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.
We do have to be a little sympathetic. It isn’t really the fault of psychiatry that there is no scan that can predict bipolar disorder, or a blood test that can screen for depression or anxiety states. Dr. Seder wraps up his article by saying that mental disorders are rapidly becoming the leading cause of disability worldwide. His hope rests with neuroscience and scientific enquiry and in the meantime those with mental health issues are urged to “learn about your condition [and] relentlessly monitor response to treatment and insist on proven diagnostic inquiries and treatments that are comprehensive and continuous in their delivery.” It’s an uplifting comment but with things the way they are exactly how practical is it?
Professor Jane Plant is a well established author who makes the point that psychiatry remains a Cinderella service. Psychiatrists are the butt of humor, often referred to as ‘shrinks’. Clever doctors by contrast are brain surgeons. There remains a perception of psychiatrists as mediocre doctors persuaded to move into the area because they were little use in ‘real’ medicine. Professor Plant argues that the time is overdue for those who specialize in psychiatry “to pass examinations in the neurology, physiology and biochemistry of the brain and nervous system. Such specialists should be designated neurophysicians to indicate they are qualified to work with the human brain and they should replace psychiatrists.” You’ll hear no arguments to the contrary from me.
Plant, J.P. and Stephenson, J.S. (2008) Beating Stress, Anxiety and Depression. Piatkus.
Sederer, L. (2012, 07 18). How thoughts become a psychiatric diagnosis. Retrieved from http://www.theatlantic.com/health/archive/2012/07/how-thoughts-become-a-psychiatric-diagnosis/260012/
Published On: September 04, 2012