By Gerald D. Klee, M.D.
[Winter 2003; Vol. 29, No. 2; Pg 3, 15]
Last spring I attended the 50th Anniversary celebration of my Harvard Medical School Class. My generation grew up in a badly battered world. We hoped to leave it in better condition than we found it. The following comments summarize some of my views about how psychiatry evolved into its present state. I believe that most of my classmates share my views.
Life has been good to most of us. Our careers spanned
the golden age of medicine, when scientific progress grew rapidly and there was
little interference in our relationships with patients by outside agents. We
experienced the Great Depression and World War II and entered medical school,
where we would get an education that we hoped would help us save the world. Like
me, most of my classmates had the benefit of having their tuition of $800 a year
paid for by the GI Bill. Tuition now is about forty times that (4000%), about
the same rate of inflation as for a hospital bed. Compared to tuition and health
care, the general inflation rate during the half century is modest, a mere 700%
or so, according to the Consumer Price Index.
At the time of our graduation, no one could have foreseen the extraordinary
increase in medical costs to come, nor how the healthcare system would be
hijacked by clever business people who make fortunes by denying treatment and
pocketing one third or more of the money meant to pay for medical care. And who
would have believed that a time would come when a doctor’s time and interest
in patients would be treated as valueless?
At Harvard, as elsewhere, there is much more for students to learn in medical
school than ever before. Information technology makes the process more efficient
and virtual patients provide ingenious ways for students to deal with
realistically simulated clinical situations. However, access to actual patients
has decreased under managed care, which won’t allow attending physicians to
delegate responsibility for patients. This deprives residents and students of
valuable patient contact. Psychiatric trainees are further deprived of patient
contact by the reduction or elimination of hospital beds in many institutions.
Hospital stays are shorter, commonly three days, which gives attendings and
trainees little chance to get to know patients, let alone learn enough about
them to make accurate diagnoses, or to treat them effectively. Thus, trainees
learn a badly flawed model of treatment, which they eventually carry into their
practices under managed care.
When I entered residency, neuroscience was primitive and psychotherapy was the
most widely recognized form of psychiatric treatment. I saw a stunning change
beginning in 1954 when chlorpromazine brought chronic schizophrenic patients
into remission by the thousands. This was the beginning of the
psychopharmacology revolution that changed how we think about and treat
patients with mental illnesses. Drugs have become so important that there’s a
tendency to forget about psychotherapy, which is a big mistake.
In less than half a century, neuroscientists have discovered most of what is now
known about the brain. Fifty years ago, acetylcholine was the only known
neurotransmitter in the brain. Now we know of numerous transmitters and
receptors and how various drugs affect them.
The application of psychopharmacology has its good and
bad sides. On the positive side, it has led to better drugs and better
treatment, but all too frequently drugs are the only treatment patients get.
Worse yet is the fact that psychiatrists doing "med checks" seldom
have enough time with their patients to prescribe wisely. Still worse, those
prescribing the drugs are most often untrained in psychiatry. Throughout my
career, it has been the psychiatrist's role to integrate physical and mental
care, psychotherapy and pharmacology. Thanks to managed care, the psychiatrist
is now supposed to be no more than a pill pusher. That model is a major cause of
medical errors and rising costs.
I’m told that up to 80% of patients admitted to inpatient psychiatric services
in Baltimore have problems with illicit drugs and/or alcohol in addition to
their psychiatric diagnoses. They are usually put on prescription drugs and are
back on the street within a few days, with no treatment for chemical dependency.
This is partly due to the Medicaid reimbursement system, which splits treatment
for diagnoses of chemical dependency and mental illness and doesn’t pay enough
for either.
Science and technology grow exponentially, but human wisdom grows little, if at
all and old wisdom is often forgotten. A well known consequence is that
discoveries in science and technology are often put to wrong or even harmful
uses. Dynamite is an example of a discovery being put to unintended uses. It was
invented by Alfred Nobel for use in construction projects. An ardent pacifist,
Nobel thought his invention would put an end to war by making it so horrible
that no one would want to engage in it. Of course he was disappointed. The
scientists who created the foundations of modern psychopharmacology must be
equally disappointed by the misuse of their discoveries.
In the 1960s, LSD guru Timothy Leary and many of his hippie followers shared a
belief that all human problems can be solved by recklessly taking drugs. Their
slogan, Better Living Through Chemistry, was borrowed from the chemical giant
DuPont, a maker of dynamite. Often, the drugs Leary promoted turned out to be
dynamite for those who used them.
Over time, diverse streams have ways of merging to produce unexpected
consequences. Take the sixties drug culture, blend it with the pharmaceutical
industry’s need for constantly expanding markets and profits, add managed care’s
voracious drive to profit by quick fixes for complicated psychiatric illnesses.
Stir the pot and Presto! Psychotropic drugs are a cure for all life’s
problems.
We hoped we would leave the world in better condition than we found it, but I’ve
begun to feel pessimistic. I wonder if there’s a pill for that.
Doctor Klee is a Life Fellow Emeritus of the American College of
Neuropsychopharmacology.