As of 2012, I've been a psychiatrist for 30 years in the United States. During that period, I worked in a lot of places, from hospital to clinic, from Fargo to Providence, and back to Fargo, in a government institution, two universities, large healthcare systems, and private practice. I had been a practitioner, a researcher, and a teacher. My career seemed to be at its peak. This occurred at a time when the pharmaceutical industry was in its golden years as far as psychiatry was concerned. Most of the medications that psychiatrists prescribe today have come onto the market in those years. I've been through a lot of training, programs, and promotions, and therefore I gained a body of knowledge, perhaps even expertise in pharmacotherapy. The requirement was that if you were going to be a respected psychiatrist, you needed to know your drugs.
Identity crisis
Many older psychiatrists, who were educated at the time when psychiatric drugs were few and between and their training was predominantly influenced by psychoanalysis, felt out of place, outdated, and unable to pass the certification exam necessary to remain in practice. The biological revolution was in a full swing. It shifted the scope of psychiatry from broad mind theories to specific brain-function processes joining the neurosciences and moving away from psychoanalytic theories. Biological psychiatrists believed that mental illness could be linked to genetic inheritance and flawed biology, which can be treated with medications. This was a newfound mantra and a “grounding” territory where psychiatry landed in an effort to be recognized as a legitimate medical discipline.
As a result, the professional identity of psychiatrists had become closely connected with the privilege of prescribing drugs. Every attempt by other mental health professionals to enter that “turf” has been fought “tooth and nail.” Psychologists have tried and succeeded in some states and agencies, but not surprisingly, many medical organizations were against granting prescribing rights to psychologists. Among them was the powerful American Psychiatric Association, the largest professional organization of psychiatrists in the world. It argued that psychologists had insufficient training in medicine and pharmacology and because of that would overlook many important factors if allowed to prescribe psychotropic drugs.
A little gentler attitude was toward the advanced practice registered nurses, better known as nurse practitioners (NPs). They were considered a lesser threat than psychologists. NPs currently have the authority to prescribe medications, in some states independently and in others under the supervision of the physician. Many of them had to complete a three-year-long transition to practice period before being allowed prescribing privilege.
The fight for this “tree of knowledge of good and evil” was not just a rational one. It was a dispute born and wrapped in a cloak sprinkled with pharmaceutical money. The drug companies endowed continuing education and psychiatric “grand rounds” at hospitals and universities. They paid for training workshops. Many research studies were sponsored by the drug industry. Psychiatric “bigwigs” have been financially rewarded as “thought leaders” for speaking out in favor of drug use and promoting the theory of “chemical imbalance” as a biological basis of psychiatric disorders. Lack of transparency and conflict of interest due to financial gain from the pharmaceutical industry started to influence the objectivity of science, research publication, and even patient management. Pharmaceutical representatives had been trained to influence doctors in a number of ways, some subtle and some more obvious. Visits from drug industry representatives often came with gifts, food, free samples of their medications, and other incentives.
Big Pharma
I was affected by this environment too. When I worked in Rhode Island, interactions with drug representatives were almost a daily occurrence. All my colleagues were willing participants. I joined the crowd and even became a speaker for some pharmaceutical companies. At that time, I believed that I could maintain the objectivity of my own prescribing and effectively balance the role of medications and other strategies in patients’ care. But I have to agree with experts when they say that the cornerstone of effective marketing is the subliminal influence of the target. In the deep recesses of the human mind, the subliminal expectation for reciprocity accompanies gift-giving. In addition, the effect of desensitization, due to the pervasive presence of the pharmaceutical industry in the everyday life of most physicians, has a tendency to lower ethical standards regarding the inappropriate influence on physicians’ judgment, conflicts of interest, or serving the best interests of the patients. *
Pharma companies are not charitable organizations. They are not in the business of education, philanthropy, or even health care. Their business is to manufacture and sell drugs. And doctors were their intermediary agents in selling their products. The pharmaceutical industry spends billions and billions of dollars to promote drugs to doctors each year, which is significantly more than what all U.S. medical schools spend to educate medical students. Major drug companies employ one sales representative for every 4 doctors in the United States. Many physicians learn about new drugs largely through information provided by the companies that market these products.
Psychiatric pharmacotherapist
When I moved back to Fargo, my ties with the pharmaceutical companies gradually diminished and eventually stopped. I was free at last. I was able to shake off the heavy cloak and clear the fogginess in my head space. I have been using psychotropic drugs during my whole career as a psychiatrist. My extensive training, drug treatment of a large number of patients, and experience with multiple pharmaceutical companies equipped me with the capacity to ensure the rational, safe, appropriate, and economical use of psychotropic medications in the treatment of relevant psychiatric conditions. Due to my workaholic nature and years of practice, I had the advantage over most other psychiatrists. I met many patients in different settings with different mental health problems and it was almost second nature to know which medicines to use to achieve the best outcomes.
More recently, my experience was assisted by the use of genetic tests of the genes involved in the metabolism or other relationships through which psychoactive drugs render their effect on the body. One of the tests that I have been using is called the GeneSight. ** It currently tests 57 psychiatric medications and 12 genes. Drug-gene interactions can significantly affect the outcome of treatment in many ways. Some of them are due to a lack of genes necessary for drug metabolism, or the presence of genes that cause either slow or ultrafast metabolism which requires a significant adjustment in the dosing of the drug.
Pharmacogenomics, the scientific discipline that studies how a person's genes influence the response to medications, has become a part of so-called precision medicine, which involves individualizing and customizing treatments for each individual. The application of precision medicine in psychiatry is still in its early phase. But there are already studies that lead to the use of drugs with higher efficacy, reduced adverse effects, decreased costs, and drug repurposing. ***
Reductionism
The emphasis on the use of drugs in psychiatry is not only influenced by “Big Pharma” and its long hand. The pendulum of the theory and practice of psychiatry has swung to the reductionistic side in which the brain has become the central object of relevance (or reverence) for psychiatry. It seems that so-called biological psychiatry has lost the mind in its reliance on a medical model, its terminology, and bio-reductionism, which leads to the excessive use of medication to heal the “broken brain.”
My patients don’t speak the language of the brain, they speak the language of the mind. They talk to me about their experiences, existence, and expressions of their desires and beliefs. By empathic listening, I hear their description of situations that lead to the emergence of psychic pain and the unique way how they deal with their life circumstances. Hope or despair may be contained in their gaze and posture, and in the words that were chosen. The manner of relating and energy in the room becomes more relevant to healing than the counting of the symptoms, applying DSM criteria to them, and assigning a diagnostic category. Patients came to me because they had mind-driven problems with their thoughts, moods, perceptions, and behaviors. My intervention was designed to restore (heal) their minds by changing the biology, psychology, or environment of my patients. I thought that it was more appropriate for psychiatrists to call themselves mind healing specialists rather than brain disease specialists as some of them started calling themselves. My proposal was not “politically correct” for the time (or place) when I “threw my hat into the ring.” My argument was against reductionistic materialism which claims that the mind is reduced to the brain (rather than partially or fully dependent on it). Because despite all the advances neuroscience has not achieved the actual translation of mind-to-brain phenomena.
Concerns
I was lucky that I didn’t build my professional identity exclusively around pharmacotherapy and biological psychiatry. As a teacher and “provider of care”, I was concerned about the “shaping” of the new generations of psychiatrists. In their training, lip service was given to biopsychosocial and integrative models. In practice, most psychiatrists apply DSM based diagnosing and almost like a knee-jerk reaction, prescribe drugs. This is how they practice “at the top of their medical license”, in other words, doing tasks that no one else in the healthcare system is authorized to do. It is not easy to resist the attractiveness and lucrativeness of this model of care and not jump on this wagon so heavily supported by the machinery of the health industry. Psychiatrists are well paid for 15 minutes “med checks” and not so well for 60 minutes of psychotherapy, which can be done much cheaper by a clinical psychologist, a nurse practitioner, a psychiatric nurse, a social worker, a mental health counselor, and many others.
Teaching
During this period of my professional life, I continued to teach pharmacotherapy. In fact, I was given an assignment by the psychiatry residency training director to create both introductory and advanced courses in clinical psychopharmacology for psychiatry residents. I was in a position to provide instruction to both beginners and “seasoned” doctors-in-training based on my knowledge and experience about the benefits and limitations of drug use for the treatment of psychiatric disorders. I taught them about the power of suggestion. I said something similar to what I wrote in my book, in the essay The Power of Suggestion. To illustrate it, I present this excerpt:
The suggestion is very present in my work because the doctor is the authority, and the patient is in a dependent position. Patients rely on the knowledge and experience of physicians so that every word and procedure is wrapped in a layer of possible suggestions, either positive (placebo) or negative (nocebo). This was not discussed during my medical school training, but I became aware of it during my psychiatric training by observing the work of my colleagues. Placebo and nocebo effects are based on the patient’s expectations and the physician’s belief in the usefulness or harmfulness of the therapeutic intervention. It is used by pharmaceutical companies that are trying to convince doctors that their product is better than the competition. This often works, but I have learned from experienced colleagues to only use new treatment methods so long as they are useful; that is, as long as the effectiveness of the drug is enhanced by positive expectations from both the patient and the doctor. I had just arrived in America when a new cure for depression, Prozac, received mythological wings with the epithets of a “miracle drug.” There were even suggestions to dissolve it in drinking water or to prescribe it as a cosmetic preparation meant to create the desired personality characteristics in all of us. This enthusiasm lasted for several years until other companies started making copycat drugs with even more bombastic advertisements. The power of suggestion is potentially enormous and must be used responsibly considering the cardinal rule of medicine: Primum non-nocere (First, do no harm). Therefore, it is necessary to inform the patient in the best possible way about his diagnosis and the positive and negative consequences of treatment or non-treatment using the principles of evidence-based medicine. ****
Ethics of pharmacotherapy
Medications should be given only when the benefits outweigh the risks. A treatment decision ought to occur on the basis of value judgments, made by the patient and the physician, which are dependent on a number of factors, but primarily on the Hippocratic maxim first, do no harm as a primary ethical standard for moral practice. Any successful treatment depends on a solid therapeutic alliance, and psychotherapy techniques enhance the formation of that alliance, especially related to the elements of the patient-centered therapy approach where empathy, authenticity, collaboration, and positive emotional connection are emphasized. No medication has a chance to “work” unless the patient takes it, which is dependent on trust and an empowered state of mind nurtured through the co-creative patient-doctor relationship. This leads me to clearly state that psychopharmacotherapy should never be “med checks,” but a treatment that is informed by psychotherapeutic methods. A good psychiatrist conceptualizes a patient’s mental health issues both in terms of a dysfunctional brain and a distressed human being needing help. This stance is what I adhere to in my professional life as a practicing psychiatrist and a teacher of others.
* Are Gifts From Pharmaceutical Companies Ethically Problematic? Allan S. Brett, MD; Wayne Burr, MD; Jamaluddin Moloo, MD, MPH; Arch Intern Med.163:2213-2218, 2003
*** Challenges and Future Prospects of Precision Medicine in Psychiatry, by Mirko Manchia et al., Pharmgenomics Pers Med.,13: 127–140, 2020
**** Reflections of a psychiatrist, by Zelko Leon, Independent publishing, 2022
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