This collection of articles is put together by psychiatrists at the heart of the establishment of American Psychiatry. 
Weissman is at Loyola University Stritch School of Medicine, Sabshin is
Medical Director Emeritus of the APA, and Eist is a past president of the
APA. It features articles by notable
psychiatrists such as Glen Gabbard, Steven Hyman (director of NIMH), Donald
Klein, and Harold Pincus. So this is as
close to a definitive statement about the current and future state of
psychiatry as we are likely to get from those at the head of the profession.

According to the editors, the book
is aimed at practicing psychiatrists; the introduction says it is designed to
provide “the conceptual tools that will enable him or her to assess and use
psychiatry’s vast professional literature base” and also provide “a basis on
which to effectively assess the presentations at scientific meetings.”
(xxiii). However, this stated aim seems
to sell the book short, since it does more than this. It gives us an opportunity to assess at least some aspects of
psychiatry as it is currently understood, and to contemplate the future role of
psychiatry in our society.

There are twenty chapters grouped
into four sections: the first is in two parts, “The Impact of Changing
Conceptual, Organizational, and Philosophical Issues and on the Shape of
Psychiatry,” and “The Impact of Research Findings on the Shape of Psychiatry,”
then The Practice of Psychiatry, The Psychiatric Workforce and Its Education,
and finally, The Future.

Joseph Coyle writes on “The
Neuroscience Revolution and Psychiatry.” 
He sets out come of the advances in out understanding of how mental
disorder affects the brain, and some of the discoveries in genetics and
molecular psychology. He expresses hope
that our expanded knowledge will lead great advances in treatment through medication,
but he also emphasizes the dangers of reductionist attitudes. He emphasizes that environment and
psychotherapy can have measurable effects of people’s emotional lives and their
brains. He also stresses that psychiatric
training needs to broad enough to enable psychiatrists to be leaders, and that
we need to reverse the current trend of managed care putting the least
qualified mental health professionals in charge of mental health care. The chapter contains a great deal of
interesting scientific information, presented in a technical manner that will
be intimidating to people who are not familiar with the notation and
terminology.

Weissman’s chapter on psychoanalysis
is lightweight. He defends ten major
psychoanalytic concepts by responding to critiques of psychoanalysis. He says that there are two main reasons why
psychoanalysis has been held in disrepute recently. First, people think that recent advances in neuroscience have
undermined it because psychoanalytic thinking is dualist. Second, philosophers and others have
criticized psychoanalysis for failing to meet the criteria of good
science. Weissman’s response it to
point out that psychoanalysis is compatible with monism about the mind, and
that Freud himself was a monist. 
Furthermore, he points out that neuroscience has not provided anything
like an explanation of the nature of experience. He also says that although it is true that psychoanalysis is not
as scientific as Newton’s theory of motion, this is not a significant
criticism. He points out, citing Duhem
and Quine, that confirmation or falsification is never a simple relation
between a single observation and a theory. 
He then goes on to discuss familiar concepts of consciousness, the
dynamic unconscious, repression, defense mechanisms, models of the psychic
apparatus, drives, identification, empathy, and Kohut’s concept of selfobject,
giving a few examples to illustrate these concepts.

This defense of psychoanalysis and
in particular his criticism of Adolf Grűnbaum (whose name he consistently
misspells throughout the paper) are weak. 
Grűnbaum is well aware of the work of Duhem and Quine, and his
criticism of Freud rests on a particular argument of Freud’s, which he calls
the “Tally argument.” Weissman says nothing
to give the reader any reason to think that psychoanalysis has a good
evidential base or is worth taking seriously. 
His assertion that people object to psychoanalysis because it is
dualistic may be true, but this objection is not one that is taken seriously by
any of the informed parties to the debate over psychoanalysis, since it is well
known that Freud’s project was ultimately based on the hope that the mind could
be understood in terms of brain function and that psychoanalytic theory be
vindicated by out understanding of the brain. 
Insofar as modern neuroscience is a threat to psychoanalysis, it is
because it shows little sign of actually vindicating Freudian models of the
mind.

In the paragraphs setting out
psychoanalytic concepts, Weissman seems to take himself as showing their
usefulness in relation to his examples. 
Of course, his discussion here is so brief that it could not possibly do
anything more than hint at a defense of psychoanalysis, and he does not even
acknowledge that there may be competing explanations of the phenomena he
mentions. These limitations of space is
of course inevitable given the place of the paper in the book – a defense of
psychoanalysis would really require a book – but it’s striking that Weissman
does not refer to one other work that defends psychoanalysis from its
critics. Not only does Weissman fail to
defend psychoanalysis here from anything but the most superficial criticisms,
but also his paper exemplifies the shoddy state of thinking about
psychoanalysis in psychiatry today.

Joseph A. Flaherty and Boris M.
Astrachan write chapter 3 on social psychiatry. This outlines how social issues and
sociological discussion impact on psychiatry. 
It includes epidemiology, substance use and abuse, violence, aggression and
trauma, and breakdown of family bonds. 
The simple message is that sociological issues are relevant to
psychiatry. The chapter contains no
controversial claims.

Sidney Weissman writes on psychiatric
diagnosis. He explains how DSM-IV
came to be as it is, and how we could improve our classification scheme. The discussion is a little
idiosyncratic. It does not engage with
other major discussions of psychiatric diagnosis. Daniel Offer’s chapter on “Normality and the Boundaries of
Psychiatry” is also eccentric. This
builds on previous work of Offer and Sabshin, and makes the basic point that
psychiatrists are better at identifying abnormality than normality. Studying normal coping methods and ways of
living can be helpful to psychiatric practice.

Lois Flaherty’s “The Evolution
of Psychiatric Subspecialities” ends this section of papers. She points out that psychiatry has fewer
subspecialities than other areas of medicine, and she suggests this may be due
to the psychoanalytic ideal that practitioners should be able to master all
psychopathology. But given the modern
pressures of clinical practice, it is inevitable that there will be increasing
specialization, and the psychoanalytic idea is now less commonly shared. Child psychiatry and geriatric psychiatry
are the major specialities, but she also discusses clinical neurophysiology,
forensic psychiatry, and other subfields, and the effect of increasing
specialization on the whole field. She
provides a competent survey of issues.

In Chapter 7, Steven Hyman explains
“The Role of Genetics and Molecular Biology in Research on Mental Illness.” This is basically the information one would
also find in a psychiatric textbook. It
is rather technical and only readers with a strong background in biology will
be able to follow the details. There’s
very little discussion of the future of any of the wider implications of
current research for the future of psychiatry. The chapter deals with a large
topic, and so it’s inevitable that it cannot deal with all aspects of the
issue, but given the theme of the book, it is still disappointing that the
chapter does not venture into more speculation.

Another chapter of great potential
interest is “Functional Brain Imaging: Future Prospects for Clinical
Practice,” by Joseph Callicott and Daniel Weinberger. Neuroimaging has been one of the greatest
areas of growth in modern psychiatry and there are often tantalizing
announcements of new advances in the field. 
The authors start by noting how few clinical applications have resulted
from research so far. The most common
application is n the identification of structural pathology. But the authors note that the structural
abnormalities associated with the major mental illnesses are likely to be
subtle, and they stress the difficulties of acquiring useful data when scanning
people with major mental illnesses. 
Given these concerns, they ask whether clinical functional neuroimaging
is feasible. They give a brief but
technical summary of recent scientific progress in the field. The upshot of the summary is that brain
imaging cannot yet provide a diagnosis of a patient, but the authors remain
optimistic that it will soon produce clinically useful results. New technology
is developing that is less invasive, nonradioactive, and which can provide more
fine-grained images.

The next section deals with the
practice of psychiatry. First to come
under scrutiny is the use of practice guidelines, by John McIntyre,
Deborah Zarin and Harold Pincus. They
assert that the APA (American Psychiatric Association) has “developed a
rigorous process for the development of practice guidelines.” (143). 
The aim is to assist clinicians and patients in clinical
decision-making. These standards and
options provided are not meant to be inviolable rules, but the authors say that
exceptions to the recommendations “should be rare and require considerable
justification.” (143).

           According
to the authors, there are at least four reasons for the explosion in the
development of practice guidelines in a wide range of professions.

1. There
   has been an exponential growth in our knowledge base, and so it is very
   difficult to stay abreast of the latest developments, and it is hard to
   integrate all the data available.
2. Health
   care costs have risen dramatically, and it has become necessary to contain
   expenditure. Guidelines help to do
   this.
3. National
   guidelines help to minimize regional variation on treatment approaches.
4. The
   availability of guidelines helps patients and potential patients to be
   more involved in the decision-making process.

Recently in the health care profession, there has been more
need for standardized guidelines, and the AMA has provided a series of
principles to be followed in the development of guidelines. The Institute of Medicine identified eight desiderata
for guidelines: validity, reproducibility, clinical applicability, clinical
flexibility, clarity, multidisciplinary process, scheduled review, and
documentation. (146)

There is also resistance to the use
of guidelines. Some have complained
that they lead to a ‘cookbook’ approach to dealing with patients, and that they
will limit innovations, as well as increasing professional liability
exposure. The authors suggest that
guidelines should acknowledge their limitations, especially with regard to evidence,
and this will leave room open for innovation. They also note that APA
guidelines emphasize that they are not intended to serve as a standard of
medical care, and that they do not ensure a successful outcome of treatment.
They also say it is unclear what impact guidelines have on professional
practice.

The authors move on to setting out
the APA guidelines for developing guidelines. 
The eight stages are:

• Topic
  selection,
• Work
  group appointment,
• Evidence
  definition,
• Draft
  development,
• Review
  process,
• Dissemination
  and implementation,
• Evaluation,
  and
• Revision.

These are very much what one would expect. The guidelines have the following format:

I.                   
Executive Summary (with different recommendation weighted with
its level of clinical confidence; substantial, moderate, or on the basis of
individual circumstances)

II.                
Disease Definition, Epidemiology, and Natural History (which
uses DSM-IV)

III.              
Treatment Principles and Alternatives (three broad categories:
psychiatric management, psychosocial interventions, and somatic interventions)

IV.             
Formulation and Implementation of a Treatment Plan

V.                
Clinical Features Influencing Treatment

VI.             
Research Directions

VII.           
Individuals and Organizations That Submitted Comments

VIII.        
References

Again, these are very much as one would expect. The authors note that the development of
guidelines has helped to identify gaps in psychiatric knowledge. The APA is taking steps to fill those
gaps. It has formed the APA practice
research network (PRN) to increase the communication between researchers and
clinicians. By 2000, it will have over
1000 APA members.

Glen Gabbard writes an impressive
chapter on “The Psychiatrist as Psychotherapist.” He cites a wide range of data that
demonstrate that psychotherapy is effective even with disorders identified as
“disorders of the brain” such as schizophrenia and manic depression. He emphasizes that it is important that
psychiatrists continue to perform psychotherapy. He expresses concern about the trend towards psychiatrists
becoming merely dispensers of pills while other people with fewer
qualifications do therapy. He argues
that not only does it improve the quality of treatment when it is one and the
same person providing psychological and biological treatments, but also this
approach can in the long term be the most cost-effective. One of the major reasons for relapse of
people with serious mental illnesses is that they stop taking their medication,
and when psychiatrists are psychotherapists, patients tend to keep on taking
their medication more than in other treatment circumstances. While it may save money in the short term to
get non-psychiatrists to do psychotherapy, this often turns out to be a false
economy. Of course, it seems likely
that Gabbard’s warnings will go unheeded; managed care continues to divide
treatment between different specialists, and most of the signs point toward
psychiatrists having only one function, to prescribe medication.

           Maybe it is
worth lamenting the fact that Gabbard has nothing to report on recent research
on new forms of psychotherapy. He takes
it as given that we know the range of forms of psychotherapy that might be
available, and while he acknowledges that some may be more appropriate for some
kinds of disorders, Gabbard does not focus much on the differences between
different kinds of psychotherapy. One
gets the impression that psychiatric research now has no interest in the idea
of making psychotherapy better and improving its techniques.

           The trend
away from psychiatric psychotherapists might not alarm the author of the next
chapter, Alan Schatzberg, who writes on “Psychopharmacology in the New
Millennium.” He surveys some of the
medications that have come into use recently. 
These are mostly approved for use as antidepressants, although they are
used in a wide range of mental disorders. 
The discussion is somewhat technical, depending on many terms from
neuroscience, so it may be beyond the understanding of non-specialists. He does discuss some of the new directions
of research on psychopharmacology, but one can’t help keeping in mind that much
of the research currently performed is confidential, since it is funded by
corporations planning to make a profit from their research.

           It is good
that more attention is being paid to the efficacy of psychiatric medication
with special populations, such as women and racial minorities. It is a little disappointing that he did not
mention the use of medication on children, even though such use of medication
has increased significantly in recent decades and looks set to continue this
upward trend. Schatzberg emphasizes
that the psychopharmacologist of the future will have to have even broader
knowledge than before, but this is compatible with retaining an understanding
of the whole person and a humanistic approach to mental disorders. It is not clear, however, what steps the
profession is taking to ensure that future researchers on brain processes do
not lose sight of the persons who experience mental illnesses.

           Especially
interesting is the division of labor between psychotherapy and medication in
the treatment of mental disorders, and this is taken up by Mark Levy in “A
Clinical Model for Selecting Psychotherapy or Pharmacotherapy.” There have been some theoretical arguments
that they are incompatible with each other, but no empirical evidence backs up
such a view. Indeed, evidence suggests
that for many mental disorders, a combination of talk therapy and medication is
most effective. This still leaves us to
explain why this is, and what kind of contribution to health each treatment
modality makes. Levy surveys various
answers to this question, and also suggests some problems with those
answers. Some have argued, in a
“two-track model,” that medication and psychotherapy treat different aspects of
a mental disorder, but there’s little evidence to support this as a general
thesis. There are methodological
problems too: it can be hard to separate out the effects of the two, since
there are psychodynamic issues even in the interaction between a patient and
the psychopharmacologist, and the medication can alter the course of
psychotherapy. The alternative to the
two-track model is a unified model using an integrated approach, and Levy finds
this has many advantages. He points out
that there is an important parallel in the discussion of the comparative
benefits of different kinds of psychotherapy, and this leads him to a
fascinating discussion of technical eclecticism versus theoretical
integration. He sets our various
proposals about how to unify different approaches, and goes into detail in
presenting a conceptual model for anticipatory anxiety. His positive proposal is somewhat
provisional and certainly it has elements that some will find problematic, but
it merits investigation. Even if his
specific proposals do not win universal agreement, his discussion makes a
strong case that these issues are at the center of the future of psychiatric
theorizing. Levy’s brief descriptions
of some patients help to bring this point home.

           In chapter
13, Donald Klein goes into related issues, explaining some of the technical
details of trying to measure the effectiveness of psychotherapy compared with
pharmacotherapy. He emphasizes the
difficulty of getting reliable data, because of the problem of creating a true
pill placebo group. He says that using
studies of people on a wait list as a control group leads to positively biased
estimates of efficacy. He insists that
a pill placebo case management control group is necessary in comparing
pharmacotherapy with psychotherapy, and suggests that studies that have been
performed without such a control group were a waste of time and money. He is also skeptical about the value of
meta-analyses of previous studies. A 1990
study by Robinson et al. “demonstrated that the investigator’s alligiance may
play an overriding role in determining differential treatment outcomes because
partialling for allegiance removes any difference in effectiveness between
studies.” (p. 227). He concludes that
it is difficult to prove the effectiveness of psychotherapy over placebo or to
show any significant differences in different forms of psychotherapy. Klein’s conclusion is that more careful work
needs to be done in measuring the effectiveness of treatment.

The next two chapters have a good
deal of overlap, although they have differences in approach. Steven Sharfstein’s “Less Is More:
Financing Mental Health Care for the New Century” details some of the major
changes in the in the structuring of psychiatric treatment over the last
century, and especially the rise in managed care companies. His approach is to give a rather sweeping
survey of major trends, and he gives only two references, one being the 1952
DSM, and the other being a 1983 APA report on “Madness and Government.” In striking contrast, Jeremy Lazarus, discussing
“Ethical Conduct of the Psychiatrist,” gives three pages of references;
he focuses on how the rise in managed care introduces new ethical issues for
psychiatrists. Sharfstein suggests that
a major issue is the fact that health insurance does not treat major mental
illness and major physical illnesses equally, and lifetime limits on
compensation tend to be much less for psychiatric treatment. He also points out that often outpatient
care, day hospital, and residential alternatives for major mental illness is
more cost-effective than inpatient care. 
For some reason he does not explain, he voices extreme optimism about
the future of psychiatric care, saying that the remedicalization of psychiatry
will lead to greater integration of mental health care with the rest of
medicine, and this will ensure that there will be no more discrimination
against the mentally ill. The challenge
for the future is to ensure that mental health care is regulated in an ethical
manner, with humane treatment for the seriously ill. Given that allocation of funds for different forms of health care
is inevitable, which is to say that we cannot avoid rationing treatment,
Sharfstein points out that the standard methods of cost containment and profit
making – “risk selection, denial of care, and the dumping of the most seriously
ill,” (247) – need the oversight of government to avoid the problematic
policies this mentality can lead to. He
suggests that the APA needs work as an advocate in order to ensure the future
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Categories: Philosophical, General

Tags: Psychiatry, Behavioral and Cognitive Sciences