Psychiatry Today

In this corner, Maggie Doherty’s long article in Harpers about the decline and fall of the American Psychoanalytic Association. This august and venerable institution, the cornerstone for American psychoanalysis, is in serious decline. Its remaining members, most of whom are over 70 years of age, are making funeral arrangements. 

Doherty examines the organization’s efforts to hook into today’s social justice mania. Will that save psychoanalysis, or are they just rearranging the deck chairs on the Titanic?

More importantly, aside from a brief remark to the effect that Doherty herself underwent psychoanalysis and felt that it was beneficial, nothing at the New York APA meeting suggests that the practice counts as something like therapy. That is, psychoanalysis still does not promote itself for its curative powers. 

That remains one of the most important reasons why it has passed into insignificance and irrelevance. Doherty explains that cognitive and behavioral treatments have overtaken psychoanalysis. Worse yet, insurance companies are no longer willing to pay for it. 

And then there is the Prozac effect. With the advent of the new generation of antidepressants people discovered that taking a pill was more effective than years on the couch. The story was pervasive when the new SSRIs were introduced.

But that is not all. One of the most significant problems is that not all mental illnesses are mental. Some involve neurological anomalies. Some involve metabolic dysfunction. Many only respond to medication.

Thus, arguing about whether medication does or does not work is an iffy proposition. It depends on which medication, for which condition, in which patient.

In the meantime, the New York Times has an article by Ellen Barry regarding the overuse of psychoactive medication. It should not come as a surprise. Each time a new medication has been discovered, psychiatrists have chosen to over-prescribe it. Many believe that biochemistry is the problem and the solution. And that it’s just a question of finding the right medications.

Barry offers the case of a woman named Laura Delano who was overmedicated, and then who just stopped. I cannot tell you how typical her case is, but it is probably not an outlier.:

Ms. Delano is not a doctor; her main qualification, she likes to say, is having been “a professional psychiatric patient between the ages of 13 and 27.” During those years, when she attended Harvard and was a nationally ranked squash player, she was prescribed 19 psychiatric medications, often in combinations of three or four at a time.

Then Ms. Delano decided to walk away from psychiatric care altogether, a journey she detailed in a new memoir, “Unshrunk: A Story of Psychiatric Treatment Resistance.” Fourteen years after taking her last psychotropic drug, Ms. Delano projects a radiant good health that also serves as her argument — living proof that, all along, her psychiatrists were wrong.

Needless to say, psychiatrists are aware of the problem. Many of them are working to assure that patients do not take psychotropic medications forever:

Increasingly, many psychiatrists agree that the health care system needs to do a better job helping patients get off psychotropic medications when they are ineffective or no longer necessary. The portion of American adults taking them approached 25 percent during the pandemic, according to government data, more than triple what it was in the early 1990s.

As it happens, Delano has a coaching practice to help wean people from their psychiatric medications. And yet, as Barry points out, it is generally a bad idea to quit all medications unless a physician is supervising.

But they also warn that quitting medications without clinical supervision can be dangerous. Severe withdrawal symptoms can occur, and so can a relapse, and it takes expertise to tease them apart. Psychosis and depression may flare up, and the risk of suicide rises. And for people with the most disabling mental illnesses, like schizophrenia, medication remains the only evidence-based treatment.

In Inner Compass gatherings, many people describe tapering processes as so difficult that they had to stop and reinstate medications. Some were on their fifth or sixth attempt, and some wept, describing how challenging it was.

Credit to Barry for presenting all sides of a complex issue.