Treatment in Psychiatry
Alan B. Doris 2021
“The art of medicine consists of amusing the patient while nature cures the disease”.
Since Voltaire wrote this in the 19th Century there have been huge advances in science and the development of effective treatments. Despite this, there is often considerable uncertainty about the best treatment for someone as there are large gaps in our understanding of mental disorders and treatments. It can be difficult to know whether a treatment is truly effective, or if it is the doctor unknowingly “amusing the patient”.
Historically, medical decisions were often idiosyncratic and unscientific and made with an attitude of benign paternalism. Some treatments were not helpful, or perhaps even harmful, and often did not adequately consider the values and preferences of the patient. In psychiatry there have been some notorious examples of treatments given to vulnerable people causing serious harm[i].
Every mental disorder has a natural course which it follows, whether it gradually resolves, progressively gets worse, or waxes and wanes in intensity. Treatment aims to improve on the natural course by speeding up recovery, slowing down progression, shortening periods of ill health or reducing harm and disability caused by the disorder. However, as we are all unique, a treatment which is effective for one person may be useless, or even harmful, for the next. This means that a key skill in medical practise is carefully exercising judgement when making treatment decisions despite a lot of uncertainty, sometimes spiced up with high stakes and critical time pressure!
The Range of Treatments in Psychiatry
The tools we have in psychiatry to try to improve on nature are numerous. These include pharmacological, psychological, neurostimulation, behavioural, relationship, lifestyle interventions or even surgery and implantable devices. Very often a person has a combination of treatments. Availability of treatment resources is a major problem in many places though with modern technology many treatments can be delivered over the internet by telehealth or using smartphone apps.
Making Treatment Choices
“Medicine is a science of uncertainty and an art of probability”[ii]
Treatment decisions usually aim to improve on the natural course of a disorder by predicting the most helpful intervention. Better decisions are made when there is accurate scientific information about the options available, there is a partnership between the patient and clinician to carefully consider the patient’s priorities, and best use is made of the clinician’s skills and experience to manage the inevitable uncertainties.
The rise of the Evidence Based Medicine (EBM) movement was largely in response to increasing recognition of the need to make better clinical decisions. Evidence-Based Medicine is the integration of the best scientific evidence with clinical expertise and patient values. [iii] EBM has rapidly expanded and there are now international organisations and academic centres throughout the World which aim to improve healthcare by applying the principles of EBM to clinical practice. Organisations such as the Cochrane Collaboration[iv] bring together thousands of people to find and critically assess the best available research so that reviews of the latest and best research are produced which are freely available to patients and clinicians.
Where Evidence Based Medicine Happens
The amount of published medical research is continuously expanding and is far too much for any clinician to keep up to date with. In the 21st century it is much more important that a clinician has the skills to ask the right questions, then accurately search for and assess the research, rather than attempt to have all the required knowledge in their head. They must also be skilled in understanding the values and priorities of the patient and in shared decision making.
“The skills needed to find potentially relevant studies quickly and reliably, to separate the wheat from the chaff, and to apply sound research findings to patient care have today become as essential as skills with a stethoscope.” [v]
The principles of EBM have been enthusiastically embraced worldwide, gone beyond medicine to other professions, and become a mark of quality assurance. However, all evidence is not equal. Critically weighing up the strengths and weaknesses of research evidence is very important though technically challenging; an outline of how this can be done is included in another article.
There is a danger that some treatments are promoted as “evidence-based” when the evidence for effectiveness is weak, or there are better and more appropriate options available for a particular person. It is essential that a patient and their clinicians look beyond the marketing spin and have a well-informed and careful consideration of the treatment options when deciding on the right one.
Taking Research into the Real World
Ideally, high quality research evidence will be available which is directly relevant to the health problem the patient has. However, in clinical practice situations are rarely ideal! A few real-world issues may crop up that will need some thinking about, such as -
Good research studies are expensive to do and take years to complete and publish. It is not usually possible to delay a treatment decision until better evidence is available, so decisions sometimes must be made with what limited evidence there is.
It is not unusual that the treatment with the best research evidence for effectiveness has already been tried and not worked, so the next best options need to be considered.
Because evidence of good effects for a treatment does not exist does not mean that the treatment does not work, just that there currently is no good evidence. It is possible that research which is yet to be published will show that it is effective. Keeping an open mind is important – though it is more important not to believe in unlikely cures promoted by people with vested interests -beware “snake oil” salespeople!
A shortage of good research evidence is particularly the case for uncommon health problems, or ones that are not popular with organisations which have the financial clout to do big research studies such as drug companies or research organisations in wealthy countries.
The best scientific evidence usually comes from randomised controlled trials (RCT). There are some treatments which are difficult to test using the methods of an RCT, such as some psychological treatments, though for some people this treatment may be the most effective. It may be necessary to rely on weaker forms of evidence with some types of treatment.
Randomised controlled trials usually study a group of people which has been carefully screened to ensure that they do not have other mental or physical health problems, use drugs, or have some other complicating factor. This can make the group in the study quite artificial and different from patients in the real world, making it less reliable.
Many of the treatments used in psychiatry were found by chance by observant clinicians and only after being used for some time had scientific evidence to back them up. For example, in the 1950s drugs used to treat tuberculosis were noticed to elevate mood and were developed into some of the earliest antidepressants; a therapeutic technique for diminishing traumatic memories was developed from the originator’s own experience of distracting eye movements caused by trees while walking in a park[vi]. Sometimes astute observations by clinicians can point to useful treatments before research establishing effectiveness has been done. It is important that too much emphasis on large RCT processes does not stop other forms of investigation and research.
Consider Placebo Effects
The “placebo effect”, or improvement in symptoms purely because there is an expectation for treatment to be helpful, is particularly powerful in psychiatry – and both patient and clinician can easily be misled by it. Psychiatric disorders involve changes in mood, anxiety, perceptions or thought patterns which are subjective rather than being objectively measurable in the way that blood pressure or the size of a tumour on an x-ray can be. The problem with not recognising a response as due to placebo, rather than a true benefit of the treatment, is that a placebo response is often short lasting. It may lead the clinician to go on to use the treatment in other patients believing it will be effective, with all the costs and possible harms associated with this.
It is especially important when carrying out research into whether a treatment for a psychiatric disorder genuinely works or not, to be able to rule out the effect of placebo. This is usually done by giving some participants in a research study a dummy pill without their knowledge which resembles the medication being investigated, or a psychological or other form of treatment which is very similar to the treatment being studied but missing the assumed vital ingredient to see if the active treatment is effective. Doing this well so that research gives true results is very important, but difficult.
The flipside of the placebo effect is the “nocebo effect” which is the experience of side effects of a treatment due to the person’s expectation that they will have side-effects, which similarly must be considered.
Completing the Magic Potion of Evidence-Based Medicine
Patient values and preferences can be clarified, and the best available research can be found and critiqued. The third element of EBM – Clinical Judgement – is required to balance the patient’s values with what scientific facts are available and using the art of medicine combine a few other ingredients to reach the best treatment decision.
Who Does What?
While other professionals will do assessments before providing care, often an important role of the psychiatrist is to carry out a comprehensive mental health assessment, decide on a diagnosis and formulation, and put together an initial treatment plan with the patient (See post on Diagnosis in Psychiatry). The psychiatrist may be involved in providing some or all of the treatment in the plan. Alternatively, having completed an assessment and come up with a plan, the psychiatrist may hand over to others to carry out the plan.
Usually, treatment plans involve several people working as a team. As well as the patient and psychiatrist, very often the General Practitioner and patient’s family are involved. As the GP has a broad view of the person’s health, and may have known the person for several years, they usually have a key role in co-ordinating care and seeing the big picture of the person’s health. The GP is often the professional who has first contact with the patient and will decide on which other professionals should become involved, if any.
Advising on medication is usually the remit of the psychiatrist or GP, though some specialist nurses prescribe medication. There are many different types of psychotherapy, and a wide range of professionals offer this. Finding the best match between the patient, the particular type of therapy, the right professional background and style of the therapist can be difficult, though important if psychotherapy is to be effective. Other professionals such as physiotherapists, occupational therapists, dieticians, and others may become involved, as well as less formal “therapists” such as family members, friends, or colleagues. Often availability of resources affects the make-up of a treatment team. Increasingly telehealth or on-line resources can be used and get round some of the geographical and economic barriers to treatment.
An initial treatment plan would usually be reviewed from time to time by the psychiatrist or GP to ensure that all the right elements are in place, working together and bringing about the desired change. Over time the plan will be modified depending on progress.
One Minute Summary
Advances in science and clinical practice has led to more treatment options and better decisions – though uncertainty about the best treatment for a person will always be there.
Better treatment decisions can be made by applying the principles of Evidence-Based Medicine. This is the integration of the best scientific evidence with clinical expertise and patient values.
In modern clinical practice a treatment has more credibility if it claims to be “evidence-based”. However, there is a wide range in quality of evidence. When treatments claim to be “evidence-based” or “scientifically-proven” it is important to assess the quality and strength of the research evidence rather than accept the claim at face value. Often the evidence is weak or not relevant in the circumstances.
There are a wide range of treatment options in psychiatry, and often different types of treatment are used in combination as a treatment plan.
Placebo effects are large in mental health. Benefitting from placebo may be just as good as benefitting from an effective treatment – though best if the placebo is an inexpensive one!
Often a team of people are involved in providing treatment for mental health problems. Good co-ordination of this team, review of progress and adjust of the plan as necessary is important.
[i] For example Deep Sleep Therapy – The Royal Australian and New Zealand College of Psychiatrists describes the nature of this treatment and the harms caused in the policy statement - https://www.ranzcp.org/news-policy/policy-and-advocacy/position-statements/deep-sleep-therapy
[ii] Attributed to Dr Sir William Osler (1849 – 1919), Canadian physician and key figure in developing training in clinical medicine.
[iii] Sackett DL Rosenberg WM Gray JA Haynes RB Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ. 1996;3127023:71-72.
[v] Evidence based medicine and the medical curriculum, Paul Glasziou, Amanda Burls and Ruth Gilbert, BMJ 2008;337:a1253
[vi] Francine Shapiro (1948 – 2019), the originator of Eye-Movement Desensitisation and Reprogramming (EMDR), describes this experience.