Andres Barkil-Oteo is an assistant professor of psychiatry at Yale University School of Medicine, with research interests in systems thinking, global mental health, and experiential learning in medical education. Find him on Google+ here.
Last spring, the American Psychiatric Association (APA) sent out a press release [pdf] noting that the number of U.S. medical students choosing to go into psychiatry has been declining for the past six years, even as the nation faces a notable dearth of psychiatrists. The Lancet, a leading medical journal, wrote that the field had an “identity crisis” related to the fact that it doesn’t seem “scientific enough” to physicians who deal with more tangible problems that afflict the rest of the body. Psychiatry has recently attempted to cope with its identity problem mainly by assuming an evidence-based approach favored throughout medicine. Evidence-based, however, became largely synonymous with medication, with relative disregard for other evidence-based treatments, like some forms of psychotherapy. In the push to become more medically respected, psychiatrists may be forsaking some of the important parts of their unique role in maintaining people’s health.
Over the last 15 years, use of psychotropic medication has increased in all kinds of ways, including off-label use and prescription of multiple drugs in combination. While overall rates of psychotherapy use remained constant during the 1990s, the proportion of the U.S. population using a psychotropic drug increased from 3.4 percent in 1987 to 8.1 percent by 2001. Antidepressants are now the second-most prescribed class of medication in the U.S., preceded only by lipid regulators, a class of heart drugs that includes statins like Lipitor. Several factors have contributed to this increase: direct-to-consumer advertising; development of effective drugs with fewer side effects (e.g., SSRIs); expansion in health coverage for mental illness made possible through the Mental Health Parity Act; and an increase in prescriptions from non-psychiatric physicians.
Unfortunately, not all of these psychiatric drugs are going to good use. Antidepressive drugs are widely used to treat people with mild or even sub-clinical depression, even though drugs tend to be less cost-effective for those people. It may sound paradoxical, but to get more benefit of antidepressants, we need to use them less, and only when needed, for moderate to severe clinically depressed patients. Patients with milder forms should be encouraged to try time-limited, evidence-based psychotherapies; several APA-endorsed clinical guidelines center on psychotherapies (e.g., cognitive behavioral therapy or behavior activation) as a first-line treatment for moderate depression, anxiety, and eating disorders, and as a secondary treatment to go with medication for schizophrenia and bipolar disorder.