Mind Over Meds
Mind Over Meds
One day several years ago, I was reaching the end of my first visit with a patient,
J.J., who had come to see me for anxiety and insomnia. He was a salesman for a
struggling telecommunications company, and he was having trouble managing
the strain on his finances and his family. He was sleeping poorly, and as soon as
he opened his eyes in the early morning, the worries began. “I wake up with a
list of things to worry about,” he said. “I just go through the list, and it seems to
get longer every day.”
A psychiatric interview has a certain rhythm to it. You start by listening to what
your patient says for a few minutes, without interrupting, all the while sorting
through possible diagnoses. This vast landscape of distress has been mapped
into a series of categories in psychiatry’s diagnostic manual, DSM-IV. The book
breaks down mental suffering into 16 groups of disorders, like mood disorders,
anxiety disorders, psychotic disorders, eating disorders and several others. As I
listened to J.J. (a nickname that he agreed I could use to protect his privacy), it
was clear to me that he had one of the anxiety disorders, but which one? In order
to systematically rule in or rule out the disorders, I asked J.J. dozens of
Mind Over Meds
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questions. “Do you have panic attacks?” “Do you get fearful in crowded
situations?” “Have you ever experienced a traumatic event that later caused
flashbacks or nightmares?”
Each of J.J.’s answers provided me with a clue, closing off one possibility while
opening up others. At its best, when you are working with an intelligent,
insightful patient, the process is fun, involving a series of logical calculations,
much like working a Sudoku puzzle. Finally, toward the end of the hour, I felt
confident that I had arrived at J.J.’s diagnosis. “I think you have what we call
‘generalized anxiety disorder,’ ” I told him. It may start with a defined series of
causes, as was true for J.J., but then it spirals outward, blanketing the world with
potential threat. J.J. worried about what the future would bring and experienced
a predictable series of physical symptoms: insomnia, muscle tension, irritability
and poor concentration.
“I’m going to write you a prescription for a medication called Zoloft,” I said,
picking up my prescription pad. He asked what was causing his anxiety, and I
began one of the stock neurochemical explanations that psychiatrists typically
offer patients about low serotonin levels in the brain. The treatment involved
“filling up the tank” by prescribing a medication like Zoloft, Celexa or Paxil.
“So Dr. Freud, the causes are all in the brain? Isn’t there some explanation in my
childhood?” It was a good-natured tease.
“I specialize in prescribing medications,” I said with a smile. I was a
psychopharmacologist and specialized in medication rather than psychotherapy.
“I can refer you to a good therapist in the area if you’d like.”
After J.J. left my office, I realized, uncomfortably, that somehow, over the course
of the decade following my residency, my way of thinking about patients had
veered away from psychological curiosity. Instead, I had come to focus on
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symptoms, as if they were objective medical findings, much the way internists
view blood-pressure readings or potassium levels. Psychiatry, for me and many
of my colleagues, had become a process of corralling patients’ symptoms into
labels and finding a drug to match.
Leon Eisenberg, an early pioneer in psychopharmacology at Harvard, once
made the notable historical observation that “in the first half of the 20th century,
American psychiatry was virtually ‘brainless.’ . . . In the second half of the 20th
century, psychiatry became virtually ‘mindless.’ ” The brainless period was a
reference to psychiatry’s early infatuation with psychoanalysis; the mindless
period, to our current love affair with pills. J.J., I saw, had inadvertently
highlighted a glaring deficiency in much of modern psychiatry. Ultimately, his
question would change the way I thought about my field, and how I practiced.
I originally became interested in psychiatry primarily because of my father: he
is a psychiatrist practicing in San Francisco. But there was a darker side to my
career choice. My mother suffered severe mental illness, with debilitating
depressions and paranoid thoughts. One autumn day during my junior year in
college, she committed suicide. Psychiatry then became personal, a way for me
to come to terms with her illness.
I majored in psychology at U.C. Berkeley, and at U.C. San Francisco I labored
through medical school’s rites of passage in order to qualify for a psychiatric
residency. Eventually, on a steamy July day in 1992, I stood on a Boston street,
far from home, gazing at Massachusetts General Hospital (known as M.G.H.),
where I was about to start my training.
This was a momentous time at M.G.H. Prozac was introduced four years earlier
and became the best-selling psychiatric medication of all time. Zoloft and Paxil,
two similar medications, were in the pipeline, and many of the key clinical trials
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for these antidepressants were conducted by psychiatrists at M.G.H. who were
to become my mentors. M.G.H. and other top programs were enthralled with
neurobiology, the new medications and the millions of dollars in industry grants
that accompanied them. It was hard not to get caught up in the excitement of the
drug approach to treatment. Psychopharmacology was infinitely easier to
master than therapy, because it involved a teachable, systematic method. First,
we memorized the DSM criteria for the major disorders, then we learned how to
ask the patient the right questions, then we pieced together a diagnosis and
finally we matched a medication with the symptoms.
But learning the formal techniques of therapy was like navigating without a
compass. While I learned how to form an alliance with my patients and begin a
good dialogue, becoming a skillful therapist requires much more practice than
busy psychiatry residencies allow.
When my father did his residency at U.C.S.F. in the 1950s, he learned therapy
well, because, with few medications available, it was the main treatment
psychiatrists could offer their patients. Psychiatric residencies focused on
therapy, and many residents extended their training further by enrolling in
postgraduate psychoanalytic institutes. When modern medications came on the
scene, my father adapted by incorporating them into his therapy practice, as did
many of his colleagues. I call this the “golden” generation of psychiatrists, those
currently approaching retirement age, who were skilled at offering the full
package of effective psychiatric treatments to patients.
The newer generation of psychiatrists, who graduated in the 1980s and
afterward, trained in programs that were increasingly skeptical of therapy and
that emphasized a focus on medications. M.G.H. was by far the most influential
of these modern programs. Graduates of the M.G.H. program and its sister
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program at nearby McLean Hospital have fanned out throughout the country,
becoming chairmen of departments and leaders of the National Institute of
Mental Health.
A result is that psychiatry has been transformed from a profession in which we
talk to people and help them understand their problems into one in which we
diagnose disorders and medicate them. This trend was most recently
documented by Ramin Mojtabai and Mark Olfson, two psychiatric
epidemiologists who found that the percentage of visits to psychiatrists that
included psychotherapy dropped to 29 percent in 2004-5 from 44 percent in 1996-
97. And the percentage of psychiatrists who provided psychotherapy at every
patient visit decreased to 11 percent from 19 percent.
While it is tempting to blame only the biologically oriented psychiatrists for this
shift, that would be simplistic. Other forces are at work as well. Insurance
companies typically encourage short medication visits by paying nearly as much
Reinhard Hunger; Set Design by Sarah Illenberger
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for a 20-minute medication visit as for 50 minutes of therapy. And patients
themselves vote with their feet by frequently choosing to see
psychopharmacologists rather than therapists. Weekly therapy takes time and is
arduous work. If a daily pill can cure depression and anxiety just as reliably, why
not choose this option?
In fact, during my 15-to-20-minute medication visits with patients, I was often
gratified by the effectiveness of the medications I prescribed. For perhaps a
quarter of them, medications worked so well as to be nearly miraculous. But
over time I realized that the majority of patients need more. One young woman I
saw was referred to me by a nurse practitioner for treatment of depression that
had not responded to several past antidepressants. She was struggling to raise
two young children and was worried that she was doing a poor job of it. Her
husband worked full time and was rarely available to help. She cried throughout
our initial interview. I started her on Effexor and referred her to a social-worker
colleague. She improved initially, but over the years since, her symptoms have
waxed and waned. When she reports a worsening of her anxiety or depression,
my first instinct is to do one of three things — switch medications, increase her
dosage or add another. Over the course of 15 or 20 minutes, this is about all I can
offer.
My treatment of this young woman follows the “split treatment” model, but a
less charitable description is “fragmented care.” Like the majority of
psychiatrists in the United States, I prescribe the medications, and I refer to a
professional lower in the mental-health hierarchy, like a social worker or a
psychologist, to do the therapy. The unspoken implication is that therapy is
menial work — tedious and poorly paid.
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But over the past few years, research studies have shown that therapy is just as
effective as medications for many conditions, and that medications themselves
often work through the power of placebo. In one study, for example, researchers
did a meta-analysis of studies submitted by drug companies to the F.D.A. on
seven new antidepressants, involving more than 19,000 patients. It turned out
that antidepressants are, indeed, effective, because on average patients taking
the pills showed a 40 percent drop in depression scores. But placebo was also a
powerful antidepressant, causing a 30 percent drop in depression scores. This
meant that about three-quarters of the apparent response to antidepressants
pills is actually due to the placebo effect.
Nobody knows exactly how the mysterious placebo effect works, but it is clear
that it has impacts on the brain that can be seen as clearly as medication effects.
In one study conducted by pain researchers at the University of Michigan,
subjects were given an ache-inducing injection of saline into their jaws and were
placed in a PET scanner. They were then told that they would be given an
intravenous pain treatment, but the “treatment” was merely more saline
solution, acting as a placebo. The PET scan showed that the endogenous
endorphin system in the brains of the subjects was activated. The patients
believed so strongly that they were receiving effective treatment that their
brains followed suit. Presumably, a corresponding brain change occurs when
depressed patients are given placebo pills.
Like placebo, psychotherapy has typically been considered a “nonbiological”
treatment, but it has become clear that therapy, like placebo, also leads to
measurable changes in the brain. In an experiment conducted at U.C.L.A.
several years ago, with subjects suffering from obsessive-compulsive disorder,
researchers assigned some patients to treatment with Prozac and others to
cognitive behavior therapy. They found that patients improved about equally
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well with the two treatments. Each patient’s brain was PET-scanned before and
after treatment, and patients showed identical changes in their brain circuits
regardless of the treatment.
In depression treatment, too, pills and therapy each lead to brain changes, but in
this case they appear to be intriguingly distinct. In studies by Helen Mayberg, a
professor of psychiatric neurology at Emory University, depressed patients
given cognitive behavior therapy showed decreased activity in the frontal lobe,
the brain center that might be responsible for the overmagnification of life’s
problems that leads to depression in some patients. And they showed increased
brain activity in parts of the limbic system, a brain region associated with strong
emotion. But Mayberg found that when patients were given medication, their
brain activities changed in the opposite direction, stimulating the frontal lobe
and damping down the limbic system. “Our imaging results suggest that you can
correct the depression network along a variety of pathways,” she said.
Clearly, mental illness is a brain disease, though we are still far from working out
the details. But just as clearly, these problems in neurobiology can respond to
what have traditionally been considered “nonbiological” treatments, like
psychotherapy. The split between mind and body may be a fallacy, but the split
between those who practice psychopharmacology and those specializing in
therapy remains all too real.
After I saw J.J., I decided that I wanted to try to change my approach to
treatment. I gradually began to carve out room in my schedule for longer visits
with my patients. I endeavored to do what’s called “supportive” therapy, a
technique favored by many therapists and involving basic problem solving and
emotional support. It is a bit like what a friend would do for another friend
offering advice in times of trouble, but more elaborate and with an
accompanying raft of studies endorsing its effectiveness in psychiatry.
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When I started to probe my patients, I realized I barely knew most of them. I
had exuberantly documented their moods, sleep habits, energy levels and
whether they had suicidal thoughts, but I didn’t know what made them tick as
people. For example, I had treated Jane (her middle name), a health care
administrator in her 40s, for depression and bulimia for many years, focusing on
a complicated combination of medications like Effexor, Provigil and Xanax. Then
she had a depressive relapse. This time, rather than simply adjusting her
medication, I asked her what was going on in her life. I found out that her boss
had recently given her an impossible assignment to complete and had berated
her when the results were not to his liking. It seemed clear to me that her
depression was partly triggered by the fact that she blamed herself for her
boss’s poor communication skills and managerial lapses. I encouraged her to
question that assumption each time it popped into her mind. Over the next few
visits, she improved — relating better to her boss, able to take his criticism with
a grain of salt and feeling more confident.
But while my simple therapeutic suggestions were helpful, as Jane and I
continued to explore her work issues in detail, she said that she often lacked
focus on the job. Knowing that poor concentration can be a symptom of
depression, I asked if she associated her distractibility with periods of sadness.
But she said there was no such correlation with her moods.
I wondered if she might have an adult version of attention deficit disorder.
Indeed, carefully reviewing her years in school, I saw she was always easily
distracted but overcame this problem by working extra hard, and managed to
achieve good grades. Even now, her job performance was consistently rated as
excellent, but the extra work this entailed sapped her energy.
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I decided to prescribe her a version of Ritalin, the standard treatment for A.D.D.
The next month, she said she felt that this medication had turned her life around.
Not only did she feel more focused and productive at work, but she was more apt
to get things done at home, which in turn enhanced her mood, indirectly
improving her depression.
Is Jane’s story an argument for psychiatrists providing both medication and
some sort of psychotherapy? I think it is. This does not mean that dedicated
psychotherapists are not crucial — they are, because they can provide the in-
depth therapy that psychopharmacologists will never have time to deliver. When
our patients need more from us than just medication, however, we should be
prepared to provide it. Oddly, managed-care companies discourage us from
doing psychotherapy, arguing that it is cheaper to have psychiatrists do 20-
minute medication visits every three months and to hire a lower paid non-M.D.
for more frequent therapy visits. But the few studies that have analyzed the
economics of these arrangements have found that integrated treatment actually
saves money. Mantosh Dewan, the chairman of psychiatry at SUNY Upstate
Medical University in Syracuse, found that when psychiatrists do both
medication and psychotherapy, the overall amount of money paid out by
insurance companies is actually less than when the treatment is split between
psychiatrists and psychotherapists. When patients see only one provider, they
require fewer visits overall.
It may be time to consider whether the term “psychopharmacologist” is actually
doing damage to the field of psychiatry. The American Society of Clinical
Psychopharmacology defines “psychopharmacology” on its Web site as “the
study of the use of medications in treating mental disorders.” But in a recent
article, three Harvard psychiatrists (interestingly, two of them from Mass
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General) have pointed out that no other medical specialty has carved out a
separate “pharmacology”subspecialty. Good doctoring, they remind us, involves
perfecting all the skills relevant to healing and deploying them when needed.
During my mother’s last months, she isolated herself from her family, so I don’t
know what kind of treatment she was receiving before her death. But I do know
what kind of treatment I would have hoped for her. She needed medication to
combat her paranoia and the emotional pain of her depression. She needed
someone who could expertly probe her thought process, in order to understand
the fateful logic that led her to conclude that the only solution was to end her
own life. She needed treatment that was intensive and exquisitely coordinated.
Such care is not always capable of saving damaged lives. But it is the best that
we can do. It’s what we owe our patients — and ourselves.