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Kudos for your very thoughtful paper, Awais! I agree with the statement in your paper:

"...uncertainty about the evidence complicates labeling an intervention as disease modifying or symptom reducing. In particular, if we link the palliative status of psychopharmacological treatment to whether or not it is disease modifying, we’d have to acknowledge that there is a lack of scientific consensus on the matter, precluding us from saying with certainty whether the intervention is palliative or not."

Indeed, I believe that a binary approach to these terms is not helpful. A pharmacological intervention may be both disease modifying and symptom reducing, in varying proportions; and a putative binary distinction would require a complete--or nearly complete--understanding of both the disease process and the precise mechanism of action of the medication.

In my view, we do not have that degree of understanding for the major psychiatric diseases, or for the medications we use to treat them. I believe this limitation applies to the use of antipsychotic, antidepressant, and most mood stabilizing medications.

I prefer the term "life-modifying" to either "disease-modifyng" or "symptom reducing". "Life-modifying" implicitly invokes the critical--and under-emphasized--concept of "quality of life", which you rightly highlight. A medication that substantially improves the patient's quality of life--defined using scales such as the QOLS [1]--may be considered a "life-modifying" medication.

This construct does not commit us to answering the question of whether the medication alters the underlying disease process (to the extent we even know what this is) or whether it "merely" relieves symptoms. (I think symptom relief has been vastly under-rated as a central goal in psychiatry).

Of course, understanding and modifying the underlying disease process (or, more likely, processes) is devoutly to be wished, but may simply be beyond our reach, for most psychiatric diseases--at least, in our present state of knowledge.This acknowledgment should not lead us to disparage our treatments, and the positive difference they can make in a patient's life. (Yes, there are side effects and risks, as well--as with literally every somatic treatment in the field of medicine). This point was recently made in a study of antidepressants and "quality of life". [2] The study concluded--rightly, in my view--that "patients with depression benefit more from treatment than is suggested by only examining outcome from a symptom-based perspective."

Kind regards,


Ronald W. Pies, MD

1. https://pubmed.ncbi.nlm.nih.gov/14613562/

2. https://www.medscape.com/viewarticle/995195?ecd=mkm_ret_230902_mscpmrk_psych_anxiety_etid5811850&uac=430527SG&impID=5811850#vp_2

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