NATHANIEL S. LEHRMAN, M.D.

February 19, 2003

HOW DRUGS DESTROYED PSYCHIATRY

By Nathaniel S. Lehrman, M.D.

The doctor-patient relationship is important throughout medicine. In no specialty is it more important than in psychiatry, which lacks specific treatments unrelated to that relationship, such as antibiotics. In no specialty is the relationship more important than in psychiatry because of the calming, encouragement and understanding - the heart of good psychiatric treatment - which should be provided within it. And in no specialty today is it more ignored and denied than in psychiatry.

This anomalous and destructive situation has been caused by psychiatry's takeover by medications; despite the brain damage these substances cause, the specialty has become addicted to drugs.

Dr. Kerr L. White, former deputy director for medical affairs at the Rockefeller Foundation, quantified in 1991 the importance of the doctor-patient relationship. He concluded that "'factor X' - the sum of the placebo and Hawthorne phenomena - seems to account for about half of the benefits associated with medical and other health professions' ministrations" [Italics in original]. (The placebo effect depends on expectation; the Hawthorne effect is the increased productivity following any interest by management in what its workers were doing.) To repeat: about half of any physician's therapeutic impact is the direct consequence of his trusting relationship with his patient. That impact is even greater in psychiatry.

The personal impact of the general physician upon his patient was examined in psychoanalyst Dr. Michael Balint's 1957 book, The Doctor, The Patient and The Illness. It pointed out that "by far the most frequently used drug was the doctor himself, i.e. that it wasn't only the medicine that mattered, but the way the doctor gave it to his patient - the whole atmosphere in which the drug was given and taken."

Dr. Balint also noted that "no pharmacology of this important drug exists," and that "no guidance whatever [could be found] in any textbook as to [how] the doctor should prescribe himself." He concluded that "a physician's effectiveness with his patient depends largely on the patient's trust in him. The doctor's competence, integrity and sensitivity help to create and maintain that trust - to maximize the effectiveness of the 'drug' doctor."

The therapeutic impact of trust rests on expectation. The latter was the subject of a 1986 Medical Tribune editorial, "The Doctor as Therapeutic Agent" by its international publisher, the late Arthur M. Sackler, M.D.. He was commenting on an article there which cited Dr. Balint: "The MD as a Drug: the Role of Trust in Strengthening His Healing Effect."

Dr. Sackler vividly recalled a demonstration from medical school fifty years earlier. His pharmacology class had been divided into three sections: one received a central nervous system depressant, a barbiturate; the second a stimulant, amphetamine; and, without the class's knowledge, a third group was given a disguised placebo. Thinking that all class members got either a depressant or a stimulant, each was asked (before doing the tests) to indicate whether his medication was a stimulant or a depressant. Reaction times were then tested on smoked drums and mental acuity evaluated by timed arithmetic procedures.

No correlation whatsoever existed between the objective findings and the medication the medical students actually took. Correlation did exist, however, with what each believed he had taken. If the student thought it was a depressant, performance was decreased even if he had actually gotten a stimulant - and vice versa. The placebo group manifested either depressed or stimulated responses. "My classmates and I," Dr. Sackler concluded, "have retained for life a healthy respect for the effect and interrelationships between psychic and pharmacologic effects."

Expectation has powerful effects. Indeed, before scientific medicine developed in the late 19th century, expectation, based on trust in the doctor, was the latter's most important therapeutic tool. That trust underlies Ambroise Pare's classic statement, "I bound the wounds, God healed them." Any treatment given hopefully by a trusted physician will therefore have positive effects, at least briefly.

Patients trust their doctors when they begin treatment. A particularly intense type of trust is created in psychoanalysis, because the "analysis of the transference" which characterizes it represents very close attention by the analyst to the therapeutic relationship. With its focus on feelings, psychoanalysis may indeed be, as Richard Webster points out, "the only branch of the human sciences which even begins to recognize the existence of the human imagination in all its emotional complexity. In this respect, it might well be said that the incorrect theory elaborated by Freud has been infinitely preferable to no theory at all, and in the vast desert of 20th century rationalism, it is scarcely surprising that many have seen, in the drop of imaginative water which is contained in Freud's theories, a veritable oasis of truth." The relationship between a patient and the doctor who listens carefully to him can continue for years; it was recently reported that the average length of psychoanalytic treatment is five and a half years.

Psychoanalysis ruled psychiatry in the 1950's but has been replaced since then by pharmacotherapy and biological psychiatry. The latter's triumph ended not only psychoanalysts' excessive attention to the past and to the doctor-patient relationship, but also erased recognition of that relationship's importance. The baby got thrown out with the bath water.

Psychoanalysis is widely believed to be the best and deepest form of psychotherapy/counseling. But it fails badly in treating the mentally disturbed. All forms of psychotherapy/counseling have therefore been defined as equally ineffective in treating these patients. For them, psychiatric counseling has consequently been abandoned in favor of drugging.

My 1982 paper, "Effective Psychotherapy in Chronic Schizophrenia," described the successful treatment of over a hundred unselected state hospital aftercare patients. As their psychiatrist, I worked out with them ways to improve their functioning, overcome their delusions and reduce their medications. If they needed re-hospitalization, I visited them on the ward and discussed their cases with the ward psychiatrist, who, of course, did not know them. When they were released, they returned to my formal care.

The strong, continuing relationship between us was a major factor in their improvement. Indeed, the optimal organization of care for the mentally disabled requires that they continue with the same trusted psychiatrist as long as they need treatment and wherever they are. This is called continuity of care.

Public care for the mentally disabled has always been discontiunuous, with patients being treated by different doctors and treatment teams in ward and clinic. That discontinuity, and the consequent fragmentation of care, have been greatly aggravated, however, by changes in the organization of care over the past three decades.

Despite universal intuitive recognition of the importance of continuity of care - having the same doctor/caretakers treating a patient from the beginning of his illness to its end - a simple semantic redefinition, actively supported by the American Psychiatric Association, became a national rationale for accepting fragmentation. In 1980, sociologist Leona Bachrach proposed to redefine continuity of care as "the orderly, uninterrupted, and unlimited movement of patients among the diverse elements of the service delivery system" - ensuring merely that patients' papers don't get lost during repeated transfers among agencies. Her new definition was presented in a lead article in the American Journal of Psychiatry, and she was then invited all over the country to present her views.

At the time that she wrote, patients discharged from New York State psychiatric centers were cared for at clinics closely connected administratively with the ward - including the one I worked at. The clinic and ward doctors knew each other well and worked closely together. Then administrative changes justified by Bachrach's new definition increased the number of doctors and treatment teams each patient saw during the course of his illness. In New York, the most important of those various changes occurred in 1986, when aftercare services were shifted from clinics connected with state psychiatric centers to independent social agencies "in the community." One or more of the thousand agencies providing state-funded services was supposed to pick up patients discharged from hospital, but huge treatment gaps developed between ward and clinic. Even when that gap was bridged, however, the alternate raising and lowering of patients' hopes, caused by their frequent changes in caretakers (including doctors), gradually destroyed both their self-confidence and their trust.

Today's primary reliance on drugs has essentially limited the psychiatrist's role to prescribing and managing them. His overall role in patient care, and his personal knowledge of the patient and his problems, have been greatly reduced. Responsibility for discussing patients' problems with them - the physician's role for millenia - has been relegated instead to non-medicals: psychologists, social workers and "case managers," a position for which the training requirements seem to be diminishing. Rather than seeking to raise patients toward normality, as I sought to do, the non-medicals' focus is primarily on maintaining them - at current levels of inadequate functioning - and continuing their medications. When the psychiatrist sees them, he can choose only among maintaining present dosages, increasing them or changing drugs. Reducing medication is not an option available to him because it requires close, 24-hour doctor-patient contact.

The drugs interfere with normal social, intellectual and emotional functioning, so many patients want to stop them. But since sudden termination often produces explosion, and gradual reduction - the preferred method - is unavailable, patients find themselves in a catch-22 situation.

Further aggravating this dilemma is the insistence of most psychiatrists that medications be continued indefinitely despite patients' objections. This difference can transform the doctor-patient relationship, which should be a major positive therapeutic force, into one which is adversarial and, therefore, overtly anti-therapeutic.

Many patients believe the drugs have helped them because they improved after starting to take them. But most of whatever improvement occurs - and that improvement is much less with major mental illness today than it was before the drug era - is based on the physician's expectations and the patient's acceptance. So far as I was concerned, however, I continued whatever drugs patients seemed to accept, but tried gradually to reduce them as far as I could.

Nathaniel S. Lehrman, M.D., 10 Nob Hill Gate, Roslyn NY 11576; 516/626-0238; former Clinical Director, Kingsboro Psychiatric Center, Brooklyn NY