You’re probably wondering what the title of this Sharepost alludes to and I have to confess the answer is a little opaque. To say that it’s an update on the world of psychiatry is too grand a statement, so maybe it’s better to say it’s a snapshot?

Recently, the Medical Director of the New York State Office of Mental Health wrote an article in The Atlantic where he outlines both the difficulties and the progress made in psychiatric diagnoses and treatments. It’s an interesting piece, particularly as the author tries to formulate a balanced appraisal of the complexities of psychiatric diagnosis set against the increasingly technical and sophisticated world of physical medicine. As physical medicine shoots ahead, psychiatry increasingly looks like it’s being left in the shadows, especially as the advances in medicine appear not to have benefitted psychiatric diagnostic practice.

As anyone who has ever had a psychiatric diagnosis will know, the process generally starts by ruling out physical conditions that can give rise to psychological symptoms; this is when blood samples are taken. It’s possible other tests may be run, like MRI scans, but the basis of all these investigations is the same and that is they attempt to seek abnormalities that may later be corrected. Dr. Lloyd Seder, the author of ‘How Thoughts Become a Psychiatric Diagnosis’ is effectively the chief psychiatrist for New York. He says, “The field of psychiatry knows what works, but not exactly why.” I feel compelled to take issue with such a bold claim, but only mildly as I do concede that huge strides have been made. My own modest contribution is to suggest – the field of psychiatry sometimes knows what works, but not exactly why, but it also finds difficulty explaining why certain things work for some people yet not for others.

So, while genomic analysis, brain imaging, micro-surgery and a heap of other innovations come our way psychiatry continues doing what it has always done. It gathers a personal history and gradually by listening, looking and seeking out patterns it attempts to settle on a diagnosis. This is a process that Dr. Seder and his contemporaries call differential diagnosis. It’s a method for telling two, sometimes quite similar things, apart. Having asked the questions and drilled down the possibilities a diagnosis is reached and medication (invariably) prescribed. Maybe the medication will alleviate symptoms and maybe not: if not why not? It’s a big question. Might it be that the drug is ineffective, or might it be the diagnosis and/or its relationship to the drugs is faulty?

Drug use in psychiatry has moved on, but it’s still far from a sophisticated science. Many patients are left with a decision to make as to whether the benefits of medication outweigh the costs in terms of their side effects. Some feel no benefit at all from medication and are labeled “treatment resistive” as though the fault may rest with the patient rather than the treatment. Then again, psychiatrists are amongst the first to acknowledge the powerful placebo effect, where a patient’s improvement has no biochemical or psychological basis in treatment.