Psychiatry hasn’t lost its mind after all!
It isn’t easy to tell when a large ship is turning at sea, but there are signs the large vessel of the American Psychiatric Association (APA) is turning back toward a biopsychosocial model. In Toronto at the APA annual meeting there was new openness to the importance of environmental factors in the causation and treatment of mental and substance use disorders. At the opening session former Congressman Patrick Kennedy, APA president Paul Summergrad and brain researcher Helen Mayberg all spoke with new inclusion of psychotherapy in their remarks--how neurobiology may help differentiate those who need medications from those who need therapy—or how drugs may provide enough symptom relief to allow patients to better use therapy. This is a significant shift from past positions that offered chemistry as the main answer. Following their comments, APA medical director/CEO Saul Levin unveiled the new tag line: “American Psychiatric Association—Medical leadership for mind, brain and body.” Although many of us have worried about the way the APA, in its focus on the brain, had lost its mind, it now seems “mind” is solidly back in American psychiatry! After a long time and much effort, there are signs the ship is beginning to turn back toward the biopsychosocial.
In this change the emerging science is leading the way: At a lecture by translational researcher Moshe Szyf about epigenetic changes mediated by environmental factors, he spoke about how environmental stress in young animals leads to methylation of genes—in cells in every organ, including the gametes that transmit these changes to the next generation—a genetic take on intergenerational transmission of trauma. He spoke about the potential value of developing demethylating drugs to undo the damage—but also of demethylation occurring through therapy. For example, in translational research using animal models, most of the demethylation (recovery from early maternal separation) occurred during animals’ periods of “reappraisal” of the traumatic experience of early maternal separation that were cued by reminders of the loss--which sounds a lot like an animal model of therapy to me.
Later in the week the APA Psychotherapy Caucus held its second meeting. Starting with 10 psychiatrists a bit over a year ago, this group has now grown to over 200, and two Caucus attendees came to Toronto just to attend the Caucus meeting. I reported to the Caucus on progress over the last year and David Mintz, MD presented results of an electronic survey completed by 116 Caucus members. As we had hoped in our vision of a “big tent” for psychotherapy and psychosocial treatment, Caucus members come from around the country and overseas, range in career level from medical students, residents and early career psychiatrists to senior clinicians and researchers, and represent perspectives including psychodynamic, cognitive behavioral, group and family therapy, among others. They are concerned about psychiatry’s drift away from a biopsychosocial model and toward what former APA president Steven Sharfstein (a Caucus member and attendee) called a bio-bio-bio model. Caucus attendees were pleased to hear and join the notion that “epigenetic is just another way to say biopsychosocial,” and were pleased with the new APA tag line emphasizing mind, brain and body.