"Not Dead Yet!" - Confronting the Legacy of Dualism in Modern Psychiatry

Therapeutic and Structural Dimensions in Psychiatric Prescribing: Bridging Psychedelics and Antidepressants

ABSTRACT

As practitioners seek more personalized approaches, exploring how patients' environments, relationship templates, and mindsets factor into symptom burden can help broaden understanding of how psychotropic medications facilitate recovery. Despite increasing focus on medications to provide relief, there is an important and undeniable influence the therapeutic environment has on shaping outcomes, particularly for the patient-clinician alliance. While environmental dimensions are relevant for informing possible placebo or nocebo responses, they also build upon the pharmacodynamic and neurobiological effects of medications. By heightening neuroplasticity, some antidepressants may amplify the effects of nonmedication factors in patients' lives, including the patient-prescriber therapeutic relationship. There are important parallels between antidepressants and psychedelics in emerging literature. For instance, the preparatory and integrative work with a provider can be crucial in determining outcomes. This paper will draw from the extant literature to discuss the therapeutic relationship in psychiatric practice, including in acute care settings and instances in which psychotropic prescribing is a key aspect of treatment.

Beyond psychedelics: set and setting in general psychiatric practice

Psychedelic compounds continue gaining scientific and regulatory traction as potential new treatments for psychiatric disorders. While most psychiatrists will likely not work directly with these compounds, psychedelic research practices provide insights that may improve conventional psychiatric care. Through its emphasis on 'set and setting' (mindset and environment, respectively), psychedelic research highlights the importance of non-pharmacologic factors maximizing therapeutic outcomes. While psychedelics and serotonergic antidepressants are distinctly different in their subjective experience, new findings suggest mechanistic overlap between them. Both have been found to modulate neurotrophins, enhance neuroplasticity, and reopen critical periods of learning, molded by the environmental context in which they are administered.

This paper will argue that by integrating insights from psychedelic research (particularly set and setting), depression treatment outcomes in traditional psychiatric settings can improve by optimizing non-pharmacological factors in treatment, including the provision of high-quality psychotherapy.

Biological Psychiatry is Dead, Long Live Biological Psychiatry!

The failure of biological psychiatry to deliver on its promises of enlightening the origin of psychiatric disorders and optimizing their treatment is due to invalid theoretical postulates that derive from an outdated conceptualization of human biology. The crisis of biological psychiatry depends on its identification with functional biology. A major contribution of evolutionary biology (the other current of biological thought) is to integrate the study of environmental variables (developmental, interpersonal, and ecological) with those mechanisms that are the field of study of functional biology (genetics, anatomy, and physiology). A new theoretical framework based on the integration of functional and evolutionary explanations can revitalize the crippled field of biological psychiatry.

Dualism and the 'Difficult Patient': Why Integrating Neuroscience Matters

Patients with psychiatric illness present a unique challenge to clinicians: in contrast to the traditional medical model, in which patients are conceptualized as being stricken by a disease, patients with certain psychiatric illnesses may seem complicit with the illness. Questions of free will, choice, and the role of the physician can cause clinicians to feel helpless, disinterested, or even resentful. These tensions are a lasting legacy of centuries of mind-body dualism. Over the past several decades, modern tools have finally allowed us to break down this false dichotomy. Integrating a modern neuroscience perspective into practice allows clinicians to conceptualize individuals with psychiatric illness in a way that promotes empathy and enhances patient care. Specifically, a strong grasp of neuroscience prevents clinicians from falling into the trap in which behavioral aspects of a patient's presentation are perceived as being somehow separate from the disease process. We demonstrate the value of incorporating neuroscience into a biopsychosocial formulation through the example of a "difficult patient."