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The trend toward scientific reductionism in psychiatry may be driving the economic reductionism of managed care, according to James Scully Jr., M.D.
Scully, professor and chair of the department of neuropsychiatry and behavioral science at the University of South Carolina School of Medicine and former director of the APA Office of Education, spoke on "Reduction and Reductionism: A Dilemma for Psychiatry" at APA’s Institute on Psychiatric Services in October in Washington, D.C.
Scully suggested that scientific reductionism is reflected in the way in which insurers conceive of and pay for psychiatric services. If a brief visit and a bottle of pills get the patient functionally well, why bother to pay for extended psychotherapy? This line of reasoning is the economic analog of the scientific reductionism now in vogue, he observed.
In the 1980’s medicine experienced the advent of managed care. This followed the post-World War II proliferation of employer-provided health insurance, which divorced patients from price sensitivity, Scully observed. This price insensitivity, combined with technological advances, progressively drove up health costs, giving rise to managed care.
Psychiatry was "the canary in the coal mine" when it came to how managed care would treat medical specialties, Scully said. The psychiatric profession was the first to suffer the full economic and clinical impact of managed care.
The practices of managed care, however, including those that have elicited an outcry from psychiatrists and other specialists, are an economically rational response to marketplace contingencies, he noted. "The market has no social conscience," he commented.
Absent externally imposed constraints, insurers tend to insure the healthy, maximizing profit and minimizing risk.
Scientific reductionism has "bedeviled our field for generations and generations," remarked Scully. It is the reductionist mindset that underlies the rationale of health care payers who limit psychotherapy coverage but generously reimburse medication. Compared with other medical specialties, psychiatry has been criticized both for being too soft as medical science and too harsh for trying to reduce behavior to neuromolecular terms.
Yet comprehending behavior’s molecular template need not reduce mental illness to a mere series of biochemical reactions to be altered with medication, said Scully. Neuroscientist Eric Kandel, M.D., has shown that learning, including the learning involved in psychotherapy, results in both functional and neuronal changes, he observed. Hence, effective psychotherapy results in not only behavioral change, but also a biochemical alteration of the brain.
Despite its pitfalls, reductionism has been a boon to those campaigning against stigma and for enhanced insurance coverage of mental illness, said Scully, for it has permitted them to describe mental illnesses as "brain disorders." But the shift has also occasioned the loss of a more comprehensive view of human behavior.
"Consider the fate of ‘neurosis,’" Scully mused. "Think of the changes in our field. This was once the core principle of psychiatry. So what happened to that?"
He recalled a recent encounter with a second-year psychiatry resident who was working with a patient suffering from an anxiety disorder. In discussing this patient with the resident, Scully used the term "neurosis." The resident furrowed his brow, and Scully found that this bright student was unfamiliar with the concept of neurosis.
The term "neurosis" was dropped in DSM-III, which became a powerful influence because "the ideas it contained worked," Scully noted. But the DSM (now in its fourth edition) is "a tool," not "a bible," Scully asserted. Tools, while useful, may be overwhelming when so powerful. The broad, humanistic perspective of an earlier psychiatry may have been a casualty of DSM’s utility and power, he observed.
Although psychoanalytic models enriched psychiatry, they did nothing to reduce stigma, said Scully. Indeed, such concepts as "the schizophrenogenic mother" may have greatly worsened the stigma of severe mental illness. Understanding that schizophrenia is a brain disease, not a mysterious outcome induced by poor parenting, has helped reduce stigma.
Yet there is risk in pushing the psychiatrist "into the role of clinical neuroscientist," warned Scully. While it is good that schizophrenia is recognized as a brain disease and that insurance increasingly covers its treatment, it is not good if that translates into coverage of only pharmacological treatment without much needed psychosocial rehabilitation.
Thus has biological reductionism led to economic reductionism, Scully said.
The poverty of a reductionist approach became dramatically apparent to Scully through a series of encounters with one patient over a 20-year period.
When Scully originally saw the patient twice weekly during the 1970’s, he had followed a psychodynamic model in treating the patient’s severe panic disorder. At that time, he had at hand neither the biological knowledge nor the pharmacological tools taken for granted today. But when the patient returned recently, Scully prescribed medication.
The patient said he felt better physically than ever before. But he turned to Scully one day and said, "Can we talk?" The medication was covered by insurance, but the subsequent series of psychotherapeutic sessions that helped the patient sort out what was happening in his life were not.
In all illness, psychiatric or nonpsychiatric, hope and meaning are critical components of how people cope with their circumstances, said Scully. Those who work with cancer and heart patients know how important it is for the patient to find meaning in his or her affliction.
"Human behavior is complex, which is why our field of psychiatry is so interesting," Scully concluded.