for financial reasons and to do medication management, as you discussed with Dr. Friedman.
And what I was surprised with, in that article - and there was a tremendous backlash, I think, against this mentality within psychiatry, but what I thought was more surprising was that the backlash wasn't even greater. I mean the message that I took home from that was that patients are, for better or for worse, satisfied with that type of treatment.
Now I have to say there's a very vocal minority of patients who feel that they've been hurt by psychiatry, they've been hurt by psychiatric medications. I think many of their arguments are well taken. But there's also a large number of people who seem to accept this treatment.
The patients for whom I recommend psychotherapy but choose not to because it's inconvenient, it's too expensive, et cetera, they come back to me every month, every two months, and accept their refills of their prescriptions and feel they're getting good care. And so when you ask, is this better for the patient, there's a large number of patients who seem to benefit from this whole process.
Now, we can talk about whether that's placebo effect, whether the medications are actually doing any good, whether there's something else going on in that person's life, there are lots of other explanations. But I think patients have resigned themselves to the fact that this is how psychiatric treatment is these days.
CONAN: And Dr. Friedman, have doctors, psychiatrists, resigned themselves to this is the way treatment is going to be in the future?
FRIEDMAN: I think they have, more or less, and I would add to what Dr. Balt said, you know, when answering your question, you know, do patients find this beneficial. You know, I think it depends on what the problem is and who's getting the treatment.
You know, if you're talking about people who have, you know, depressive disorders or anxiety disorders, it well may be that, you know, psychopharmacologic treatments do just as well as psychotherapies, and in particular the more severely ill they are, the more likely that is to be the case. But if they have, you know, problems, complex problems like personality disorders, where they're merely unhappy but don't actually have syndromes for which these psychotropic drugs are well-designed, they will do poorly in psychopharmacology, and they will be unhappy consumers of psychopharmacology.
CONAN: We want to hear from psychiatrists today. How has your practice changed? Give us a call, 800-989-8255. Email us, email@example.com. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION coming to you from NPR News.
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CONAN: This is TALK OF THE NATION from NPR News. I'm Neal Conan. The most frequently used medication among people between the ages of 18 and 44: antidepressants. That's according to the Centers for Disease Control and Prevention. More than one in 10 Americans use them to treat depression, anxiety disorders and other conditions, and as the use of drug treatment grew in recent years, use of talk therapy declined.
We're talking today about changes in the profession of psychiatry. We want to hear from psychiatrists in our audience. How has your practice changed? 800-989-8255. Email firstname.lastname@example.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.
Our guests are Dr. Richard Friedman, professor of psychiatry and director of the Psychopharmacology Clinic at Weill Cornell Medical College in New York, a frequent contributor to the New York Times, as well; also with us, Dr. Steve Balt, a psychiatrist with a private practice in the San Francisco Bay Area, editor-in-chief of the Carlat Psychiatry Report, he also runs the Thought Broadcast blog.
And let's get a caller on the line. Elizabeth(ph) is with us from Oklahoma City.
ELIZABETH: Hi, yes. I'm in the odd position of being in my last year of fellowship to become a psychiatrist, I'm a doctor, but also having received psychiatric and psychological therapy treatments since the age of 17. And what I thought was very interesting is earlier on the show there was some discussion about how in the 1980s and prior, a lot of training to be a psychiatrist was training to be a therapist.
And then in the boom of modern psychopharmacology, the training shifted much more to deal with medication. And I'm currently being trained in the U.T. system, actually learning to, yes, work mostly on the psychopharmacology side but to do so in conjunction with a psychologist or a social worker as therapist and that - being trained with the idea that those two parts must work together, which actually is reflected in my own experience as a patient.
Previously, I had doctors - psychiatrists, not psychologists, who either only did therapy and then did not look at how some of my personal chemical issues really just couldn't be controlled with that, or just wanted to medicate every single little thing, and then I ended up overmedicated and underserved in terms of medicine.
And I think it's - this particular discussion is very interesting, and I wanted to hear your thoughts. It's necessarily - it sounds almost like the statement is being made that it's a bad thing, the psychiatrists only being a way to medical treatment, but I personally see it as a good thing, to seeing it as separating the therapy and the medication when both are necessary to keep one particular physician from neglecting one side of the care.
CONAN: Dr. Friedman, what do you think?
FRIEDMAN: It's an interesting idea. You know, I guess you could advance an argument that, you know, you want deep expertise on each side of treatment, you want your psychopharmacologist to really understand his or her medication, and the same is true of psychotherapy.
I see it slightly differently, which is that, you know, that there's an advantage in a psychopharmacologist either being familiar with psychological issues or curious about them, even if he or she is not going to use that modality as the means of treating the patient for the reason that Elizabeth alluded to, which is in some ways you're much more likely to understand the sort of relational aspect of the patient's problem.
Like for example, most of psychopharmacology is not rocket science. It doesn't involve, most of the time, using novel treatments or unusual combinations of treatments. You know, the most common reason, for example, that people continue to get ill or depressed or anxious is they are non-adherent to treatment.
They have side effects they don't like. They have great difficulty coming to terms with having a chronic psychiatric problem both in terms of a blow to self-esteem and stigma. And all of those psychologic issues are so critically important to the outcome of a successful treatment that you want your clinician, even if the person is just prescribing medicine, to be attuned to those issues in order for the treatment to be successful.
CONAN: And working in conjunction, I guess, Dr. Balt, that might be ideal if that's what happened.
BALT: It is ideal. One of my close colleagues described the process by which we separate treatment as the psychiatrist is the mechanic for the car, where the therapist is the driving instructor. And, you know, it's a wonderful analogy, and I think it's actually fairly apt, unfortunately, but I say unfortunate because my job as a mechanic is really to make the person a better driver.
I'm not here to treat the body, necessarily, I'm here to treat the mind, I'm here to treat behaviors and thoughts and emotions and what motivates that person to get better. What does recovery look like for that individual? And yes, some of that might require that I tinker under the hood, but I also need to know how that person's driving.
Is this person a speed demon? Does this person get into accidents regularly? Does this person use their seatbelt? Those are the kinds of questions I want to answer as a psychiatrist. And one thing I'll just - I'll say with regard to Elizabeth's comments, she described herself at one point as overmedicated and underserved, and I - unfortunately, I think that that describes a lot of what we see in psychiatry today.
And we run this risk, if we require the split treatment, where psychiatrists are getting a medication and not following up on what impact this is having on that person's life and well-being. I think the overmedicated part is all too common, unfortunately.
CONAN: And overmedication in terms of dosage of any one drug or overmedication in case of, well, you've got depression so take this for that, you've got ADHD so take this for - and you can add up to be taking six or seven different drugs.
BALT: Well, that's true. Polypharmacy is certainly a large problem in our profession. But also I'd have to say that simply getting one medication alone is sometimes questionable. You started out by talking about how the most prescribed class of medication in this country is an antidepressant.
Well, the indications for which antidepressants are given are really tremendous. You know, as many as three-quarters of visits to non-psychiatrists - now I know we're talking about psychiatrists here - but non-psychiatrists are also heavy prescribers of these medications, and as many as three-quarters of those visits do not include a psychiatric diagnosis.
So antidepressants can be given for anything from premenstrual tension to backache to fatigue, and, you know, it becomes quite messy, even when only one medication is given, not to mention the fact that sometimes withdrawal from these medications can be quite complicated and difficult, and that's another element in which we psychiatrists, we - even we psychopharmacologists are rarely trained.
CONAN: Let's see if we can go next to Robert(ph), Robert with us from Cincinnati.
ROBERT: So I was trained in the early '90s, my wife and I are both child psychiatrists, and I think at that time, we had a sense that we were going to mostly do medication management as psychiatrists.
My wife was interested in being a psychologist, but her father encouraged her to go into - to become an MD to have more options. But I think she finds that her options are more limited as a psychiatrist because of the medication management. Sometimes...
CONAN: Because of medication management, that's...?
ROBERT: Because she's limited to that. And I think she would be a superb therapist. I think she uses some of her skills that she learned in her training, some dynamic, psychodynamic principles and such, with her medication management sessions, but I think that she would probably be happier if she had more therapy to do.
I find personally that as a psychopharmacologist, I don't like to think of myself exclusively as such, but there's enough work to be done with the polypharmacy in a half-hour session. And by the way, as a child psychiatrist, I have the luxury to have half-hour sessions and one-and-a-half-hour initial meetings to be able to go through an understand what we call the biopsychosocial model, all the effects on the individual, including the medication.
CONAN: And is...?
ROBERT: I have the luxury to be able to deal with polypharmacy, to be able to try to get these children off the multiple medications they're taking, or for them to understand the full extent of the side effects and the advantages of these medicines.
CONAN: I hear what you're saying, but is there anything that prevents your wife from being both, from being the medication manager and from doing long therapy sessions?
ROBERT: Well, I suppose I should explore that with her more, but I think it's the fact that there's an underserved population as far as medication management, but that could be market-driven. There may be some financial aspect to this, too. But you're right, she probably could, but I think that the insurance companies would prefer to, you know, pay less for those services.
But it may be something she may find herself doing more in the future.
CONAN: Pay less for those services from a psychologist who does not have an MD or a social worker.
CONAN: All right, Robert, thanks very much for the call, appreciate it.
ROBERT: Thank you.
CONAN: And I wanted to ask about, well, Dr. Friedman, one of the pillars of psychiatry, as I understand it going in, was that you didn't rush to make a diagnosis. You listened carefully to the patient's problems. And that's not the case these days.
FRIEDMAN: Right, sadly, you're right. I think volume rules. And, you know, when you're talking about large market forces that, you know, push for, you know, psychopharmacology, you're in a difficult situation where patients who are evaluated may be evaluated first by a non-psychiatric practitioner. In fact, most people who have mental illnesses never see psychiatrists. You know, most people are seen in a primary care setting, and most psychopharmacologic visits in this country are probably performed by non-psychiatrists.
CONAN: Interesting. We have an email from that point from James(ph): As a psychologist in St. Louis, I review many medical files in the suburbs and rural areas around here. The standard of care is a nurse with a prescription pad saying, try this.
FRIEDMAN: Yes. You are absolutely right. If you just go back to the epidemiology, you know, if you say, roughly 45 or 50 percent of all Americans in their lifetime will have either a psychiatric illness of one type or a substance abuse problem, and there are only 45,000 psychiatrists or so in the United States. You know, you come to the obvious conclusion that most people, if they have a psychiatric complaint, will never be seen by a psychiatrist.
CONAN: Are there alternatives, Dr. Balt? Are there people who do it the old way even if it costs them money?
BALT: Well, yes, there are. Before I answer that question, though, I just want to comment on the 45 to 50 percent. That's going on DSM criteria, and the DSM is the Diagnostic and Statistical Manual. It has received a lot of criticism these last few years because its fifth iteration is due next year, and there has not been a tremendous deal of transparency. I think a lot of critics are commenting and criticizing, fairly accurately, that we're starting to pathologize normal behavior.
But even with the existing DSM, the DSM-IV, to apply DSM-IV criteria in an even semi-rigorous way, we start to label a large number of people who are at one extreme of normal, or even towards the extreme of what we might call normal behavior - we start to label them. And when our visits are very short and we're only asking about symptoms coming from this book, it's very easy to diagnose, and it's very easy to come up with this massive prevalence of psychiatric disease.
And, sure, if we have a prevalence of true psychiatric disease, then I think we need more practitioners. But we need to be careful of what we're treating. Now that's not to say that somebody who's experiencing some mild depression or mild - or grief from a recent loss needs to get a prescription from a nurse practitioner. That is not ideal treatment, but we need to look at what we're counting and what we're calling psychiatric disease.
CONAN: Dr. Steve Balt is a psychiatrist with a private practice in the San Francisco Bay Area, editor-in-chief of the Carlat Psychiatry Report and runs the Thought Broadcast blog. Also with us, Dr. Richard Friedman at our bureau in New York, professor of psychiatry and director of the Psychopharmacology Clinic at the Weill Cornell Medical College in New York. You're listening to TALK OF THE NATION coming to you from NPR News.
And Alice(ph) is on the line, calling us from Huntsville, Alabama.
CONAN: Hi. You're on the air. Go ahead, please.
ALICE: Yeah. I'm a psychiatrist. I retired from my practice about five years ago. And my practice, which lasted about 20 years - I finished my training, by the way, in 1989, so it was sort of on the cusp of the explosion of neurochemistry and psychopharmacology. But my practice, throughout my 20 years of work, was pretty well balanced, psychotherapy and psychopharmacology.
I had very few patients who were getting either all one or all the other. I had patients who came in and felt very stigmatized by having been referred to a psychiatrist and didn't want to take medications. And that was always fine with me to begin with, as long as things remained manageable and we did psychotherapy.
And often those folks would come to the point of saying - well, I think they came to trust me enough to say, this medication that you mentioned in the early days, maybe we should try it. I also had a lot of patients who wanted only medication and not therapy, and that was OK with me too. But a lot of times they would switch back and forth, as well.
But I think that the story here is that people with psychiatric illnesses and their psychiatrists develop a very intense and emotionally intimate relationship, and that's an important part of treatment. It's hard for me to really believe that you can give the best psychiatric care to someone without being ready to have both of those two interventions right at the - right at hand to use for people because you're going to have to deal with people when they become noncompliant with their medications, or when they're going through a crisis, or when you're trying to get them to be admitted to a hospital and they don't want to go and their life's in danger. And these things, I think, require a longstanding and fairly deep relationship, and I'm really very happy that I was able to have my practice be that way. It's sad to think that it's moving so far in the other direction.
CONAN: Dr. Friedman, is that kind of relationship that Alice is describing critical, and is it possible under present circumstances?
FRIEDMAN: I could not agree more with Alice, who sounds very wise, and also sounds like she's had a very rich clinical experience in her career. I - I'll tell you an anecdote by way of explaining it, which is I treated once a very severely depressed woman who herself was a therapist, who, at the end of treatment, when she got better, said to me, you know, Dr. Friedman, I just want to tell you what made me better.
And I thought she was going to say, you know, this miraculous combination of medication. She said, no. It was when I first came to see you and we spent a few sessions talking about the nature of my problem. You looked at me, you told me what was wrong, and you said, you know, you are going to get better, meaning that there was something about this optimism in the human relationship and the contact that I had with her that at least the patient felt was the therapeutic action in the treatment.
And for all I know, she may have been entirely right. And I think that, you know, once we move to a model in which psychiatrists merely function as psychopharmacologists and de-emphasize the therapeutic alliance and all of the stuff that that entails, the therapeutic encounter will be all the more poorer for that. But this is, you know, driven not because it's desirable. I think it's driven largely by market forces.
CONAN: And market forces, you're talking about the number - the demand and insurance companies?
CONAN: Dr. Balt, would you agree?
BALT: I would absolutely agree. I agree with what Dr. Friedman's talking about. I agree with Alice and her comments. And I would add to it, though, that part of the relationship between the doctor, the psychiatrist and the patient is not just the emotional exchange, it's also the problem-solving technique. I was partially trained as a scientist, and one of the basic principles of science is that we come up with hypothesis for what we observe and these ought to be testable hypothesis that we can go out and test and hopefully falsify, because if we falsify a hypothesis, that means we can refine our question, we can refine our state of knowledge.
And it takes time to do that. When I see a patient return to me after four weeks and they say, well, Dr. Balt, the antidepressant is really working quite well, I have to entertain alternate hypothesis for why that might be working. Could it be a placebo effect? Could it be the impact of my relationship with that person? Could it be what else is going on in that person's life? I think those are the questions we need to ask, and we can only do that when we have the time to do so.
CONAN: Dr. Steve Balt joins us from KQED in San Francisco. Thanks for your time.
BALT: Thank you.
CONAN: And Dr. Richard Friedman joined us from our bureau in New York. Nice to have you back in the program.
FRIEDMAN: My pleasure. Thank you.
CONAN: And, Alice, thanks very much for the phone call.
ALICE: Enjoyed it. Thank you.
CONAN: When we come back, Mary Schmich of the Chicago Tribune on slacks, neat and other words that might identify us as geezers. It's the TALK OF THE NATION.
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