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Caution about ‘miracle cures’
I thank Drs. Katherine Epstein and Helen Farrell for the balanced approach in their article “‘Miracle cures’ in psychiatry?” (Psychiatry 2.0,
We need to pay serious attention to the small sample sizes and limited criteria for patient selection in trials of ketamine and MDMA, as well as to what sort of “psychotherapy” follows treatment with these agents. Many of us in psychiatric practice for the past 40 years have been humbled by patients’ idiosyncratic reactions to standard medications, let alone novel ones. Those of us who practiced psychiatry in the heyday of “party drugs” have seen many idiosyncratic reactions. Most early research with cannabinoids and lysergic acid diethylamide (and even Strassman’s trials with N,N-dimethyltryptamine [DMT]1-5) highlighted the significance of response by drug-naïve patients vs drug-savvy individuals. Apart from Veterans Affairs trials for posttraumatic stress disorder, many trials of these drugs for treatment-resistant depression or end-of-life care have attracted non-naïve participants.6-8 Private use of entheogens is quite different from medicalizing their use. This requires our best scrutiny. Our earnest interest in improving outcomes must not be influenced by the promise of a quick fix, let alone a miracle cure.
Sara Hartley, MD
Clinical Faculty
Interim Head of Admissions
UC Berkley/UCSF Joint Medical Program
Berkeley, California
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
References
1. Strassman RJ. Human psychopharmacology of N,N-dimethyltryptamine. Behav Brain Res. 1996;73(1-2):121-124.
2. Strassman RJ. DMT: the spirit molecule. A doctor’s revolutionary research into the biology of near-death and mystical experiences. Rochester, VT: Park Street Press; 2001.
3. Strassman RJ, Qualls CR. Dose-response study of N,N-dimethyltryptamine in humans. I. Neuroendocrine, autonomic, and cardiovascular effects. Arch Gen Psychiatry. 1994;51(2):85-97.
4. Strassman RJ, Qualls CR, Berg LM. Differential tolerance to biological and subjective effects of four closely spaced doses of N,N-dimethyltryptamine in humans. Biol Psychiatry. 1996;39(9):784-795.
5. Strassman RJ, Qualls CR, Uhlenhuth EH, et al. Dose-response study of N,N-dimethyltryptamine in humans. II. Subjective effects and preliminary results of a new rating scale. Arch Gen Psychiatry. 1994;51(2):98-108.
6. Albott CS, et al. Improvement in suicidal ideation after repeated ketamine infusions: Relationship to reductions in symptoms of posttraumatic stress disorder, depression, and pain. Presented at: The Anxiety and Depression Association of America Annual Conference; Mar. 28-31, 2019; Chicago.
7. Abdallah CG, Sanacora G, Duman RS, et al. Ketamine and rapid-acting antidepressants: a window into a new neurobiology for mood disorder therapeutics. Annu Rev Med. 2015;66:509-523.
8. Mithoefer MC, Mithoefer AT, Feduccia AA, et al. 3,4-Methylenedioxymethamphetamine (MDMA)-assisted psychotherapy for post-traumatic stress disorder in military veterans, firefighters, and police officers: a randomised, double-blind, dose-response, phase 2 clinical trial. Lancet Psychiatry. 2018;5(6):486-497.
Continue to: Physician assistants and the psychiatrist shortage
Physician assistants and the psychiatrist shortage
J. Michael Smith’s article “Physician assistants in psychiatry: Helping to meet America’s mental health needs” (Commentary,
There needs to be a multifocal approach to incentivize medical students to choose psychiatry as a specialty. Several factors have discouraged medical students from going into psychiatry. The low reimbursement rates by insurance companies force psychiatrists to not accept insurances or to work for hospital or clinic organizations, where they become a part of the “medication management industry.” This scenario was created by the pharmaceutical industry and often leaves psychotherapy to other types of clinicians. In the not-too-distant future, advances in both neuroscience and artificial intelligence technologies will further reduce the role of medically trained psychiatrists, and might lead to them being replaced by other emerging professions (eg, psychiatric PAs) that are concentrated in urban settings where they are most profitable.
What can possibly be left for the future of the medically trained psychiatrist if a PA can diagnose and treat psychiatric patients? Why would we need more psychiatrists?
Marco T. Carpio, MD
Psychiatrist, private practice
Lynbrook, New York
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
The author responds
I appreciate Dr. Carpio’s comments, and I agree that the shortage of psychiatrists will not be addressed solely by the addition of other types of clinicians, such as PAs and nurse practitioners. However, the use of well-trained health care providers such as PAs will go a long way towards helping patients receive timely and appropriate access to care. Unfortunately, no single plan or method will be adequate to solve the shortage of psychiatrists in the United States, but that does not negate the need for utilizing all available options to improve access to quality mental health care. Physician assistants are well-trained to support this endeavor.
J. Michael Smith, DHSc, MPAS, PA-C, CAQ-Psychiatry
Post-Graduate PA Mental Health Residency Training Director
Physician Assistant, ACCESS Clinic, GMHC
Michael E. DeBakey VA Medical Center
Houston, Texas
Continue to: Additional anathemas in psychiatry
Additional anathemas in psychiatry
While reading Dr. Nasrallah’s “Anathemas of psychiatric practice” (From the Editor,
- Cash-only suboxone clinics. Suboxone was never intended to be used in “suboxone clinics”; it was meant to be part of an integrated treatment provided in an office-based practice. Nevertheless, this treatment has been used as such in this country. As part of this trend, an anathema has grown: cash-only suboxone clinics. Patients with severe substance use disorders can be found in every socioeconomic layer of our society, but many struggle with significant psychosocial adversity and outright poverty. Cash-only suboxone clinics put many patients in a bind. Patients spend their last dollars on a needed treatment or sell these medications to maintain their addiction, or even to purchase food.
- “Medical” marijuana. There is no credible evidence based upon methodologically sound research that cannabis has benefit for treating any mental illness. In fact, there is evidence to the contrary.1 Yet, in many states, physicians—including psychiatrists—are supporting the approval of medical marijuana. I remember taking my Hippocratic Oath when I graduated from medical school, pledging to continue educating myself and my patients about evidenced-based medical science that benefits us all. I have not yet found credible evidence supporting medical marijuana.
Greed in general is a strong anathema in medicine.
Leo Bastiaens, MD
Clinical Associate Professor of Psychiatry
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Reference
1. Radhakrishnan R, Ranganathan M, D'Souza DC. Medical marijuana: what physicians need to know. J Clin Psychiatry. 2019;80(5):45-47.
Caution about ‘miracle cures’
I thank Drs. Katherine Epstein and Helen Farrell for the balanced approach in their article “‘Miracle cures’ in psychiatry?” (Psychiatry 2.0,
We need to pay serious attention to the small sample sizes and limited criteria for patient selection in trials of ketamine and MDMA, as well as to what sort of “psychotherapy” follows treatment with these agents. Many of us in psychiatric practice for the past 40 years have been humbled by patients’ idiosyncratic reactions to standard medications, let alone novel ones. Those of us who practiced psychiatry in the heyday of “party drugs” have seen many idiosyncratic reactions. Most early research with cannabinoids and lysergic acid diethylamide (and even Strassman’s trials with N,N-dimethyltryptamine [DMT]1-5) highlighted the significance of response by drug-naïve patients vs drug-savvy individuals. Apart from Veterans Affairs trials for posttraumatic stress disorder, many trials of these drugs for treatment-resistant depression or end-of-life care have attracted non-naïve participants.6-8 Private use of entheogens is quite different from medicalizing their use. This requires our best scrutiny. Our earnest interest in improving outcomes must not be influenced by the promise of a quick fix, let alone a miracle cure.
Sara Hartley, MD
Clinical Faculty
Interim Head of Admissions
UC Berkley/UCSF Joint Medical Program
Berkeley, California
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
References
1. Strassman RJ. Human psychopharmacology of N,N-dimethyltryptamine. Behav Brain Res. 1996;73(1-2):121-124.
2. Strassman RJ. DMT: the spirit molecule. A doctor’s revolutionary research into the biology of near-death and mystical experiences. Rochester, VT: Park Street Press; 2001.
3. Strassman RJ, Qualls CR. Dose-response study of N,N-dimethyltryptamine in humans. I. Neuroendocrine, autonomic, and cardiovascular effects. Arch Gen Psychiatry. 1994;51(2):85-97.
4. Strassman RJ, Qualls CR, Berg LM. Differential tolerance to biological and subjective effects of four closely spaced doses of N,N-dimethyltryptamine in humans. Biol Psychiatry. 1996;39(9):784-795.
5. Strassman RJ, Qualls CR, Uhlenhuth EH, et al. Dose-response study of N,N-dimethyltryptamine in humans. II. Subjective effects and preliminary results of a new rating scale. Arch Gen Psychiatry. 1994;51(2):98-108.
6. Albott CS, et al. Improvement in suicidal ideation after repeated ketamine infusions: Relationship to reductions in symptoms of posttraumatic stress disorder, depression, and pain. Presented at: The Anxiety and Depression Association of America Annual Conference; Mar. 28-31, 2019; Chicago.
7. Abdallah CG, Sanacora G, Duman RS, et al. Ketamine and rapid-acting antidepressants: a window into a new neurobiology for mood disorder therapeutics. Annu Rev Med. 2015;66:509-523.
8. Mithoefer MC, Mithoefer AT, Feduccia AA, et al. 3,4-Methylenedioxymethamphetamine (MDMA)-assisted psychotherapy for post-traumatic stress disorder in military veterans, firefighters, and police officers: a randomised, double-blind, dose-response, phase 2 clinical trial. Lancet Psychiatry. 2018;5(6):486-497.
Continue to: Physician assistants and the psychiatrist shortage
Physician assistants and the psychiatrist shortage
J. Michael Smith’s article “Physician assistants in psychiatry: Helping to meet America’s mental health needs” (Commentary,
There needs to be a multifocal approach to incentivize medical students to choose psychiatry as a specialty. Several factors have discouraged medical students from going into psychiatry. The low reimbursement rates by insurance companies force psychiatrists to not accept insurances or to work for hospital or clinic organizations, where they become a part of the “medication management industry.” This scenario was created by the pharmaceutical industry and often leaves psychotherapy to other types of clinicians. In the not-too-distant future, advances in both neuroscience and artificial intelligence technologies will further reduce the role of medically trained psychiatrists, and might lead to them being replaced by other emerging professions (eg, psychiatric PAs) that are concentrated in urban settings where they are most profitable.
What can possibly be left for the future of the medically trained psychiatrist if a PA can diagnose and treat psychiatric patients? Why would we need more psychiatrists?
Marco T. Carpio, MD
Psychiatrist, private practice
Lynbrook, New York
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
The author responds
I appreciate Dr. Carpio’s comments, and I agree that the shortage of psychiatrists will not be addressed solely by the addition of other types of clinicians, such as PAs and nurse practitioners. However, the use of well-trained health care providers such as PAs will go a long way towards helping patients receive timely and appropriate access to care. Unfortunately, no single plan or method will be adequate to solve the shortage of psychiatrists in the United States, but that does not negate the need for utilizing all available options to improve access to quality mental health care. Physician assistants are well-trained to support this endeavor.
J. Michael Smith, DHSc, MPAS, PA-C, CAQ-Psychiatry
Post-Graduate PA Mental Health Residency Training Director
Physician Assistant, ACCESS Clinic, GMHC
Michael E. DeBakey VA Medical Center
Houston, Texas
Continue to: Additional anathemas in psychiatry
Additional anathemas in psychiatry
While reading Dr. Nasrallah’s “Anathemas of psychiatric practice” (From the Editor,
- Cash-only suboxone clinics. Suboxone was never intended to be used in “suboxone clinics”; it was meant to be part of an integrated treatment provided in an office-based practice. Nevertheless, this treatment has been used as such in this country. As part of this trend, an anathema has grown: cash-only suboxone clinics. Patients with severe substance use disorders can be found in every socioeconomic layer of our society, but many struggle with significant psychosocial adversity and outright poverty. Cash-only suboxone clinics put many patients in a bind. Patients spend their last dollars on a needed treatment or sell these medications to maintain their addiction, or even to purchase food.
- “Medical” marijuana. There is no credible evidence based upon methodologically sound research that cannabis has benefit for treating any mental illness. In fact, there is evidence to the contrary.1 Yet, in many states, physicians—including psychiatrists—are supporting the approval of medical marijuana. I remember taking my Hippocratic Oath when I graduated from medical school, pledging to continue educating myself and my patients about evidenced-based medical science that benefits us all. I have not yet found credible evidence supporting medical marijuana.
Greed in general is a strong anathema in medicine.
Leo Bastiaens, MD
Clinical Associate Professor of Psychiatry
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Reference
1. Radhakrishnan R, Ranganathan M, D'Souza DC. Medical marijuana: what physicians need to know. J Clin Psychiatry. 2019;80(5):45-47.
Caution about ‘miracle cures’
I thank Drs. Katherine Epstein and Helen Farrell for the balanced approach in their article “‘Miracle cures’ in psychiatry?” (Psychiatry 2.0,
We need to pay serious attention to the small sample sizes and limited criteria for patient selection in trials of ketamine and MDMA, as well as to what sort of “psychotherapy” follows treatment with these agents. Many of us in psychiatric practice for the past 40 years have been humbled by patients’ idiosyncratic reactions to standard medications, let alone novel ones. Those of us who practiced psychiatry in the heyday of “party drugs” have seen many idiosyncratic reactions. Most early research with cannabinoids and lysergic acid diethylamide (and even Strassman’s trials with N,N-dimethyltryptamine [DMT]1-5) highlighted the significance of response by drug-naïve patients vs drug-savvy individuals. Apart from Veterans Affairs trials for posttraumatic stress disorder, many trials of these drugs for treatment-resistant depression or end-of-life care have attracted non-naïve participants.6-8 Private use of entheogens is quite different from medicalizing their use. This requires our best scrutiny. Our earnest interest in improving outcomes must not be influenced by the promise of a quick fix, let alone a miracle cure.
Sara Hartley, MD
Clinical Faculty
Interim Head of Admissions
UC Berkley/UCSF Joint Medical Program
Berkeley, California
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
References
1. Strassman RJ. Human psychopharmacology of N,N-dimethyltryptamine. Behav Brain Res. 1996;73(1-2):121-124.
2. Strassman RJ. DMT: the spirit molecule. A doctor’s revolutionary research into the biology of near-death and mystical experiences. Rochester, VT: Park Street Press; 2001.
3. Strassman RJ, Qualls CR. Dose-response study of N,N-dimethyltryptamine in humans. I. Neuroendocrine, autonomic, and cardiovascular effects. Arch Gen Psychiatry. 1994;51(2):85-97.
4. Strassman RJ, Qualls CR, Berg LM. Differential tolerance to biological and subjective effects of four closely spaced doses of N,N-dimethyltryptamine in humans. Biol Psychiatry. 1996;39(9):784-795.
5. Strassman RJ, Qualls CR, Uhlenhuth EH, et al. Dose-response study of N,N-dimethyltryptamine in humans. II. Subjective effects and preliminary results of a new rating scale. Arch Gen Psychiatry. 1994;51(2):98-108.
6. Albott CS, et al. Improvement in suicidal ideation after repeated ketamine infusions: Relationship to reductions in symptoms of posttraumatic stress disorder, depression, and pain. Presented at: The Anxiety and Depression Association of America Annual Conference; Mar. 28-31, 2019; Chicago.
7. Abdallah CG, Sanacora G, Duman RS, et al. Ketamine and rapid-acting antidepressants: a window into a new neurobiology for mood disorder therapeutics. Annu Rev Med. 2015;66:509-523.
8. Mithoefer MC, Mithoefer AT, Feduccia AA, et al. 3,4-Methylenedioxymethamphetamine (MDMA)-assisted psychotherapy for post-traumatic stress disorder in military veterans, firefighters, and police officers: a randomised, double-blind, dose-response, phase 2 clinical trial. Lancet Psychiatry. 2018;5(6):486-497.
Continue to: Physician assistants and the psychiatrist shortage
Physician assistants and the psychiatrist shortage
J. Michael Smith’s article “Physician assistants in psychiatry: Helping to meet America’s mental health needs” (Commentary,
There needs to be a multifocal approach to incentivize medical students to choose psychiatry as a specialty. Several factors have discouraged medical students from going into psychiatry. The low reimbursement rates by insurance companies force psychiatrists to not accept insurances or to work for hospital or clinic organizations, where they become a part of the “medication management industry.” This scenario was created by the pharmaceutical industry and often leaves psychotherapy to other types of clinicians. In the not-too-distant future, advances in both neuroscience and artificial intelligence technologies will further reduce the role of medically trained psychiatrists, and might lead to them being replaced by other emerging professions (eg, psychiatric PAs) that are concentrated in urban settings where they are most profitable.
What can possibly be left for the future of the medically trained psychiatrist if a PA can diagnose and treat psychiatric patients? Why would we need more psychiatrists?
Marco T. Carpio, MD
Psychiatrist, private practice
Lynbrook, New York
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
The author responds
I appreciate Dr. Carpio’s comments, and I agree that the shortage of psychiatrists will not be addressed solely by the addition of other types of clinicians, such as PAs and nurse practitioners. However, the use of well-trained health care providers such as PAs will go a long way towards helping patients receive timely and appropriate access to care. Unfortunately, no single plan or method will be adequate to solve the shortage of psychiatrists in the United States, but that does not negate the need for utilizing all available options to improve access to quality mental health care. Physician assistants are well-trained to support this endeavor.
J. Michael Smith, DHSc, MPAS, PA-C, CAQ-Psychiatry
Post-Graduate PA Mental Health Residency Training Director
Physician Assistant, ACCESS Clinic, GMHC
Michael E. DeBakey VA Medical Center
Houston, Texas
Continue to: Additional anathemas in psychiatry
Additional anathemas in psychiatry
While reading Dr. Nasrallah’s “Anathemas of psychiatric practice” (From the Editor,
- Cash-only suboxone clinics. Suboxone was never intended to be used in “suboxone clinics”; it was meant to be part of an integrated treatment provided in an office-based practice. Nevertheless, this treatment has been used as such in this country. As part of this trend, an anathema has grown: cash-only suboxone clinics. Patients with severe substance use disorders can be found in every socioeconomic layer of our society, but many struggle with significant psychosocial adversity and outright poverty. Cash-only suboxone clinics put many patients in a bind. Patients spend their last dollars on a needed treatment or sell these medications to maintain their addiction, or even to purchase food.
- “Medical” marijuana. There is no credible evidence based upon methodologically sound research that cannabis has benefit for treating any mental illness. In fact, there is evidence to the contrary.1 Yet, in many states, physicians—including psychiatrists—are supporting the approval of medical marijuana. I remember taking my Hippocratic Oath when I graduated from medical school, pledging to continue educating myself and my patients about evidenced-based medical science that benefits us all. I have not yet found credible evidence supporting medical marijuana.
Greed in general is a strong anathema in medicine.
Leo Bastiaens, MD
Clinical Associate Professor of Psychiatry
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Reference
1. Radhakrishnan R, Ranganathan M, D'Souza DC. Medical marijuana: what physicians need to know. J Clin Psychiatry. 2019;80(5):45-47.
