Comments and Controversies
Creating new dogma
In “Shattering dogmas” (From the Editor, Current Psychiatry, January 2011, p. 12-16), Dr. Henry A. Nasrallah’s statement that “similar to a revolution to depose a dictator, the demise of a dogma will have a salutary effect on medical practice” is merely evidence of how a reactionary, overly medicalized approach to psychiatry ends up reproducing the very system it seeks to replace. Instead of exploring the nuanced aspects of dogmas, he makes one-sided global assertions, which do little to further our understanding of the topics.
For instance, his assertion about contemporary practitioners not touching their patients being “irrelevant in modern-era psychiatry” discounts that there is a spectrum of clinical practice and the implications of a physical exam performed by a psychiatrist engaged in intensive psychotherapy or psychoanalysis with a patient are much different from those of a psychiatrist doing once-monthly medication management checks. At a minimum, consideration of the nature of the treatment and the particulars of the relationship should inform the individual practitioner’s decision-making process on this issue.
Furthermore, blanket statements such as “whether we like it or not, the pharmaceutical industry is the only source of new medication” shifts our attention away from the problematic nature of the too cozy relationship that has developed between academic psychiatrists and industry and diverts our efforts away from political efforts to demand more funding from the public sector. Unfortunately, such global assertions only result in the promulgation of Dr. Nasrallah’s own dogma, which—much like that of Freud—relies heavily on military metaphor, and leaves little room for either exploration or dissent.
Geoffrey Neimark, MD
Clinical Associate Professor of Psychiatry
University of Pennsylvania
Dr. Nasrallah responds
In my opinion piece, in addition to being provocative to stimulate opposing points of view, I was speaking not as a “therapist” but as a psychiatric physician who has additional critical medical responsibilities to carry out. Although I believe in and practice a medical model of psychiatry, I provide my patients with several types of psychosocial treatments—including psychodynamicpsychotherapy, in which I was heavily trained 3 decades ago. If you were in my shoes, supervising medical students and training psychiatric residents to treat seriously mentally ill patients who have grave medical comorbidities, you would agree that some of the dogmatic dictums of the past are hard to reconcile with modern psychiatric or medical practice. As for the “cozy” relationship between academics and the pharmaceutical industry, you should be complimenting rather than demeaning that relationship because as their expert consultants and advisors, we often warn the industry about publishing abuses, such as concealing negative findings or poor research trial designs that are unfair to competing products, or inappropriate marketing of medications, etc. We also conduct FDA studies with industry and provide feedback about research design, and we demand additional data analyses beyond what the FDA requires. It is unfortunate that aspersions are cast on anyone who collaborates with the “demonized” industry without which the mentally ill would have no medications. I certainly wish our government would develop psychiatric drugs at the National Institute of Mental Health, but that enterprise would require hundreds of billions of dollars, which will have to come from substantial new taxes, the prospects of which are practically nil.
Henry A. Nasrallah, MD