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“Is Psychiatry Becoming Extinct?” Dr. David Mintz Responds

David Mintz, MD|
July 17, 2024
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I think it is worth commenting briefly on Dr. Damian Kim’s recent article, “Is Psychiatry Becoming Extinct?” in Psychiatric Times. Dr. Kim, a stalwart defender of a psychodynamically-informed biopsychosocial approach, dialoguing with writings by equally stalwart biomedical psychiatrists, wonders if psychiatry is at risk of extinction. He observes changes in past decades that reify the DSM, reduce the complexity of our understanding of our patients, and promote medical solutions, even for primarily psychosocial troubles.
As a psychodynamic psychiatrist, I share some of these concerns. However, where Dr. Kim worries, I think, in many cases, there are reasons for optimism. The path of mental health treatment has never been a straight line. Instead, it is a pendulum that swings from one extreme to another as we encounter the truly complex suffering experienced by our patients and, in the context of that complexity, grapple with our limitations in understanding and being of use to them.
While some of the authors that Dr. Kim quotes envision the current trajectory of psychiatry to intersect with that of neurology, I think that the biomedical turn in psychiatry reached its apex 15 years ago. The pendulum is now gaining momentum toward a more integrative position. While psychodynamic psychiatry was once pummeled by data (in the face of the field’s decades-long rejection of the need for research), increasingly, the data is now on the side of a biopsychosocial perspective. One consequence of the focus on "evidence-based practice" is that the evidence for psychopharmacotherapy is often underwhelming. For some of the most common psychiatric conditions, psychosocial factors contribute more than medical factors to pharmacologic outcomes, and psychological treatments are shown, as Dr. Kim points out, to be at least equally effective as medical ones. In this context, I see psychiatry as searching, not for reductive solutions, but for integrative ones. Developments such as Motivational Interviewing (Miller and Rolnick), Collaborative Care models (APA), and Psychodynamic Psychopharmacology (Mintz, 2022) are signs of this integrative spirit in psychiatry.
The data, also suggest that a rigid dualism between structural and functional disorders breaks down. Supposedly "psychological" treatments affect the structure and function of the brain. At the same time, data show that psychological factors in pharmacotherapy often have greater influences over medication outcome than does the drug itself. The clearer this becomes, the more it becomes apparent that the most effective psychiatrists will be those who can address the patient on multiple levels, respecting the contributions of the patient's biology, their psychology, and pathogenic interpersonal and social dynamics to optimal outcomes.
I might add, however, that, while I ultimately have faith that the science will support a view of psychiatry as a skill set that requires a complex (psychodynamic) understanding of the patient and the thoughtful use of psychotherapeutic skills (even in pharmacotherapy), I do worry about nonscientific influences on the practice of psychiatry, particularly the increasing influence of business over the practice of medicine, with, what seems to me, to be a prioritization of efficiency over effectiveness. Dr. Kim suggests that the medical model is supported because psychiatrists choose the easy way. That is not my experience. I see psychiatrists, especially the next generation, struggling mightily to preserve a complex understanding of the patient in the face of massive pressures from corporate medicine to ignore the complexity of the patient for the sake of efficiency, even if it means administering treatments in ways that are likely to be less effective. I think most of us know that this 15-minute med-check model is not an optimal practice of psychiatry–and lacks an evidence-base. Like Dr. Kim, I do think we need to push back, but it seems to me that we need to get clearer on exactly what it is we are pushing back against.