Mostly whimsical reflections on life
One of my most rewarding, albeit unsuccessful, lobby efforts was to authorize specially trained psychologists to prescribe psychotropic drugs. The legislation failed because of opposition from psychiatrists and doctors who said psychologists lacked medical training and wouldn’t comprehend the physical effects of the drugs they prescribed.
I felt then that was a dubious claim. The vast majority of scripts for psychotropic drugs are written by primary care physicians who receive little training in the diagnosis of mental illness. The legislation would have required prescribing psychologists to consult with a patient’s primary care physician before writing a script. Primary care docs don’t have to consult with anyone before prescribing an antidepressant.
Now the British Psychological Association has produced a document that, as T. M. Luhrmann writes in a New York Times commentary, concludes “there is no strict dividing line between psychosis and normal experience.” Mental illness is more than brain disease and can be caused by conditions such as abuse, deprivation, trauma and inequality.
Psychiatrists receive training as medical doctors and psychotherapists. But the profession is shrinking and facing a patient caseload wave that has forced many psychiatrists to abandon talk therapy and act like medication managers.
“For decades,” Luhrmann says, “American psychiatric science took diagnosis to be fundamental. These categories – depression, schizophrenia, post-traumatic stress disorder – were assumed to represent biologically distinct diseases, and the goal of the research was to figure out the biology of the disease. That didn’t pan out.”
The report adds that antipsychotic medications are sometimes helpful, but that “there is no evidence that it corrects an underlying biological abnormality.” It then warns about the risk of taking these drugs for years, according to Luhrmann.
A possible outcome of this revised view of mental illness and its diagnosis is a return to talk therapy, which brings me back to the failed legislation I worked. Psychologists advocating prescription authority for their specially trained peers wanted to see fewer prescriptions written, not more. They wanted to address the wide spectrum of mental illness with a combination of talk therapy and drugs.
In light of this latest study, their arguments resonate. Talk therapy combined with medications when needed have proven to be the most effective. Professionals with psychological training are better able to diagnose symptoms, for example, better able to distinguish between anxiety and depression and decide who needs and doesn’t need an antidepressant, the use of which has exploded in recent years.
It’s impractical to provide psychological training to all medical students, so embedding specially trained psychologists into integrated health care teams makes both economic and medical sense.
Specially trained psychologists can fill the gap caused by a shortage of psychiatrists and perhaps help the practice of psychiatry to rediscover its own roots in psychotherapy combined with medication.
While it’s true the brain is part of the body, it’s also true that the brain and its functionality is distinct from the body. We can transplant a heart, but have a harder time calming a troubled heart. It certainly takes more than a scalpel. And a pill.
Luhrmann writes that the rethinking of mental illness treatment “comes at a time of disconcerting awareness that mental health problems are far more pervasive than we might have imagined. The World Health Organization estimates that one in four people will have an episode of mental illness in their lifetime. Mental and behavioral problems are the biggest single cause of disability on the planet.”
An evolving recognition of the breadth of mental illness in our population should be accompanied by an acceptance of the need for a wider phalanx of medical professionals to care for them. Smug dismissals of psychologists with advanced training in psychopharmacology aren’t helpful. Handing out prescriptions to people who are suffering, but really need someone to talk to isn’t a solution, either. We need all competent hands on deck and the prescription pad left more often in the drawer.