Correspondence
Progress in Psychiatry
N Engl J Med 1994; 330:285-286January 27, 1994
- Article
To the Editor:
The recent two-part review article “Progress in Psychiatry” by Michels and Marzuk (Aug. 19 and 26 issues)1 should be balanced by pointing out regressive developments in psychiatry during the past two to three decades. Michels and Marzuk offer a splendid review of progress in neurosciences related to psychiatric disorders and at least by implication seem to approve of the similarities between practices in internal medicine and practices in latter-day psychiatry. These practices are symptom-oriented and, although in both fields more stringent lists of symptoms related to a particular diagnosis have been developed, they lead to the implication that such a symptom cluster can be used to indicate a specific treatment. To some degree this is true in psychiatry, in the sense that we know that certain drugs counteract neurochemical aberrations that are grossly different for certain diagnostic groups, but we have no drugs such as antibiotics that treat the specific cause.
Treating the patient has taken a back seat to treating the symptoms, and this development is particularly retrogressive in psychiatry, which used to be the medical specialty par excellence that dealt with people, their lifestyles, their intimate environments, and their psychological milieus. Addressing problems in these areas, whether or not they arise from the genes, was the earmark of good psychiatry until recently, and there is no indication that this tradition of holistic treatment will again become part of psychiatric education and, hence, of practice. This deplorable development has been abetted by the diagnostic statistical manuals published in the past 10 to 12 years that, however inadvertently, suggest that if a patient has a precise constellation of symptoms, you know how to treat him or her. Furthermore, it has provided comfort and profit to the managed-care providers, whether in the private or the public sector.
1 ReferencesStephen Fleck, M.D.
Yale University, New Haven, CT 065191
Michels R ,Marzuk PM . Progress in psychiatry. N Engl J Med 1993;329:552-60, 628
Full Text | Web of Science | Medline
To the Editor:
Drs. Michels and Marzuk's review article implies that psychodynamics does not have a major role in modern psychiatry. The authors seem to suggest that psychoanalytic investigation belongs in a philosophy seminar, when in fact, psychoanalytic principles are useful in patient assessment and doctor-patient relationships. They are also crucial for the development of empathy.
Current pressures well known to all of us are bringing about a revisionary process whereby interviews with patients are being reduced to the level of surveys. Biologic approaches are much more effective when allied with psychodynamic insight, and I wish this point had been made in the article. Ironically, Dr. Michels himself wrote in 1971, “A clear understanding of psychopathology and psychodynamics is the foundation for the psychiatric interview.”1
1 ReferencesKim J. Masters, M.D.
Appalachian Hall, Asheville, NC 28813To the Editor:
We wish to address the issue of tardive dyskinesia raised in the excellent review by Michels and Marzuk. We agree that there is no consensus on therapy for the tardive dyskinesias (classic oral-buccal-lingual tardive dyskinesia, tardive dystonia, and tardive akathisia). However, the statement that there is no effective treatment “except to lower the dose of the neurolepic agent” is unduly pessimistic, and their comment that this treatment “often results in transient worsening of tardive symptoms” does not adequately emphasize the importance of making every effort to discontinue these drugs should dyskinesia occur.
Kane et al. showed that the cumulative incidence of tardive dyskinesia increases linearly with the increasing duration of exposure to a neuroleptic agent and that the likelihood of remission is inversely related to the level of exposure after tardive dyskinesia is diagnosed1. This finding suggests that continued exposure to the neuroleptic agent increases the likelihood of the persistence of tardive dyskinesia.
Dopamine-depleting agents (tetrabenazine, reserpine, and α-methylparatyrosine) have been shown to be effective in the treatment of tardive dyskinesia2,3. Sixty-four percent of 96 patients with classic tardive dyskinesia who were treated with dopamine-depleting agents had at least a 50 percent improvement4. Reserpine and tetrabenazine produce improvement in about 50 percent of patients with tardive dystonia,3 and anticholinergic agents are almost as effective as antidopaminergic agents3. Burke et al.5 reported that 87 percent of patients with tardive akathisia responded to reserpine (at a dose of up to 5 mg per day) and 58 percent responded to tetrabenazine (at a dose of up to 175 mg per day). The goal of treatment should be to eliminate the cause of tardive dyskinesia, if clinically possible, in order to permit a remission to occur.
5 ReferencesTimothy Lynch, M.D.
Robert E. Burke, M.D.
Stanley Fahn, M.D.
Columbia-Presbyterian Medical Center, New York, NY 100321
Kane JM ,Woerner M ,Weinhold P ,Wegner J ,Kinon B ,Borenstein M . Incidence of tardive dyskinesia: five-year data from a prospective study. Psychopharmacol Bull 1984;20:387-389
Medline2
Fahn S . A therapeutic approach to tardive dyskinesia. J Clin Psychiatry 1985;46:19-24
Web of Science | Medline3
Kang UJ ,Burke RE ,Fahn S . Natural history and treatment of tardive dystonia. Mov Disord 1986;1:193-208
CrossRef | Medline4
Jeste DV ,Wyatt RJ . Therapeutic strategies against tardive dyskinesia: two decades of experience. Arch Gen Psychiatry 1982;39:803-816
Web of Science | Medline5
Burke RE ,Kang UJ ,Jankovic J ,Miller LG ,Fahn S . Tardive akathisia: an analysis of clinical features and response to open therapeutic trials. Mov Disord 1989;4:157-175
CrossRef | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: Recent remarkable advances in biologic psychiatry have led to the improved diagnosis and treatment of mental disorders and the possibility of better and more humane care for patients with these disorders. However, we agree with Dr. Fleck that social and economic forces affecting contemporary psychiatry (along with the rest of medicine) have sometimes resulted in an unfortunate focus on the use of these improved treatments to control symptoms and too little concern for the lives of the patients with these symptoms. We see no conflict between a modern biomedical approach to psychiatric disorders and the humane, comprehensive care of patients with these disorders; indeed, we believe the former to be an absolute prerequisite for the latter.
Dr. Masters infers that we believe that “psychodynamics does not have a major role in modern psychiatry.” We believe that it is clearly important to the field. One of us, a practicing psychoanalyst, has recently discussed this issue in detail.1 Our article focused on the developments in the field in recent years that would interest the readers of the Journal; we did not discuss psychodynamics, just as we would not discuss Newton's laws in a review of progress in physics.
We agree with Dr. Lynch et al. that every effort should be made to discontinue neuroleptic medications in patients in whom tardive dyskinesia develops when the physician believes the morbidity and prognosis of the dyskinesia outweigh the need for continued treatment. The studies they cite regarding the use of dopamine-depleting agents to treat tardive dyskinesia were retrospective reviews of open trials of these drugs. They involved small numbers of patients, many of whom had side effects. In the absence of controlled trials, we cannot conclusively recommend these drugs; however, they may be useful in selected patients.
1 ReferencesRobert Michels, M.D.
Peter M. Marzuk, M.D.
New York Hospital-Cornell Medical Center, New York, NY 100211
Michels R . The future of psychoanalysis. Psychoanal Q 1988;57:167-185
Web of Science | Medline
