Just a few years in the past, I had a reasonably testy e mail alternate with a senior official at a authorities well being company. We had been debating the importance of a research of antidepressant efficacy, which concluded that about 15% of contributors have a considerable antidepressant impact past a placebo impact in medical trials. This doctor (who was not a psychiatrist) argued that psychiatrists are sometimes misled into believing that antidepressant therapy is pharmacologically efficient for a given affected person, when supposedly the psychiatrist is merely observing a placebo impact. Whereas not denying that placebo results are actual and important, I argued that skilled psychiatrists are fairly able to distinguishing a placebo response from one that’s pharmacologically primarily based. I gave the instance of a affected person of mine who had nearly no response to 2 sturdy antidepressant trials, then confirmed a exceptional response to a 3rd agent from a distinct antidepressant class—a monoamine oxidase inhibitor—after about 4 weeks of therapy. I argued that nothing in my work with this affected person over greater than a yr would have led me to conclude that this dramatic remission represented a placebo response. My interlocutor was not impressed, arguing that my conclusion was not scientific.
He was basing his skepticism on the outcomes of this massive research, analyzing 232 randomized, double-blind, placebo-controlled trials of drug monotherapy for main depressive dysfunction.1 I used to be basing my conclusion on dozens of medical observations, together with sequential scores on the Beck Depressive Stock over greater than a yr of therapy, in addition to on my affected person’s subjective stories. A philosophical chasm separated our positions—one that’s explored intimately in Douglas W. Heinrichs’ well-reasoned e book, How Psychiatrists Make Choices: The Science of Medical Reasoning. For my part, among the many most essential claims of Heinrichs’ e book is the assertion that “a science of the person is feasible,” and that “the era of explicit fashions to characterize concrete items of actuality is in truth the central scientific exercise” of fine psychiatric care. A corollary of this declare is that evidence-based drugs (EBM) by itself “fails to offer an sufficient framework for translating analysis findings into good medical care of the person.”2 Certainly, Heinrichs argues, some robust proponents of EBM “degrade the epistemological standing of medical judgment by seeing it as basically unscientific.” My interplay with the federal government well being official definitely confirmed this impression.
Within the preface to his e book, Heinrichs notes that the e book “grew out of reflections on [his] expertise of over 40 years as a training psychiatrist” in varied capacities, and his experience is definitely evident on this e book. Heinrichs signifies that his main audiences for this e book are “psychiatric residents and people liable for the training of future psychiatrists.” Nonetheless, he hopes the e book can even be of worth to psychiatrists in any stage of their careers in addition to to “these philosophers with an curiosity within the conceptual underpinnings of psychiatry.” That could be a very broad viewers, and I think that amongst this big selection of readers, many will discover some chapters of the e book extra related to their wants than others. Chapter 10, for instance, offers with such thorny philosophical issues as, “are the legal guidelines of nature actually true?” and “logical empiricism and the demarcation drawback.” I think this chapter—essential although it’s—will resonate primarily with philosophers of science. Alternatively, the detailed medical circumstances Heinrichs presents ought to be of nice sensible curiosity to psychiatrists at any stage of coaching, and properly reveal the utility of what Heinrichs calls the “patterns of propensity (POP) mannequin.” This time period requires a little bit of unpacking.
In easiest phrases, the POP mannequin “affords a speculation to clarify how the affected person’s present state of affairs developed and might generate a set of predictions as to the affect of potential interventions.” A propensity is outlined as “a component or state of affairs that, when current in a system of interacting components, has a disposition to result in sure outcomes.” Heinrichs makes use of “propensity” as opposed to “trigger” so as “to stay impartial as to how strictly deterministic the interactions between components are and what room ought to be left for human selection and existential freedom.” We would consider propensities as tendencies to carry a few sure end result, reasonably than so-called arduous causes.
Importantly, POP fashions “are at all times a few particular concrete affected person, not a bunch or class of sufferers.” Therefore, my treatment-resistant depressed affected person—not depressed sufferers basically—could be the recipient of the POP mannequin. Heinrichs describes the POP mannequin as “an imaginative act relating to a selected particular person, however one disciplined and knowledgeable by the final information base of psychiatry,” and notes that “all fashions should be considered as provisional.” Heinrichs acknowledges the worth of contemplating organic, psychological and social components with respect to any given affected person, however regards the ever-present biopsychosocial mannequin (BPS) as “not a mannequin in any respect,” and finds it “vacuous and quick on particulars.” On this respect, Heinrichs follows Nassir Ghaemi’s critique of the BPS.3 For Heinrichs, the POP mannequin represents “pluralism at work,” reasonably than mere eclecticism.
The case research Heinrichs presents are accompanied by detailed diagrams that illustrate the advanced interplay of quite a few components, such because the affected person’s coping expertise, parental and familial components, present calls for on the affected person, intrinsic anxiousness modulating mechanisms, and so forth. Critically, for Heinrichs, the POP mannequin is organized across the affected person’s objectives and develops “by means of a means of alternate between psychiatrist and affected person resulting in some shared perspective that turns into the premise for the medical work.” In essence, the POP mannequin mirrors how professional clinicians already assume, and represents the evolution of the BPS idea into one thing operational, testable, and clinically highly effective. In some respects, the POP mannequin has affinities with the DSM’s idea of the “case formulation”—a broadly uncared for element of the DSM-5 diagnostic course of—although the POP mannequin is extra particular and testable.4
There may be rather more useful materials in Heinrichs’ e book than might be summarized on this transient area, and extra points of the e book could also be gleaned from the writer’s visitor posting on Psychiatry on the Margins.3 Suffice it to say that I like to recommend How Psychiatrists Make Choices to any clinician who needs to achieve an appreciation of how skilled psychiatrists truly purpose about their sufferers. Equally essential: Heinrichs’ e book reaffirms the scientific legitimacy of cautious medical statement—a degree that has gotten misplaced within the fixation on evidence-based drugs.
Be aware: All quotes are from Dr. Heinrichs’ e book except in any other case indicated.
Dr Pies is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical College; medical professor of psychiatry, Tufts College Faculty of Drugs; and editor in chief emeritus of Psychiatric Occasions (2007-2010). He’s additionally a part of the creation of the PRISM diagnostic instrument, which might be discovered
Psychiatric Occasions is internet hosting a writing contest for the PRISM diagnostic instrument! See the writer tips
References
1. Stone MB, Yaseen ZS, Miller BJ, et al. Response to acute monotherapy for main depressive dysfunction in randomized, placebo-controlled trials submitted to the US Meals and Drug Administration: particular person participant knowledge evaluation. BMJ. 2022;378:e067606.
2. Heinrichs D. The science of medical psychiatric reasoning. Psychiatry on the Margins. Might 25, 2025. Accessed February 3, 2026.
3. Ghaemi SN.
4. Pies RW. Poor DSM-5—so misunderstood! Psychiatric Occasions. March 23, 2021.