In a viewpoint piece published in JAMA Psychiatry, researchers write that there is no evidence that psychiatric interventions lead to “successful” outcomes. Successful outcomes, they write, include “the prevention of undesirable events, such as death and disability, and the achievement of desirable ones, such as remission.”
Psychiatry, unlike other medical specialties, has not developed efforts to investigate this question. They write:
“Despite advances in measurement-based psychiatric care, clinical [success rate] reporting systems do not exist for most psychiatric services. This applies to all psychiatric treatments, including pharmacotherapy, psychotherapy, and neuromodulation.”
The viewpoint was written by Kenneth Freedland and Charles Zorumski at Washington University School of Medicine in St. Louis, Missouri.
One way to measure “successful outcomes” is to assess whether current treatments are more effective “for a variety of clinically important outcomes” than previous treatments. Other medical specialties can point to such progress.
Freedland and Zorumski write, “Cardiologists, oncologists, and other medical specialists can point to temporal trends in success rates for a variety of clinically important outcomes to confirm that current treatments are more effective than the ones that were available 20 or 30 years ago.”
Yet, they note, “Similar data are hard to find for psychiatric disorders.”
This is the very data that the public wants to know. They want to know that a medical treatment leads to “successful outcomes” and that outcomes have improved over time.
“Patients with serious illnesses care about their chances of having successful treatment outcomes. They also expect to receive more effective treatments than the ones that were available to their parents or grandparents, and they hope that even more effective treatments will be available for their children and grandchildren,” Freedland and Zorumski write.
If this assessment is applied to psychiatry, it raises this question: Are mental health outcomes today—in this era of Prozac, ECT, CBT, and so forth—better than they were in the era of, say, insulin coma therapy and lobotomy? Or even better than in the early 1800s, when Quakers introduced “moral therapy”?
According to Freedland and Zorumski, there is an absence of “successful outcomes” data that could answer that question.
The authors focus on the need for psychiatry to develop such measurements, focusing on the “success rate” of new psychiatric treatments compared to existing treatments.
“If psychiatric treatment success rate data systems were available, they would show us that it is difficult to improve clinical [success rates] by devising new interventions for patients who are potentially responsive to existing ones.”
The two authors don’t delve into the outcomes data that do exist, which tell of a public health failure in psychiatric care. Instead, all the data today tells of worsening mental health in the United States, particularly among the young. For instance, new data from the CDC found that 57% of teen girls feel “persistently sad and hopeless,” and 30% “seriously considered attempting suicide.”
And the data also shows that current interventions may contribute to that decline. For instance, researchers have warned that well-intentioned “mental health awareness” campaigns may be worsening outcomes. Antidepressants have been shown to increase the risk that depression will run a more chronic course, and they increase the risk of diabetes, hypertension, and other evidence of poor health.
In the long term, antipsychotics—on the whole—lead to worse outcomes for people diagnosed with schizophrenia and other psychotic disorders, including worse work functioning, even when comparing people with similar baseline symptom severity.
While the authors have pointed out the absence of successful outcome data for psychiatric treatments, they then jump to this conclusion, which nevertheless presents psychiatric care in a positive light: If systemic measurements were created for assessing “successful outcomes,” they write, this could ensure that psychiatry “continues” to improve:
“The development of well-designed, sustainable success rate data systems would facilitate this kind of progress and help ensure that psychiatric treatment outcomes continue to improve in the decades ahead.”
That sentiment suggests that psychiatric treatments have been shown in the past to lead to successful outcomes; yet, as they write here, there is no data on whether medical treatments for psychiatric disorders, past or present, produce that bottom-line result. As such, this paper highlights the fact that there is no evidence that psychiatric interventions do more good than harm.
Freedland, K. E. & Zorumski, C. F. (2023). Success rates in psychiatry. JAMA Psychiatry. Published online March 22, 2023. doi:10.1001/jamapsychiatry.2023.0056 (Link)