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What’s in store for psychiatry?

the front cover of a crosscurrents magazine- the main image is a vase with bold coloured flowers

The future of psychiatry lies in revisiting the past

Winter 2003-04, Vol 7 No 2

 

Without exception, commentators who have ventured opinions about “the world 100 years from now” have made themselves ludicrous – and yes, they were only human. I accept a similar fate in exchange for the opportunity to comment on where the discipline of psychiatry is likely to go in the next while.

Where psychiatry is going differs sharply from where it should be going. Few would disagree that it is veering starkly into the hands of industry, for drug money funds the scholarly meetings, subsidizes the steered research and is responsible for much of the continuing medical education of community psychiatrists in the form of sales reps whose only goal in life is to “make sure that you have the information you need, doctor.”

There is nothing wrong with psychiatry’s involvement with industry, provided the discipline does not surrender the autonomy of making its own diagnoses. It is, after all, from industry that important new drugs come. But surely, more psychotropics cannot be psychiatry’s future. Already, 90 per cent of consultations in psychiatry end with the provision of medication. We know that many psychiatric conditions are not really amenable to currently available drugs. More of the same is not really desirable.

Similarly, it is meaningless to say that psychiatry’s future lies in a deeper understanding of brain biology and the pathogenesis of illness. Of course we need to know more about these matters. But neuroscience is not on the plate of most academic psychiatrists, who are charged with training medical students to look after patients and not with doing research in molecular biology. Despite many predictions of the death of psychiatry and its supposed looming merger with neurology, psychiatry remains a healthy, independent specialty. It will not merge with neurology, simply because serious mental illness is not going to blend in with multiple sclerosis or Wilson’s Disease. Nor will it merge with neuropsychopharmacology or anything else in the near future.

Instead, what is going to happen – and this will be entirely salutary – will be a revival of interest in psychopathology. This will happen as surely as the sun will rise because, of the great research themes in psychiatry’s 200-year history, psychopathology is the one that offers the greatest promise, while having the lowest startup cost: it requires merely a return to the bedside.

Psychopathology, the careful observation of symptoms in the hopes of building up disease entities on the basis of homogeneous symptom-pictures, began in 19th-century Germany. It is associated with the royal road of Emil Kraepelin, Karl Jaspers and Kurt Schneider, names that retain some resonance today. It is a tradition that fell off the cliff with the triumph of psychoanalytic thinking in North American psychiatry after the 1940s.

Despite a revival of psychopathology in Europe since the 1970s, and despite growing European interest in the diagnostic schemas of Carl Wernicke, Karl Kleist and Karl Leonhard, this tradition of psychopathology has made almost no headway in North America. A shame, really, given that the DSM has proven to be such an unfruitful way of cutting nature at the joints.

The new psychopathology is starting to bear fruit: the Leonhard tradition is beginning to come up with verifiable treatment-specific sub-groups, which is the name of the game. Getting into this game doesn’t require expensive labs or costly imaging facilities. It doesn’t require industry involvement, although industry looks on eagerly from the sidelines to see what new diagnoses may be niche-marketed. And it doesn’t require a renunciation of any of psychiatry’s historic traditions of clinical care – looking after sick people and making them better. If anything, psychopathological research encourages a closer doctor-patient relationship – quizzing patients quite minutely about how they’re feeling and what symptoms they’re experiencing and then following them to see how stable the presentation is.

So the benefits of taking a position in psychopathology are convincing: The costs are manageable with straightened academic budgets, and the potential rewards in terms of identifying new treatment-responsive sub-groups are enormous. If successful, this will be  a trail studded with Nobel Prizes.

So if this view about psychopathology as the sleeping miracle child waiting to spring forth is true, what are the predictions for the future?

First, there will be a wholesale shredding of the DSM. Major depression, schizophrenia and the market-driven micro-diagnoses into which anxiety has split will vanish. Ten or more years from now, we’ll end up with real diseases that are verifiable on the basis of predictable outcome, common family history and common response to therapy.

Second, psychiatry’s relationship to industry will not change, but no problem! Psychiatry will acquire the same self-confidence that internal medicine now has in possessing solid, science-based diagnoses rather than diagnoses manipulated by industry and academic fashion. New, safe and effective medications for real diseases are always welcome. Why should the sales reps not be enthusiastically received?

Finally, renewed interest in psychopathology will lead to renewed interest in patients themselves. The German psychopathological tradition was filled with empathic concern about patients, not because the German psychiatrists were nice guys, but because Jaspers in particular differentiated between illnesses that physicians could “psychologically understand” and those they could “causally explain”: If you could see the condition as an outgrowth of the patient’s premorbid personality (i.e., “psychologically understanding” your patient), it wasn’t “process” schizophrenia, the worst diagnosis. But this tradition involved much interviewing and asking patients to write down exactly what was going on in their heads at any particular moment. In short, it involved the kind of investment of care, namely the physician’s time, that patients love.

 

Edward Shorter is a professor of the history of medicine and a professor of psychiatry at the University of Toronto.