Correspondence

Of Two Minds

N Engl J Med 2001; 344:937-938March 22, 2001

Article

To the Editor:

It might surprise the readers of Dr. Michels's review of my book on the ethnography of psychiatry (Nov. 23 issue)1 that until recently, he was known for his fervent support of the psychoanalytic movement in psychiatry. A creative person may certainly integrate new information and change his or her mind, but in his review Dr. Michels does seem to underrate strikingly the relevance of psychotherapy to the treatment of psychiatric illness and the training of young psychiatrists. A discussion of the substantial evidence in support of that relevance and its economic implications can be found throughout my book (in particular on pages 203 through 212 and 239 through 265). The description of the recent history of the profession, and Dr. Michels's role within it, can be found on pages 212 through 238.2

More specifically, Dr. Michels claims that there is no evidence that the combination of psychotherapy and medications is better than each alone. There is indeed considerable evidence. This includes the study on the treatment of depression published in the Journal in May.3 Multiple studies on other disorders have reached similar conclusions.2 The combination may even be cheaper in the long run.4

Dr. Michels chides me (as a “halfie” or a “one-and-a-halfie”) for not publishing the definitive study “that will help us plan how to proceed.” I am honored that he thought this to be my task. Perhaps he is dismayed by the political and economic issues that face the psychiatric profession in its attempts to solve this problem.

T.M. Luhrmann, Ph.D.
University of Chicago, Chicago, IL 60637

4 References

1
Michels R. Review of: Of two minds: the growing disorder in American psychiatry. N Engl J Med 2000;343:1579-1579
Full Text

2
Luhrmann TM. Of two minds: the growing disorder in American psychiatry. New York: Knopf, 2000.

3
Keller MB, McCullough JP, Klein DN, et al. A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. N Engl J Med 2000;342:1462-1470
Full Text | Web of Science | Medline

4
Gabbard OG, Lazar SG, Hornberger J, Spiegel D. The economic impact of psychotherapy: a review. Am J Psychiatry 1997;154:147-155
Web of Science | Medline

Author/Editor Response

Dr. Michels replies:

To the Editor: Dr. Luhrmann's complaints about my review of her book do not reflect what I actually wrote. For example, she writes, “Dr. Michels claims that there is no evidence that the combination of psychotherapy and medications is better than each alone.” In fact I wrote, “many patients do well with this combination.” However, I did challenge her statement that “for most patients . . . psychopharmacology and psychotherapy work best in combination.” In her letter she cites evidence in support of the fact that combinations are best for some patients, but one cannot infer that what is true for some is true for most.

She also states that I underrate “the relevance of psychotherapy to the treatment of psychiatric illness and the training of young psychiatrists.” In fact, I did not mention this issue in my review, although as she probably knows, I have elsewhere written extensively about the vital role of psychotherapy in the training of young psychiatrists.

I am not certain of the reason for her annoyance, but I suspect that it might be related to her first and last comments. She opens by saying “until recently, he was known for his fervent support of the psychoanalytic movement.” My fervent support continues, but such support must be based on reason and a critical appraisal of the facts, not on ideology, philosophy, or faith. She closes by wondering whether I am dismayed by the political and economic issues that face the psychiatric profession and speculating that I might think that she should help us plan how to proceed. She is correct on both accounts. I am dismayed, and I do hope that she will address these issues in her next book, and by doing so help us plan how to proceed.

Robert Michels, M.D.
Cornell University, New York, NY 10021

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