At least that’s the impression I’ve gotten after my limited exposure to certain literary sources dedicated to the medical specialty.
Two of those sources were an article about Dr. Tom Insel in the July/August 2017 edition of The Atlantic, and a book called Brain Evangelists: How Psychiatry Has Convinced Us to Believe in It’s Far-Fetched and Dubious Treatments, by Dr. Gordon Warme. Insel is the former director of the National Institute of Mental Health (NIMH) in Bethesda, Maryland, dubber of oxytocin as the “love hormone” thanks to his research with prairie voles (those monogamous rodents), and now a Palo Alto-based entrepreneur tackling mental health with technology and social media. Warme is a Toronto-based psychiatrist and a critic of many of his colleagues’ clinical techniques1.
Both the article about Insel, and the book by Warme, allude to the fact that there seems to be an exaggerrated belief in the power of pharmacological treatment in the realm of mental health. In the article, Dr. Allen Frances, director of the task force that published the fourth edition of the Diagnostic and Statistical Manual (DSM-IV), and outspoken critic of its subsequent publications2, states that the NIMH was “already moving to a narrow, bioreductionist view of mental illness” and that Insel “moved it even further.” (Dobbs, The Atlantic, July/August 2017, 83) Frances claimed that Insel’s narrowed focus had proven “disastrous” for psychiatry, and he noticed much focus on pharmacology and brain with much disregard for the psychosocial aspects of mental health.
Warme’s central message in his book is a slightly more pessimistic, and rather nihilistic echo of Frances’ lamentations.
But psychiatrists aren’t the only physicians privy to these reported observations. Ontario-based Intensivist, Matt Strauss, recently published an article about his experience with patients being wheeled into the hospital after overdosing on the very antidepressants that were prescribed for their low mood and suicidal ideation. Throughout his piece, he sets the tragic irony of it all against the backdrop of strong evidence showing the efficacy of exercise, healthy diet, talk and light therapy in the treatment of mood disorders.
And as one who is about to embark upon his journey as a resident physician in psychiatry, I can’t help but admit a certain… partial paralysis – metaphorically speaking – when reading these accounts: I can tell that something ought to be done to improve things, but what?
Fortunately, I recovered some mobility – still metaphorical – when I recently came across a New York Times article written by Dr. Lisa Pryor about the very same issues mentioned above, but with a different approach and tone.
The brain exists within a human body, which in turn exists within a family, a culture, a society, an economy. When factors outside the brain contribute to mental illness, then the solutions to those problems may also exist outside the brain. Indeed, some of the most valuable mental health interventions we have might be preventive. I am thinking here of measures to reduce poverty and child abuse, for example.
If a diagnosis is a label, a formulation is more like a story. In a few sentences, a formulation gathers up all the biological, psychological and social factors that have led to a person becoming unwell and considers how these factors interconnect. In doing so, it provides clues to the pathway out of suffering.
(Pryor, Mental Illness Isn’t All in Your Head, New York Times, 2019)
This story might take into account the individual’s genetic predisposition for mental illness, attachment to a primary caregiver as a child, developmental trauma, intellectual functioning, economic circumstances, illicit drug use or complications created by physical illness, such as thyroid disease or chronic pain.
I think what I enjoyed most about her piece was the fact that it subtly stood in contrast to what has become commonplace in psychiatric debates, and in medical education at large.
Pryor takes a shot at synthesis, while medicine tends to stop at analysis.
What am I referring to?
Descartes spurred the modern medical revolution by introducing a mathematical and mechanical approach to the human body. It is one that allowed for the conceptual isolation of discrete systems and symptoms, and deeper dives into individual organs and their corresponding physiologies. This, in turn, has caused the development of numerous subspecialties and the creation of life-altering care that would have been unfathomable even 100 years ago.
But, as an undesired sequela, René seems to have taught us how to separate and disassemble without showing us how to put it all back together.
While pursuing my Master’s in philosophy, I had an oral exam during which I had five minutes to summarize a dense, 350-page book written by a phenomenologist. Unlike a formal PhD publication, the tome did not have a thesis that was clearly spelled out; it had to be pieced together by the reader after carefully picking every chapter apart, studying each concept individually, comparing those concepts to each other, and then reassembling them to understand the whole – Gestalt – before moving onto the next chapter.
It was analysis for the sake of synthesis, and not for analysis, alone; a difficult and arduous mental task that I haven’t had to employ as much during my medical education.
In anatomy class, we’re taught to dissect, separate, and analyze, and not how to conjoin, reassemble, and synthesize. During our multiple choice exams, we’re challenged to recognize differences in patterns, but not to articulate summaries of multi-systemic physiological processes.
I would venture to say that the closest we get to synthesis as medical learners is when we present treatment plans to our supervisors. We have to look at the presenting symptoms and complaints, devise a differential diagnosis that includes the most likely pathologies that could be responsible for what we see and what the patient experiences, ask the appropriate questions and perform the most fitting physical examination(s) to narrow down the list of possible culprits, and then devise a plan comprised of treatments and tests.
But even this process isn’t as much a synthesis as it is making a decision after working through a checklist, and targeting discrete systems and symptoms for treatment.
The approach serves its purpose, no doubt, as it makes care more efficient and organized. And truth be told, if I see that you have a viral upper respiratory tract infection, remembering the intricacies of hepatic lipid production won’t be at the top of my list.
But excessive focus on one component can leave us peripherally blind, and allow us to miss the forest for the trees.
This is the worry expressed by Warme and Frances: In our pursuit of the optimal blockade of neurotransmitter receptors, we’re running the risk of losing sight of the obvious possible causes right in front of our eyes.
The problem with their approach, however, is that they analyze their counterparts’ approaches and criticize it without offering a solution. Warme, especially, seems to perpetuate the already overly analytical and fragmentary tendency that he, himself, is disappointed with by completely discrediting psychiatric medication and advocating for his own approach: Focusing on peoples’ darker tendencies and inclinations. I’ve reserved other posts to critique Warme’s work, but I will briefly say that he deprives himself of much potential credibility by not relying on or including any studies or empirical data to support his claims. It hurts his arguments, badly, because throughout his entire book, he claims that psychiatrists who do use medications to treat, do so dogmatically and superstitiously because of the lack of available evidence to justify their clinical decisions.
His method contradicts his very argument, and his thesis is riddled with untruths.
Pryor, on the other hand, tries not to favour one piece of the puzzle over the other. Nor does she try to discard any that she doesn’t quite understand. Instead, she steps back, realizes that some pieces aren’t fitting properly, and asks, “How can we do this better?”
Pryor’s article is a manifestation of a trend that is spanning beyond psychiatry, proper, and inviting western doctors to look at their practice from a different angle.
Or rather, from many more angles.
In her book, Slow Medicine: The Way to Healing, San Francisco-based General Internist, Dr. Victoria Sweet, writes about an older gentleman who bounced from specialist to specialist with intractable chronic pain until he landed in front of her. Dr. Sweet discovered that he was walking with a fractured hip.
Focusing on one piece of the puzzle just isn’t quite enough, sometimes.
In an episode about opioid addictions, The Curbsiders – one of my favourite podcasts, hosted by four General Internists – talk about the patients who frequently return to the hospital after overdosing because of their struggles with addiction. One of their conclusions is the fact that properly treating and motivating these patients will require knowledge of both medicine and psychiatry.
Our need for doctors who can strictly analyze is diminishing; our need for ones who can analyze and synthesize is increasing.
Medicine’s hunger for competent generalists is growing.
After all, the ability to strictly analyze is being outsourced to computers. We already have FDA-approved software that can read and interpret an echocardiogram in a fraction of the time needed by a Cardiologist, and Deep Learning is being used to outdiagnose entire teams of doctors in both speed and accuracy.
An organized, discrete, and static understanding of the body wasn’t sufficient to diagnose a broken hip as the cause of a gentleman’s chronic pain. That’s what Sweet recognized, especially after studying the writings of a lesser known 12th Century German mystic, Hildgard von Bingen, which inspired in her a paradigm shift that she considers worthy of consideration by today’s physicians: Rather than thinking of the body as machine, and the doctor as mechanic, von Bingen considered the body as plant, and the doctor as gardener.
It moves one’s attention from isolation to incorporation, from the static to the dynamic; from the part to the whole.
From analysis to synthesis.
A paradigm shift that might be the next step in this difficult journey of completing the jumbled psychiatric puzzle. After all, “The brain exists within a human body, which in turn exists within a family, a culture, a society, an economy.”
(C) Laughsatives ’19
1Upon my friends’ promptings to read the two sources, I knew that some of the content would clash with my own worldview as an aspiring resident physician in psychiatry. And that is precisely why I chose to read them: The only way to form balanced and well-rounded opinions about any subject is by exposing oneself to as many different perspectives as possible, synthesizing that information, and than coming to one’s own conclusions. One of my favourite bloggers, Shane Parrish, is a huge proponent of this approach.
2In 2012, Frances gave a talk at the Centre for Addiction and Mental Health in Toronto, Ontario, about the overdiagnosis of mental illnesses, and the over-medicalization of normal human behaviour.