I was recently going through a bag of wires and adapters, trying to find a mini USB cable to charge an older electronic device that I own (newer devices use the not surprisingly smaller micro USB). Perhaps you have a similar bag, or a drawer filed with adapters, cables, and wires for gadgets you no longer own (remember the Palm Pilot?!). Divorced from their cables, I am still reluctant to throw them out, uncertain if I will need them in the future.
I’m noticing a similar problem now that I’m in the middle of a clinical psychiatric career, especially since I am teaching the next generation of practitioners. Which of our treatments do we throw out, and what do we keep as we begin to adopt new practices?
It is becoming increasingly clear that the practice of psychiatry will be changing from one in which we ask our patients to take a daily pill to one where we deliver procedures that have enduring effects. Most of the buzz at this year’s Psych Congress was not about a new pill—it was about treatments such as repetitive TMS (rTMS), esketamine nasal spray, psychedelic-assisted therapy, botulinum toxin injections for depression, brexanolone infusions for postpartum depression, and long-acting injectable antipsychotics. It’s clear a brave new world has already begun to arrive in psychiatry, and those of us who are used to daily psychopharmacologic interventions may start feeling like that bag of wires in my desk.
Of course, we’ve always had an enduring somatic treatment in psychiatry: electroconvulsive treatment (ECT), but stigma and institutional barriers have left this effective modality underutilized. Lest we forget the most common enduring form of treatment in psychiatry, psychotherapy, where the benefits of behavioral change and insight can endure for years after the treatment has stopped. Of course, this , discouraged by insurance, or difficult to access.
This difference in paradigm—from daily medicines to episodic procedures—has been characterized by my friend and colleague Dr. Charles Raison as the difference between a gas grill and a campfire.1 While both produce heat, the gas grill only makes heat when the gas is on. As soon as it is turned off, the heat quickly dissipates. A campfire, on the other hand, requires preparation and circumstances favorable to burning. But once a campfire gets going, it continues to make heat with little need for outside intervention. Occasionally, another log needs to be thrown on the fire, but in general, the heat continues to be produced with little need for additional intervention.
Most of us who prescribe medications are used to thinking about our patients like gas grills who need close attention and a steady supply of medications in order to maintain the changes that were occasioned by the drugs. But what if we didn’t need to do that? What if a short course of intensive intervention changed the state of an illness from chronic to in remission? How would that change the care we provide and the systems through which we provide it? More importantly, how would that change the experience of the patient seeking care?