I had the notion that I would slowly attack the pile of articles that I had amassed over the last 7 months and be able to comment about them fairly easily in this blog. I did not consider the possibility, or rather the actuality that there would be additional articles demanding my attention as well.

And so it is with Mind Over Meds — How I Decided My Psychiatry Patients Needed More From Me Than Prescriptions, a recent article from the Sunday New York Times magazine section. I have so many reactions, it is hard to organize them in a coherent fashion. But, I will try.I will have to leave my pile of other articles for another time. This article is written by a psychiatrist, self defined as a psychopharmacologist, who comes to realize that focusing on medications only, may not be in the best service of the patient! Duh, is all I have to say. Actually, I have a lot more to say on the subject than that.

I trained as a psychiatrist before the coming of Prozac and most of the other newer and fairly effective medications that are used in 2010. In the early 80’s when medications did not seem to work as well, one was left with having to sit with the patient and talk to them to try and help them get better. I went to a psychiatric training program, University of Colorado Health Sciences Center, that focused on teaching psychodynamic psychotherapy, but also incorporated medications or psychopharmacolgy into the treatment as an intrinsic part of the whole. It was in the early days of the rise of the primacy of medications in psychiatric treatment, even if way before Prozac. My training taught me how to talk with patients and how to listen to what they were trying to tell me.

There is no question that medications can cure or treat certain psychiatric symptoms. I still remember working with a very suicidal patient years ago, when medications could just not relieve his depression or  suicidal thinking. We spent session after session developing a checklist of things to do for distraction when he became suicidal. But, we could talk til doomsday and never really impact the depression or the suicidal thinking. Along came the new SSRIs and guess what?  The new class of antidepressants not only eliminated the depression, but completely wiped away the suicidal thoughts as if they had never been there.  Without a trace! As a psychiatrist, and as a psychotherapist, the results were incredibly powerful — medications had a life changing potential.

But just as similarly, the person who comes in who may have some trouble with sleep, motivation and sadness, may not quite benefit from an antidepressant, and instead, need some time in psychotherapy to sort out what in their life may be causing her to feel out of sorts, and what might they want to about it. Providing medications and psychotherapy, in this instance, I can assess whether the psychotherapy is allowing the complaints to remit, or whether a medication needs to be added.

Dr. Carlat indicates in this article that it is easy to learn  the science: the criteria, diagnostic categories, differential diagnosis and match it all up with medications. He recognizes that learning psychotherapy is another story. It is not my purpose in this article to review the pressures he touches on in this article that have pushed the psychiatrist to become a psychopharmacologist. However, I strongly feel that medications and psychotherapy are just two of the  tools found in my tool bag that are used to help a person when the situation warrants. Just like the washing machine repairman, who needs the very large pliers and belt to remove the drum when it is not working (and only that tool will work for to fix this problem), the psychiatrist should be able to apply their art and know what is called for in the situation: medication, psychotherapy, both, or even neither.  Patient sessions can be 15, 30 or 45 minutes to tailor the appointment to the need of the patient. It does not have to be “one size fits all” and say “over the course of 15 or 20 minutes, this is about all I can offer” ! (exclamation point is mine)

It alarms me that I get referrals for treatment where the patient or referring party comments on the fact that they can’t find a psychiatrist who provides both medications and psychotherapy in a combined treatment. Dr. Carlat relies on studies and statistics to back up his conclusions. While that approach may be helpful to the general public (e.g. only 29% of psychiatrists provided psychotherapy in addition to medications in 2004, or that it is more cost effective and decreases the number of sessions when the psychiatrist does both the medications and psychotherapy), it all seems so far removed from my everyday reality. Ultimately I feel that it is the patient that suffers.

After reading this article, I really feel like a not-quite-extinct-yet-prehistoric-animal, or perhaps a lonely voice from the wilderness. Thankfully, Dr. Carlat adds his voice to the mix that there is value and benefit for a psychiatrist to be able to prescribe medications and perform psychotherapy. I am very worried that the coming changes in healthcare, which have yet to unfold, will not support this benefit and push more of us to have to provide medications only.

for further thoughts on this subject, see my entry “What is a Psychiatrist ?” on the home page of my website:www.abetterstateofmind.com