Jay Kuten: Psychiatry's big changes

Psychiatrists have become salespeople for the pharmaceutical industry.

AS a life member of the American Psychiatric Association (APA), I've dutifully attended its annual meetings for decades.

It's been a way to keep current with the latest ideas in the field, an excuse to visit places like New Orleans or San Francisco or Toronto where these events are held, and an opportunity to catch up with old friends.

Gradually, though, as I listened to the lectures and participated in the seminars, it's begun to dawn on me that my field has changed.

From the long-ago days of my training and the decades of practice, American psychiatry, which offered a disciplined way of attempting to understand the human condition in a so-far vain hope of becoming more scientific, has instead lost its moorings in psychology. Psychiatrists have become middle men, well-paid — if unhappy — salespeople for the pharmaceutical industry.

That in itself might not be so bad. In the long run, it would probably herald the demise of another profession to the coming of artificial intelligence and robots.

As I learned at those psychiatric meetings, the current practice is for psychiatrists to meet with new patients for 30 minutes, ask a standardised set of questions that enable the doctor to reach a diagnosis — one out of the roughly 324 disorders described in the Diagnostic and Statistical Manual 5th edition (DSM V), of the APA— and prescribe a medication to fit that diagnosis.

The patient may be given follow-up visits, beginning monthly and tapering to three and six months, in accord with the insurance plan that the patient carries.

These follow-up visits, known as med-checks, are usually 15 minutes in duration.

Efficiencies of cost will inevitably dictate over time that psychiatrists could be replaced by much cheaper robots programmed to carry out the functions just described, asking a set series of questions, followed by a diagnosis and a prescription for medication.

As if that inevitability were not sufficiently critical of the present system, there are several cogent criticisms of the diagnostic framework which is all important to the issue of cost and payment by the insurance companies, who effectively determine what goes on in modern American psychiatry and in general medicine as a whole.
That equation is straightforward and elegant in its simplicity. If the insurance doesn't pay for it, patients aren't going to get it.

And critics abound for the DSM V. The newly created diagnoses lack empirical support, sections are confusing, contradictory, or poorly written.

The entirety is too heavily influenced by the psychiatric drug industry.

Critics point to the work groups who wrote the manual having conflicts of interest with financial ties to the pharmaceutical industry.

This significant criticism might be seen as just carping if the system worked and especially if the drugs worked.

Jay Kuten

In one of the last lectures I attended at the APA, a psychiatrist pointed out that the psychiatric medications are effective in less than a quarter of their intended purpose.
However, the side-effects are often much more certain and seriously problematic.

Professor Leon Eisenberg of Johns Hopkins and Harvard, an early drug advocate, became an outspoken critic of the overuse of psychoactive drugs driven by the pharmaceutical industry.

This appraisal of current American psychiatry might be seen as my mourning over the loss of a profession I have loved and which provided me an opportunity to share with my patients their struggle to come to terms with a complex world within their limits and mine.

It is more than that. Here in New Zealand it provides a cautionary tale inasmuch as our mental health system is modelled upon the American one.

With the new Mental Health Inquiry, we have an opportunity to build a new system on the embers of the old one.

We need to build a mental health system that brings together the brain and the mind and restores thereby the missing element of humanity.

Jay Kuten is an American-trained forensic psychiatrist who emigrated to New Zealand for the fly fishing. He spent 40 years comforting the afflicted and intends to spend the rest afflicting the comfortable.