Psychology vs. Psychiatry: What’s the Difference, and Which Is Better?

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Psychologists and psychiatrists tend to hate each other. The reasons are historical: beginning even before Freud, psychologists held enormous power over the cultural imagination. The whole idea of psychiatry — an explicitly chemical rather than behavioral treatment of the mind — didn’t start until the industrial age, and for a long time afterward, psychiatrists were held in disregard.

Friday morning, psychiatrists take a bit of revenge. Even after years of symposia and papers designed to reconnect the two tendril branches of mental-health treatment, the American Psychiatric Association has released new guidelines for treatment of depression that still denigrate the cognitive and behavioral approaches of the American Psychological Association. (Both organizations are called A.P.A., and neither will relinquish the shortened form to the other. Yeah, it turns out the nation’s mental-health leaders act like children.) (More on ‘Heartbrake’: How Rejection Literally Stops Your Heart)

According to the new guidelines — which will govern treatment for the 200,000 in-patient psychiatric patients in the U.S., as well as the 20 million or so who get out-patient treatment — the No.-1 preferred approach is drugs. Just drugs. The guidelines don’t mention psychological approaches like cognitive-behavioral therapy until No. 3, just after electroshock therapy. Ouch.

The new guidelines underplay an enormous body of data from the past decade showing that even the best psychiatric drugs work better than sugar pills only when the drugs are used in conjunction with psychological therapies that help patients change how they behave and how they form their thoughts. Neither a strictly psychiatric approach (just drugs) nor a strictly psychological approach (just talk therapy) works much better than a placebo pill on its own. But when used in combination, the psychiatric and psychological treatments help a majority of people get better.

So why can’t A.P.A. and A.P.A. get along?

One reason is a problem of data. The new American *Psychiatric* guidelines released today conflate several psychotherapy approaches equally because at least one or two randomized trials has shown them to be effective. But cognitive-behavioral therapy has a huge base of evidence compared to rather obscure approaches such as interpersonal therapy. In the context of national guidelines that will shape the treatment of millions, it borders on quackery to include cognitive-behavioral therapy in the same sentence that the A.P.A. (American *Psychiatric*, ugh) calls “problem-solving therapy.” (More on What Goes on Inside the Brain of a Misbehaving Boy?)

When I spoke with an A.P.A. (American *Psychiatric*, ugh again) official Thursday night, he declined to speak on the record. He referred me to an official statement the organization released, which says it “reviewed more than 10,000 studies,” revealed all ties to pharmaceutical companies, and will consider any comments to revise the guidelines. I only have one comment: the A.P.A. and the A.P.A. should start with becoming Facebook friends. Psychology and psychiatry shouldn’t be enemies.

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