The Lancet's Illogical Digression

The latest editorial in the Lancet has an illogical digression.  The brief note starts out by stating that there will soon be a revolution in psychiatry based on a genomics study published in the Lancet.  It concludes with a digression to a discussion of about the provision of mental health services across the lifespan with a pejorative connotation:

"The child with ADHD at 7 years could be seen by a child psychiatrist, but at the age of 18 often loses access to mental health services altogether, until he presents with a so-called adult mental health problem. Substance misuse and personality disorders may complicate the picture."

It seems to me that practically all adult psychiatrists would not have any difficulty at all in getting a history of an earlier diagnosis of ADHD and deciding how that would be treated.  I wonder if the Lancet's editors would make the same commentary on childhood asthma presenting to an Internal Medicine clinic.  Would that be "so-called adult asthma"?  The asthma example is instructive because it turns out that what physicians have been calling asthma for decades is more complicated than that.  Recent research has adopted the endophenotype/endotype methodology that has been used to study schizophrenia.  The reason why adults are seen by adult psychiatrists rather than child psychiatrists is the same reason why people stop seeing their pediatricians as adults.  Treating cormorbid substance misuse and personality disorders is just a part of that reason.

As far as the idea that the future of psychiatry is set to change any more than the future of the rest of medicine consider the statement:

"The future of psychiatry looks set to change from the current model, in which ADHD, bipolar disorder, or schizophrenia are considered as totally different illnesses, to a model in which the underlying cause of a spectrum of symptoms determines the treatment."

If that were true, psychiatry would have suddenly catapulted into the most scientifically advanced medical specialty because currently there is no other medical specialty that treats illness based on an underlying genetic cause.   The Lancet's attached paragraph on access to services across the lifespan is accurate, but it really has nothing to do with the possible genetic revolution in psychiatric diagnosis.  If the services are anywhere near as bad in the UK as they are in the United States (Is public health rationing as bad as rationing done by corporations?) there is a widespread lack of services and disproportionate rationing relative to the rest of medicine.

Until psychiatrists, psychiatric services, and mental illness are destigmatized there is no reason to think that a genetic revolution will mean more access to services.

George Dawson, MD, DFAPA

The Lancet.  A revolution in psychiatry.  The Lancet - 1 June 2013 ( Vol. 381, Issue 9881, Page 1878 ) DOI: 10.1016/S0140-6736(13)61143-5.

Cross-Disorder Group of the Psychiatric Genomics Consortium.  Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysis.  The Lancet - 20 April 2013 ( Vol. 381, Issue 9875, Pages 1371-1379 ) DOI: 10.1016/S0140-6736(12)62129-1

Hamshere ML, Stergiakouli E, Langley K, Martin J, Holmans P, Kent L, Owen MJ, Gill M, Thapar A, O'Donovan M, Craddock N. A shared polygenic contribution between childhood ADHD and adult schizophrenia. Br J Psychiatry. 2013 May 23.  [Epub ahead of print] PubMed PMID: 23703318.

Larsson H, Rydén E, Boman M, Långström N, Lichtenstein P, Landén M. Risk of bipolar disorder and schizophrenia in relatives of people with attention-deficit hyperactivity disorder.  Br J Psychiatry. 2013 May 23. [Epub ahead of print] PubMed PMID: 23703314.

The Lancet has it about 40% right

The Critical Psychiatry blog listed a brief editorial in the Lancet commenting on the current state of affairs in psychiatry. The commentary describes psychiatry's current "identity crisis" as an international problem and cites recent comments by the American Psychiatric Association and the Royal College of Psychiatrists suggesting that psychiatry is not "scientific" enough, that it does not have a central role in medicine, that the image of psychiatry with other professionals is negative, and that the therapeutic interventions are weak. The conclusory statement is: “But more fundamental still, it is time for the specialty to stop devaluing itself because of its chequered history of mental asylums and pseudo-science, and to realign itself as a key biomedical specialty at the heart of mental health.”

The Lancet has it right in concluding that psychiatry has a long history of self-flagellation that continues right up until present times. The Lancet is also correct in concluding that the image of psychiatry is negative, and that was well-documented in the journal Psychiatric Treatment showing that press coverage for psychiatry is four times as negative as any other specialty. The remarks about the science of psychiatry, the lack of a central role in medicine, and weak therapeutic interventions miss the mark entirely. In fact, I think the only way an editor can lump all of those negatives together is the uncritical acceptance that all of the negatives about psychiatry must be true.

What the critics of psychiatry can never explain away is the fact that psychiatric treatment is effective. I have personally gone to work every day for over 20 years confident that I have been doing far more good than harm. When you are doing the same work for a span of decades rather than the time it takes someone to do a clinical trial and you are personally responsible to your patient and their family you need to realize that you are effective. If I did not think I was effective and doing a reasonable job for people I would have quit a long time ago.  I also work with hundreds of competent psychiatrists in my home state where being competent is the rule not the exception.

My personal sense of effectiveness is built on decades of watching people suffer. That happened before I was a psychiatrist. Many of those people were my own family members and neighbors with severe problems who did not have access to psychiatrists. They were treated by generalists and the treatment did not go well. In many cases it was worse than no treatment at all. When I was growing up, it was also a fairly common practice for counties to sequester people with mental illness at subpar facilities that were designed for containment.  In some cases that meant that people were placed in facilities that were also tuberculosis sanatoriums or “poor farms” for the indigent.  I think that many of us in the mental health field got into it to compensate for the deficiencies of the past.  Much of that “chequered” past has nothing to do with psychiatry at all.

Although the Lancet associates psychiatry with asylums it leaves out the fact that psychiatry invented the paradigm to care for people with severe mental illnesses in the community. That was the direct product of psychiatrists and their collaborators realizing that state-funded institutional care was completely inadequate. Psychiatry moved people out of asylums on a massive scale and helps them stay out.  At this time many of these programs have been in place for over 30 years.  These same programs are actively working on the health problems of the people that they serve.

The scientific basis of psychiatry has exploded in the past two decades.  The criticism of the “lack” of science in the field always astounds me.  The criticism often seems to flow from the lack of understanding of the process of science and how the scientific accomplishments within psychiatry are on par with other fields of science.  It also seems to ignore the fact that many prominent scientists like Kandel, Snyder and others are psychiatrists.

The idea that psychiatrists are ineffective seems to flow from the same biases.  Details about the effectiveness of primary care physicians are usually left out of that argument.  It is well known that 30-50% of complaints presenting to general medical and specialty outpatient clinics have no medical explanation even after extensive investigation. Other studies have shown that primary care physicians deliver error free care in uncomplicated situations 73% of the time and in complex situations 9% of the time.  It is really not possible for psychiatry to be worse than that and yet there are no movements critical of other specialities and those are specialities that generally have far more toxic treatments.

So we are left with an abundance of critics. The critics all have various motivations but one thing is clear and that is at least part of their agenda is not to recognize the fact that psychiatrists are currently effective,  care about their patients, and that their clinical practice really is not removed from the rest of medicine.  In order to recruit more psychiatrists, the best thing to do is expose students to psychiatrists working with patients and to follow those patients while they recover. It might be useful to expose them to the biases against psychiatry and why a lot of the criticism does not match reality.  The fundamental work for many psychiatrists is to stop devaluing themselves, but it also requires recognition that much of that devaluation occurs due to the uncritical internalization of criticism that is far from the reality of clinical practice.

George Dawson, MD, DFAPA