Medicine and the Mind

Medicine and the Mind
Caleb GarAdner, M.D., and Arthur Kleinman, M.D.
bout 100 years ago, the psychiatrist and phi-
losopher Karl Jaspers observed that biologic
and psychological investigations of the mind were like “the exploration of an unknown continent
and most humane care to people with medically and psychologi- cally complicated conditions.
Our mind arises from brain function, and both conscious and unconscious mind processes feed back continuously to shape that function. Over the past century, both the psychodynamic tradition and basic neuroscience have paint- ed pictures of a brain-mind that is fundamentally dynamic and plastic, in which cognition is in- separable from emotion and feel- ing, and where conscious aware- ness is a porous vessel on a sea of unconscious processes. The in- f luence of the wider social world on well-being and illness has also been systematically elaborated by fields such as social psychology and anthropology. Interpersonal relations, from family dynamics to cultural practices and political constraints, affect our brain- minds. And in all our interven- tions (whether medications, cogni- tive techniques, or insight-oriented therapy), the power and centrality
The NEW ENGLAND JOURNAL of MEDICINE
Perspective
October 31, 2019
Medicine and the Mind — The Consequences of Psychiatry’s Identity Crisis
from opposite directions, where the explorers never meet because of impenetrable country that inter- venes.”1 Since then, it has been the work of psychiatry to push further into the interior while also attempting to ease the men- tal suffering of real people. To succeed in this complex endeavor, both basic science and psychologi- cally sophisticated care are needed. But something has gone wrong in contemporary academic and clini- cal psychiatry. Checklist-style amal- gamations of symptoms have taken the place of thoughtful diag- nosis, and trial-and-error “medica- tion management” has taken over practice to an alarming degree. We are facing the stark limitations of biologic treatments, while find- ing less and less time to work with patients on difficult problems.
Ironically, although these lim- itations are widely recognized by experts in the field, the prevailing message to the public and the rest of medicine remains that the solu- tion to psychological problems in- volves matching the “right” diag- nosis with the “right” medication. Consequently, psychiatric diagno- ses and medications proliferate under the banner of scientific medicine, though there is no com- prehensive biologic understanding of either the causes or the treat- ments of psychiatric disorders.
The problem is not simply one of scientific and intellectual integ- rity. This state of affairs influ- ences training and reimbursement and does a great disservice to patients, practicing psychiatrists, and our medical colleagues who are striving to provide the best
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Medicine and the Mind
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of the clinician–patient relation- ship are clear.
Basic science is, of course, es- sential both to developing new therapeutics and to increasing our knowledge of mental processes and pathology. New discoveries in genetics and neuroscience are exciting, yet they are still far from offering real help to real people in the hospital, clinic, and consulting room. Given the com- plexity of the human mind, this gap is not surprising.
In the meantime, psychiatry finds itself plagued by overpre- scription of psychiatric medica- tion for a large segment of the population; abandonment and in- carceration of people with chron- ic, severe mental illness; and an increasingly unwieldy diagnostic system of overlapping symptom checklists.2
In addition, medicine’s “era of high throughput”3 has promoted a one-size-fits-all approach to di- agnosis and treatment, and time with patients has dwindled in all specialties. For psychiatry, which still faces substantial diagnostic and therapeutic uncertainty, these trends have been especially de- forming.
Throughout medicine, patients and clinicians alike are feeling the absence of robust, therapeu- tic relationships. Psychiatry should be uniquely positioned to help with this crisis through example, scholarship, and consultation, yet the field seems to have largely abandoned its social, interper- sonal, and psychodynamic foun- dations, with little to show for these sacrifices.
So what should be done? His- torian Anne Harrington proposes that psychiatry limit its scope to severe, mostly psychotic disorders. “Make no mistake,” she writes, “today one is hard-pressed to find anyone knowledgeable who be-
lieves that the so-called biological revolution of the 1980s made good on most or even any of its thera- peutic and scientific promises.”4
Harrington’s proposal would point to an understandably dimin- ished role for psychiatry as it has come to define itself. But we be- lieve that that would be too great a loss — for patients and for med- icine as a whole.
The global aging, addiction, and immigration crises call for the expertise of geriatric, addiction, and social psychiatry, respectively. There is substantial unmet need for psychiatric treatments and care for children and adolescents, and the emergence of mental health as a priority in the global health arena has increased the role of psychiatry in both international settings and the poorest popula- tions in the United States. Other areas, such as consultation–liaison psychiatry (which focuses on pa- tients with coexisting psychiatric and general medical needs), have taken on added significance in an era concerned with improving the quality of health care in general medicine.5
Yet over the past half century, biologic research has come to largely replace all other forms of psychiatric research — psycho- social, cultural, public health, and community — which have thus been marginalized in spite of the useful knowledge these fields pro- vide for everyday care of patients and prevention of mental illness. Similarly, psychotherapy, an essen- tial and multifaceted tool that mobilizes the unique power of the clinician–patient relationship, has been increasingly neglected in psychiatric training and practice.
We believe that a fundamental rethinking of psychiatric knowl- edge creation and training is in order. If only the highest-quality biologic research were supported,
substantial funding could be re- directed to psychosocial, cultural, public health, and community studies that directly support the work of practicing psychiatrists responding to the needs of pa- tients, families, and communities. The most pressing work is re- search on addiction, elder care, community care programs, con- sultation aimed at improving the quality of care in medical clinics and hospitals, child and adoles- cent psychiatry, and global men- tal health, as well as cultural studies of vulnerable populations.
Biologic psychiatry has thus far failed to produce a comprehen- sive theoretical model of any ma- jor psychiatric disorder, any tests that can be used in a clinic to diagnose clearly defined major psychiatric disorders, or any guid- ing principle for somatic treat- ments to replace the empirical use of medications. Biologic knowl- edge is foundational to good psy- chiatry, but we believe that mis- apprehension of its limitations is stunting the field from within and subjecting it to manipulation from without by corporate and administrative interests that, in- tentionally or not, strive to bene- fit from a falsely simplified and deterministic formulation of men- tal illness and its treatment.
It seems clear that psychiatry needs to be rebuilt, and academ- ics can lead the way. Biology and dynamic psychological consider- ations can complement one anoth- er. Psychiatric training programs can promote epidemiology, social science, cultural expertise, com- munity studies, prevention, and consultation–liaison work — and most important, psychotherapy.
If advances in modern neuro- science have taught us anything, it’s that the brain-mind and its emotional and cognitive process- es are even more complicated

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Medicine and the Mind
An audio interview with Dr. Gardner is available at NEJM.org
tical implications for the practice of gen- eral medicine as well
Enabling Healthful Aging for All
and mysterious than previously thought. It is crucial that this work continue. At the same time, we are learning more and more about the interconnections of mind, body, and society, and the inter- dependence of mental, medical, and social health. This interde- pendence has profound and prac-
Rather than contracting in an ex- clusive focus on biologic struc- ture, the field needs to expand if we are to meet the needs of real people in the clinic, on medical wards, and out in the community who require comprehensive, rela- tional care to address their suf- fering effectively and humanly.
Disclosure forms provided by the authors are available at NEJM.org.
From the Department of Psychiatry, Cam- bridge Health Alliance (C.G.), and the De- partment of Anthropology, Harvard Univer- sity (A.K.) — both in Cambridge, MA; and the Departments of Psychiatry (C.G.) and Global Health and Social Medicine (A.K.), Harvard Medical School, Boston.

  1. Jaspers K. General psychopathology. Hoenig J, Hamilton MW, trans. Baltimore: Johns Hopkins University Press, 1997 (1913).
  2. Frances A. Saving normal: an insider’s revolt against out-of-control psychiatric diag- nosis, DSM-5, Big Pharma, and the medical- ization of ordinary life. New York: Harper Collins, 2013.
  3. Ludmerer K. Let me heal: the opportu- nity to preserve excellence in American medi- cine. New York: Oxford University Press, 2015.
  4. Harrington A. Mind fixers: psychiatry’s troubled search for the biology of mental ill- ness. New York: Norton, 2019.
  5. Kleinman A. The soul of care: the moral education of a husband and a doctor. New York: Penguin/Viking, 2019.
    DOI: 10.1056/NEJMp1910603
    opyright © 2019 Massachusetts Medical Society.
    as psychiatry. In many ways, the unknown continent of the mind looms even larger now than it did in Jaspers’ day — a reality that is both humbling and inspiring.
    C
    Medicine and the Mind
    Enabling Healthful Aging for All — The National Academy
    of Medicine Grand Challenge in Healthy Longevity
    Victor J. Dzau, M.D., Sharon K. Inouye, M.D., M.P.H., John W. Rowe, M.D., Elizabeth Finkelman, M.P.P., and Tadataka Yamada, M.D.
    During the past century, hu- man life expectancy has near- ly doubled globally, increasing by more years than it did in all pre- vious millennia combined. Today, 617 million people are 65 years old or older; by 2050, the number willreach1.6billion—nearly20% of the world’s population — and the population of the “oldest old,” 80 or older, will more than triple, growing from 126 million to 447 million.1 Major advances in pub- lic health, socioeconomic develop- ment, education, and health care have driven these dramatic gains. Yet this triumph presents chal- lenges as well as opportunities.
    Combined with declining fer- tility rates, the rapid growth of the older population is yielding aging societies, in which the old outnumber the young. This demo- graphic transition creates econom- ic, social, political, and health care challenges. Our core societal institutions, including education,
    health care, work and retirement, the built environment, and our economies, were not designed to support populations with this an- ticipated age distribution. As old- er adults leave the workforce and proportionally fewer younger peo- plelineuptoreplacethem,econ- omies will lose their equilibrium. Health care systems will struggle to fulfill increasing demands for treatment, hospitalization, and in- home caregiving. Communities will strain to meet needs for hous- ing, social services, and trans- portation. As a result, older peo- ple’s well-being may suffer.
    Population aging affects both high- and low-income countries, though the specific challenges fac- ing each country depend on its economic resources as well as the structure and function of its health care, social insurance, and retirement systems and cultural factors including the severity of ageism. The changes are currently
    most profound in Japan, Europe, and North America. By 2050, the United Nations estimates that older people will constitute more than one third of the population in Europe; approximately one quarter in North America, Latin America, the Caribbean, Asia, and Oceania; and 9% in Africa.
    Aging is a major risk factor for multiple chronic diseases, in- cluding cancers and cardiovascu- lar and neurodegenerative condi- tions such as Alzheimer’s and Parkinson’s diseases, all of which require extensive long-term care. Many countries are grappling with rising health care expenditures, elder care workforce deficiencies, and care needs associated with ag- ing, disability, and having multi- ple coexisting conditions. Japan, whose over-65 population reached 21% in 2006, has made substan- tial investments in robotics, arti- ficial intelligence, and other inno- vations to meet these needs. On
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