The ‘decline’ of psychoanalysis

There are many interesting aspects of Dr. Nasrallah’s review of the changes in psychiatry in recent decades (Post-World War II psychiatry: 70 years of momentous change, Current Psychiatry, From the Editor, July 2014, p. 21-22, 49-50 [http://bit.ly/1m8HcdC]). There is no doubt that great strides have been made, particu­larly in the care of the more seriously ill, and that those accomplishments owe a good deal to the introduction of psychoactive agents.

However, his reference to the “decline” of psychoanalysis was unfortunate and a gratuitous insult to those of us who continue to prac­tice psychoanalysis and who rec­ognize how much psychoanalytic thinking has contributed to the psychotherapeutic practices of non-analyst psychiatrists. If by decline he means that patients who once were in analysis now are being treated with medication alone, he is cor­rect. That might not always be in the best interest of patients, but it is a fact. If by decline he means that in all instances all patients benefit more from pills than they would from analysis, his viewpoint is derived from misinformation.

Since academic psychiatry and psy­chiatric publications became wholly owned subsidiaries of the pharmaceu­tical industry, this dismissive attitude about psychoanalysis has attained the status of established wisdom. Psychoanalysts understand that one size does not fit all, no single treatment is the best choice for all patients, and medications can be of great value. Why can’t psychopharmacologists show a similar respect for psychoanalysis?

Charles Goodstein, MD
Tenafly, New Jersey

Dr. Nasrallah responds
Thank you, Dr. Goodstein, for expressing your view about my editorial. However, it is unfair to describe the editorial as being dismissive and insulting toward psycho­analysts. I was simply stating undeniable historical facts about the evolution of psychiatry—one aspect was the reduced prevalence and influence of psychoanaly­sis over the past few decades, which was partially because of the advent of phar­macotherapy. The other reason was the emergence of other psychotherapies, such as cognitive-behavioral therapy, interpersonal psychotherapy, and dia­lectical behavior therapy, which are evidence-based, shorter in duration, and more cost effective.

Psychoanalysis remains an important component of contemporary psychiatry, albeit limited to a smaller subgroup of patients.

In my residency, I was heavily trained in psychodynamic therapy, and many of my supervisors were psychoanalysts. I developed my neuroscience skills in a post-residency fellowship at the National Institutes of Health. Nowadays, residency programs must provide both psychother­apeutic and psychopharmacologic train­ing to psychiatric residents.

Your statement that medications have replaced psychotherapy is inaccurate. We train our residents to provide each out­patient with both pharmacotherapy (when indicated) side-by-side with psychotherapy—whether supportive, psychoeducational, psychodynamic, or cognitive-behavioral therapy, or a combi­nation thereof. I continually warn residents about reducing psychiatric care to giving pills, which would be a travesty.

In addition, I regard psychotherapy as a neurobiological intervention because it modifies brain connectivity and neuro­plasticity (see my December 2013 Editorial, “Repositioning psychotherapy as neu­robiological intervention,” available at CurrentPsychiatry.com).

Last, I wish you would not insult aca­demic psychiatry as being a “wholly owned subsidiary of the pharmaceuti­cal industry.” Someone must develop new and better treatments for serious psychiatric brain disorders. The only entities dedicated to doing that, in the United States, are the pharmaceutical industry and the academic psychophar­macology experts. Together, they gener­ate new ideas and develop innovative mechanisms of action and test them in controlled clinical trials to treat disabling mental disorders. It is not fair to impugn the integrity of academic psychiatrists when they are doing what they were trained to do. They have the integrity and objectivity to criticize the industry when necessary. (See page 50 of my editorial under the subheading “Pharmaceutical industry debacle.”)

Henry A. Nasrallah, MD
Professor and Chairman
Department of Neurology & Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri

There are many interesting aspects of Dr. Nasrallah’s review of the changes in psychiatry in recent decades (Post-World War II psychiatry: 70 years of momentous change, Current Psychiatry, From the Editor, July 2014, p. 21-22, 49-50 [http://bit.ly/1m8HcdC]). There is no doubt that great strides have been made, particu­larly in the care of the more seriously ill, and that those accomplishments owe a good deal to the introduction of psychoactive agents.

However, his reference to the “decline” of psychoanalysis was unfortunate and a gratuitous insult to those of us who continue to prac­tice psychoanalysis and who rec­ognize how much psychoanalytic thinking has contributed to the psychotherapeutic practices of non-analyst psychiatrists. If by decline he means that patients who once were in analysis now are being treated with medication alone, he is cor­rect. That might not always be in the best interest of patients, but it is a fact. If by decline he means that in all instances all patients benefit more from pills than they would from analysis, his viewpoint is derived from misinformation.

Since academic psychiatry and psy­chiatric publications became wholly owned subsidiaries of the pharmaceu­tical industry, this dismissive attitude about psychoanalysis has attained the status of established wisdom. Psychoanalysts understand that one size does not fit all, no single treatment is the best choice for all patients, and medications can be of great value. Why can’t psychopharmacologists show a similar respect for psychoanalysis?

Charles Goodstein, MD
Tenafly, New Jersey

Dr. Nasrallah responds
Thank you, Dr. Goodstein, for expressing your view about my editorial. However, it is unfair to describe the editorial as being dismissive and insulting toward psycho­analysts. I was simply stating undeniable historical facts about the evolution of psychiatry—one aspect was the reduced prevalence and influence of psychoanaly­sis over the past few decades, which was partially because of the advent of phar­macotherapy. The other reason was the emergence of other psychotherapies, such as cognitive-behavioral therapy, interpersonal psychotherapy, and dia­lectical behavior therapy, which are evidence-based, shorter in duration, and more cost effective.

Psychoanalysis remains an important component of contemporary psychiatry, albeit limited to a smaller subgroup of patients.

In my residency, I was heavily trained in psychodynamic therapy, and many of my supervisors were psychoanalysts. I developed my neuroscience skills in a post-residency fellowship at the National Institutes of Health. Nowadays, residency programs must provide both psychother­apeutic and psychopharmacologic train­ing to psychiatric residents.

Your statement that medications have replaced psychotherapy is inaccurate. We train our residents to provide each out­patient with both pharmacotherapy (when indicated) side-by-side with psychotherapy—whether supportive, psychoeducational, psychodynamic, or cognitive-behavioral therapy, or a combi­nation thereof. I continually warn residents about reducing psychiatric care to giving pills, which would be a travesty.

In addition, I regard psychotherapy as a neurobiological intervention because it modifies brain connectivity and neuro­plasticity (see my December 2013 Editorial, “Repositioning psychotherapy as neu­robiological intervention,” available at CurrentPsychiatry.com).

Last, I wish you would not insult aca­demic psychiatry as being a “wholly owned subsidiary of the pharmaceuti­cal industry.” Someone must develop new and better treatments for serious psychiatric brain disorders. The only entities dedicated to doing that, in the United States, are the pharmaceutical industry and the academic psychophar­macology experts. Together, they gener­ate new ideas and develop innovative mechanisms of action and test them in controlled clinical trials to treat disabling mental disorders. It is not fair to impugn the integrity of academic psychiatrists when they are doing what they were trained to do. They have the integrity and objectivity to criticize the industry when necessary. (See page 50 of my editorial under the subheading “Pharmaceutical industry debacle.”)

Henry A. Nasrallah, MD
Professor and Chairman
Department of Neurology & Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri

There are many interesting aspects of Dr. Nasrallah’s review of the changes in psychiatry in recent decades (Post-World War II psychiatry: 70 years of momentous change, Current Psychiatry, From the Editor, July 2014, p. 21-22, 49-50 [http://bit.ly/1m8HcdC]). There is no doubt that great strides have been made, particu­larly in the care of the more seriously ill, and that those accomplishments owe a good deal to the introduction of psychoactive agents.

However, his reference to the “decline” of psychoanalysis was unfortunate and a gratuitous insult to those of us who continue to prac­tice psychoanalysis and who rec­ognize how much psychoanalytic thinking has contributed to the psychotherapeutic practices of non-analyst psychiatrists. If by decline he means that patients who once were in analysis now are being treated with medication alone, he is cor­rect. That might not always be in the best interest of patients, but it is a fact. If by decline he means that in all instances all patients benefit more from pills than they would from analysis, his viewpoint is derived from misinformation.

Since academic psychiatry and psy­chiatric publications became wholly owned subsidiaries of the pharmaceu­tical industry, this dismissive attitude about psychoanalysis has attained the status of established wisdom. Psychoanalysts understand that one size does not fit all, no single treatment is the best choice for all patients, and medications can be of great value. Why can’t psychopharmacologists show a similar respect for psychoanalysis?

Charles Goodstein, MD
Tenafly, New Jersey

Dr. Nasrallah responds
Thank you, Dr. Goodstein, for expressing your view about my editorial. However, it is unfair to describe the editorial as being dismissive and insulting toward psycho­analysts. I was simply stating undeniable historical facts about the evolution of psychiatry—one aspect was the reduced prevalence and influence of psychoanaly­sis over the past few decades, which was partially because of the advent of phar­macotherapy. The other reason was the emergence of other psychotherapies, such as cognitive-behavioral therapy, interpersonal psychotherapy, and dia­lectical behavior therapy, which are evidence-based, shorter in duration, and more cost effective.

Psychoanalysis remains an important component of contemporary psychiatry, albeit limited to a smaller subgroup of patients.

In my residency, I was heavily trained in psychodynamic therapy, and many of my supervisors were psychoanalysts. I developed my neuroscience skills in a post-residency fellowship at the National Institutes of Health. Nowadays, residency programs must provide both psychother­apeutic and psychopharmacologic train­ing to psychiatric residents.

Your statement that medications have replaced psychotherapy is inaccurate. We train our residents to provide each out­patient with both pharmacotherapy (when indicated) side-by-side with psychotherapy—whether supportive, psychoeducational, psychodynamic, or cognitive-behavioral therapy, or a combi­nation thereof. I continually warn residents about reducing psychiatric care to giving pills, which would be a travesty.

In addition, I regard psychotherapy as a neurobiological intervention because it modifies brain connectivity and neuro­plasticity (see my December 2013 Editorial, “Repositioning psychotherapy as neu­robiological intervention,” available at CurrentPsychiatry.com).

Last, I wish you would not insult aca­demic psychiatry as being a “wholly owned subsidiary of the pharmaceuti­cal industry.” Someone must develop new and better treatments for serious psychiatric brain disorders. The only entities dedicated to doing that, in the United States, are the pharmaceutical industry and the academic psychophar­macology experts. Together, they gener­ate new ideas and develop innovative mechanisms of action and test them in controlled clinical trials to treat disabling mental disorders. It is not fair to impugn the integrity of academic psychiatrists when they are doing what they were trained to do. They have the integrity and objectivity to criticize the industry when necessary. (See page 50 of my editorial under the subheading “Pharmaceutical industry debacle.”)

Henry A. Nasrallah, MD
Professor and Chairman
Department of Neurology & Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri