COMMENTARY

Psychiatrists, Do We Understand Our Treatments?

Stephen M. Strakowski, MD

Disclosures

January 03, 2019

Hello. I'm Dr Stephen Strakowski, talking with you from the Dell Medical School at the University of Texas at Austin. We're continuing our series on rebranding psychiatry and the four-step process, which is really five steps, as you'll remember.

The first step, zero, as I call it, is we recognize that we have a brand problem and we own it, which we discussed initially. We then talked in step 1 about defining ourselves better—that psychiatry is a medical specialty that studies and treats disturbances in brain function that predominantly affect behavior or behavioral brain disorders, and then we frame those in what we can provide.

Step 2 was placing ourselves into context of the rest of medicine, that we're working at the top of our licenses as physicians, not invading the space of psychologists, social workers, or other people's jobs. Meanwhile, we're also embedding ourselves in the rest of medicine and the practices of medicine as well as their societies, taking our place as a critical part and subspecialty of medical care.

That's how we're described—that our job is simply pushing pills...

Today, we're going to talk about the third step, which I call understanding treatments. Next time, we'll talk about demanding that our organizations more clearly market what we do, and that includes us. Today, step 3, is understanding our treatments. The brand worries I have around this come from publications and also from experience I have working both in policy and in practice.

Commonly, I hear that psychiatrists are prescribers. That's how we're described—that our job is simply pushing pills, as society will say. As we've talked about earlier, this grossly ignores our primary job, which is evaluating and developing treatment plans for complex psychiatric conditions.

The second common complaint is that our psychotherapies are endless, ineffective, and they tend to be mysterious and sneaky. We are constantly portrayed in the media, in movies, and on television as sneaky, duplicitous individuals who are ultimately up to no good. Rarely are we portrayed effectively as physicians.

Finally, there's just a general belief—not only in the general public but also in medicine—that our treatments are ineffective, even though in a study in the British Journal of Psychiatry in 2012, we were shown to be essentially right in the middle of all other medical treatments.[1] So we were as good or as bad as everything else.

As someone who does a fair amount of consulting, I am often referred patients who are deemed treatment failures or treatment-unresponsive. I have to say, unfortunately, that probably half the time, if not 80% of the time, they're usually not actually treatment failures but people who've lived often through long periods of inadequate treatment trials. They've often not been diagnosed and treated with the indicated medications or therapies, or they've been on and off medicines so quickly that there's no way to tell what's working. Often, too, it's a communication failure between the patient and their doctor on what exactly is being attempted and what's trying to be managed.

Addressing Polypharmacy

Too many of these patients come to me on multiple drugs. I've seen people on 10-12 drugs. Having more than four or five is routine, even though I actually recommend a three-drug maximum in most cases, unless you're doing something specific—usually in the transition between treatments. The medication approaches they tend to report to me are unstructured, as are the therapies.

The worst cases are people who've been told by their psychiatrist, "There's nothing else I can do," or at least that's what they heard. It may not be what was said, but it is what was heard. Of course, that's never true, as we'll talk about later.

Those experiences contribute to the same kind of brand worries. This is the experience people are too often having in the world with their treatment, and I think, ultimately, a lot of it is communication. Some of it is not understanding our treatments very well. Attached to this conversation today is a study from 2010 showing the polypharmacy problem I mentioned, where increasing numbers of people are on increasing numbers of medications.[2]

The worst cases are people who've been told by their psychiatrist, 'There's nothing else I can do.'

As a reminder, although most of our drugs are studied by themselves, there are some trials of combinations of two drugs, rare studies with combinations of three drugs, and virtually nothing when you have more drugs than that. That's where my three-drug maximum actually comes from. This notion that somehow we're so clever that we can understand how four or five or six drugs that are impacting the brain interact with each other is patently wrong. I can't do it. Maybe some of you can. If you really can tell me how you understand that, with what we know about the brain today, please do the research and let us know. That, again, presents a problem because the pill-pusher myth is reinforced when people are on multiple drugs for unclear reasons.

As we think about our treatments, when I think about psychopharmacology, again, a critical piece is to know what our drugs can and can't do. We then need to communicate clearly with each patient as we talk about it—what drug is indicated for this condition and why. Remember that our medications are almost always studied for diagnoses rather than symptoms, but then, unfortunately, in practice they are often used to chase symptoms rather than treat the underlying condition. Although the latter sometimes is necessary, it really needs to be carefully managed so it doesn't become the focus.

The second is recognizing how fast and how well these things work. There's a tendency with all of us, as humans and doctors, that if we have one really good experience or one really bad experience with a treatment, it either gets overutilized with everyone else or gets stricken from our menu of choices. Neither of those are good options. We want to keep medications available because patients are all different, but we want to understand when they're indicated and then use them for such. So, again—treating the diagnosis and understanding how fast and how well [treatments] work.

Many of our drugs—the antidepressants, antipsychotics, and mood stabilizers, for example—often require weeks of effective dosing before we can determine whether they've been effective or not. In my consulting practice, unfortunately, the common referrals I get for treatment failures are people who have not been on enough medicine for enough time.

There are a couple classes of drugs, like anxiolytics or stimulants, where you can know fairly quickly if they're going to be helpful. If they're not and the dose is adequate, then move on and stop using them. Again—understanding how these work, how fast, what we can expect, and then communicating that in such a way that our patients know what to expect. I think that's part of the work on our side. Let's practice along the evidence.

Psychotherapy: The Right 'Dose'

The same is true for psychotherapies. The psychotherapies have several large classes. There's a behavioral therapy class, which includes things like dialectical behavioral therapy or cognitive processing therapy. There are psychodynamic therapies with many variants. The analytic therapies predate the psychodynamic therapies but are somewhat different, as they have been evolved and practiced.

These treatments have an evidence base. Some are more established than others, and they don't work in everything. These evidence bases have been developed for diagnostic categories, not for specific symptoms. As with medications, I want to understand which of these approaches will work best with the person who's presenting with an issue to me today.

One of the challenges with psychotherapies, which is not any different than with medications, is that the fidelity of the practice—applying it in the right dose and in the right manner—is poor. There was a study by Shiner and colleagues in 2013 in the [Veterans Affairs] setting which reported a 6% fidelity rate of cognitive processing therapy, one of the most structured and best established treatments.[3]

Like with medications, we need to understand what type of therapies work for whom and how fast they work. These typically don't work in a day—they require time—and we don't understand dosing very well in psychotherapy. We want to figure out what the best use of this treatment is relative to the potential negative effects of being too involved in therapy (or not involved enough in the world, I guess is more accurate). We need to understand how to apply them most effectively.

Treatment Misperceptions

With that in mind, thinking back to our branding issues and how to start eliminating the misperceptions that we, on some level, perpetuate, the first thing that I think is critical is: Don't undersell or oversell our treatments. They are as effective as those in other branches of medicine, but they aren't 100% effective in anyone. There is a certain amount of evidence—evidence-based trial and error—that we have to follow, and that needs to be communicated clearly to our patients. [They also need] a clear plan on what they can expect and how fast they can expect it, and then it's our job to help them through what is often a slow and somewhat tedious process.

Multiple drug prescribing, particularly within-class polypharmacy where there is literally no evidence of value, is something we need to try to avoid. We need to work on trying to manage the condition instead of chasing symptoms. I try to adhere to a three-drug-maximum rule. I do violate it sometimes when I have to manage something specifically, but usually that's for a short time or when I'm crossing over a treatment and going from one to another.

We just don't understand how these drugs dynamically interact in our complex brains, and I think we need to be careful not to imply that we do. Because treatments are developed and approved for diagnoses, not symptoms, in most cases, we need to be very careful about doing a differential; and when patients aren't improving, reconsider that maybe we're treating the wrong thing.

I believe that psychotherapy, without structure and homework, is probably not evidence based. There are some exceptions to the latter. If we don't have a specific plan for why we're applying this psychotherapy now and what we're trying to fix or change, then it becomes formalist chatting. That's not going to be helpful. At least we need to acknowledge to the patient that this is really just supportive, which is what we're trying to accomplish. If that's true, perhaps we're not the best people to be applying that, given how expensive psychiatrists are.

We need to try to practice like a doctor—I say practice like a doctor, not a shaman. Let's not try to be mysterious, let's not pretend that we have some secret sauce that no one else knows. Let's work the evidence, communicate it clearly, and help our patients understand what we're doing, help other physicians understand what we do, and then ultimately lead society to a clearer understanding of the abilities and shortcomings of our profession.

Finally, I truly believe that there is never a time to say, "There's nothing I can do." I assume that you don't do that, but our patients hear that sometimes. As physicians, we can always listen and help people manage their suffering, even as we're trying to understand better interventions when our current ones are not working.

Of course, research is always advancing our ability to provide better care. We need to always keep that in mind and help engender hope. That is a fine balance—we don't oversell, but we do maintain hope. As we continue our work on that, become clearer and better communicate about what we can and cannot do, we'll find that our brand will steadily improve over time.

I hope these are some things for you to consider. I look forward to our fourth conversation, which will happen as soon as I can find the time to record it. Thank you very much.

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