Current Psychiatry and its Discontents

Psychiatry, it must be said, is at an all-time low, the culmination of a steady slide since the Eighties. Its practitioners have little to be excited about, and that hardly does much for patients. If we look back on history – something about which psychiatry is notoriously lax – the closest analogy would be the Thirties, when there were a number of biological treatments but, in truth, they were hardly successful cures (ECT was a notable exception). Cynicism ruled supreme until the Fifties, when a golden age of psychopharmacology started.

Several issues can be indicted for the current desuetude. The first is the Diagnostic & Statistical Manual of the American Psychiatric Association (DSM) which, in the eyes of some critics, has become the Mein Kampf of the discipline. Started, like so many things that go wrong, with the best of intentions, it has given the world an American-based classification of ‘disorders’ (no one is allowed to have a disease or illness now) derived from in-house committees subject to intense political, social and personality processes. The result has not been pretty.

Conditions that were determined by 150 years of careful psychiatric observation have been put through a bureaucratic grinder that killed off paraphrenia and Asperger’s syndrome, seriously messed up depression and inflicted such etymological nightmares as Late Luteal Phase Dysphoria Disorder (aka premenstrual syndrome). By putting everything in a neat pocket manual and providing a tick-box list for every disorder, the DSM made instant diagnosis a reality for professionals, if not the less skilled who wanted to get in on the mental health business. So much for the lengthy and careful psychiatric examination! Add to all this the appetite of a voracious legal profession for new “conditions” that might provide pretexts to sue and, with one thing and another, we are where we are today.

Then there are the drugs. It seems, a new product is launched on the market every day, judging by the journal ads, the glossy flyers in the mail and the bevvies of pert and perky sales reps who come calling with their latest brochures. The problem is that the new drugs are all variations on a theme. Antidepressants, antipsychotics and sedatives have not changed for decades; the only real difference is in the side effects.

A particularly egregious practice is the use of the so-called “atypical antipsychotics” as a kind of psychiatric penicillin. They are prescribed now for just about any disorder, regardless what other drugs are used. Their effect is to produce an emotional flattening. This can be considered something of an improvement, but hardly a cure. Add to this the most spectacular side effect is weight gain, turning skeletal figures into Michelin men and women in a few weeks. Journals are full of articles about the metabolic syndrome produced by these drugs.

It cannot be said that the public image of psychiatry is in the ascent. The disclosure that some prominent researchers have their hands deeply in the drug companies’ pockets is less than a good look. Add to this that psychiatry’s mandate – its exclusive control of the designated illnesses – is fragmenting to an unprecedented degree. There have always been turf wars with neurology and psychology, but they were but kindergarten squabbles compared with the present situation. Witness the disparate agencies which have not just a foot, but an arm and a leg, in invading (and, in the process, facilitating) the raging epidemics of autism and attention deficit/hyperactivity disorder ADHD (another user-friendly acronym that says as much as its hides). The best example is the widespread use of stimulant drugs to control behaviour in children. Add to that all the adult cases and you get some idea of the mess. Future generations will not thank us for this unwanted legacy.

More surprising is the passivity with which the profession deals with the situation. There is a good deal of posturing, leavened with oily dollops of political correctness, from the official bodies. Any steps to kick in on problems — notably rampant over-diagnosis of certain conditions and misuse of drugs — are timid and ineffective. All to often, when psychiatrists present in the media, it is all too clear they are pushing an ideological barrow, rather than representing the profession as a whole. A recent example: witness those rushing to pin diagnoses on Donald Trump in clear contravention of the Goldwater Rule (it is unethical for psychiatrists to make diagnoses of public figures).

And if the profession is deeply dispirited, there is the lot of patients to consider. The old, patronising doctor-patient relationship has gone out the door. Patients are now consumers, demanding the same service they would get from, say, their mobile phone providers. Heaven forbid, though, that they should get back from their psychiatrists the treatment the telcos give to their clients. The empowered consumers, using the internet and social media, band together against what they regard as an oppressive and remote agency, namely their doctors. Nowhere is this better seen than the festering, if not venomous, public debate over chronic fatigue syndrome (CSF). Despite decades of research, the cause of CSF remains unknown; no one has been able to prove that it is viral, the totemic belief of the CSF lobby.

And “lobby” is the right word, the tendentious result of patients devolving into that sociological buzz word: consumers with all the rights and expectations of supermarket customers selecting what they regard as the best washing powders. Psychiatrists are often regarded as the enemy for refusing unequivocally to accept that they have a purely physical illness and nothing else. This is, of course, Cartesian dualism gone mad. CSF consists of three overlapping clusters of musculo-skeletal, sleep and psychiatric symptoms. It is quite appropriate to treat all three clusters to provide relief to sufferers. This is not acceptable to the CSF lobby, however, whose vehemence towards psychiatry is approaching something akin to “illness terrorism”. Take a look at some of the threats being expressed on some websites devoted to and populated by CSF sufferers. The likelihood of such vehemence being translated into physical assault, perhaps even murder, cannot be excluded. So disruptive, if not dangerous are these threats that Sir Simon Wessely, president of the Royal College of Psychiatrists, has announced his withdrawal from research in the field.

Another example of the atavistic idea of illness as a sacred entity in contradiction to the observed clinical facts is Morgellon’s Disease. A certain Maria Leitao insisted that her child’s skin lesions were the result of parasitic infection, despite dozen’s of medical opinions that there was nothing to her suspicions – a case of delusional parasitosis a deux. She became convinced that it was an illness recognised as far back as the 16^th century. Thus was born Morgellon’s Disease with a pullulating support group pushing the US Congress for funding, fronted by the inevitable celebrity figure  – in this case, no less than charming chanteuse Joni Mitchell.

The problem is not just the social and cultural vectors convincing people they have this particular infection, but in sorting out the actual cases from the merely convinced. All illnesses, by definition, are social concepts. In the Middle Ages, denying the existence of God meant that you were mad or a witch; either claim was likely to have the same incendiary ending. In the Soviet Union if you denied that communism worked, you would be hospitalised with “sluggish schizophrenia”, a condition unique to the Soviet Union.

Nothing sums up the problem more than the epidemic of post-traumatic stress disorder (PTSD), the most enticing acronym of them all). Or should that be “pseudo-epidemic”? The condition goes back to the beginning of recorded time: the biblical King Saul, the berserker psychosis to which Vikings were prone and, more recently, World War One’s shell shock. In 1980 the US Vietnam Veterans Association, through intense lobbying, persuaded DSM to give it the current moniker and, in the process, a user-friendly acronym.

A state previously found in survivors of battle, concentration camps or life-threatening accidents has become the gold standard for the victim culture, rapidly becoming the commonest condition in compensation claims. Demonstrating the principles of free market economics, bracket creep is at work. PTSD can now be said to arise in someone having an argument at work. It can be occasioned by watching footage of terrorist attacks  or, vicariously, from treating patients with PTSD!

And on it goes.

There are some chinks of light in the ever-deepening gloom. Some new drugs, such as ketamine, have genuine potential as antidepressants. The hallucinogens may revolutionise the management of obsessive-compulsive disorder and traumatic anxiety, if not alcoholism and drug abuse. Transcranial magnetic stimulation (TMS) is becoming a useful alternative to ECT. Vagus nerve stimulators may allow chronic depressives to come off medication. Perhaps the most notable change is the use of cognitive behaviour therapy for psychotic delusions, something unthinkable a few decades ago. And after nearly a century of near-death, catatonia has been recognised for the pervasive and treatable condition it is.

To those who care deeply about the profession and its history over 150 years of stubborn persistence to classify and treat some of the most debilitating conditions known, for all the difficulties, missteps and mistakes en route – it is deeply dismaying, if not depressing. What is needed is nothing less than a thorough review of the framework in which psychiatry operates and a clear plan for the future.

But don’t hold your breath that this is going to happen anytime soon.

Robert M Kaplan is a forensic psychiatrist and historian of psychiatry. He has written biographies of the Melbourne psychiatrist Reg Ellery and New Zealand psychiatrist Mary Barkas