My selected articles this year were not limited to those appearing in psychiatric journals. One group of publications is devoted to psychotherapy topics, another to issues in genomic medicine and the impact of technology and burnout on the practice of medicine, and last, more traditional clinical articles addressing diagnosis and treatment of psychiatric disorders. This somewhat atypical selection was prompted by another writing assignment for The World Psychiatric Association-Lancet Psychiatry Commission on the Future of Psychiatry,1 in which my colleagues and I were asked to address clinical and technological issues potentially affecting the centrality of the doctor-patient relationship and therefore ultimately clinical care.
Included on my list, therefore, are tempered articles on the unrealized promises of genomics and the shortcomings of precision or personalized medicine. It was abundantly clear as I reviewed the literature, that to speak of precision psychiatry without acknowledging the severe limitations of its scientific foundation is quite risky. In psychiatry, we have had an unfortunate legacy of promising much more than we could ever deliver to our patients and the public. No one disagrees with advancing science and improving care. However, as an emeritus professor, now looking back on the grandiosity of the claims of psychoanalysis, psychopharmacology, diagnostic classification schemes, community mental health, the electronic medical record (EMR) and its inextricable relationship to physician burnout, and the reductionistic biomedical approaches to treatment that undercut the clinician’s ability to tolerate uncertainty and ambiguity, a slow medicine approach appears to be increasingly attractive to me.
Moreover, personalized psychiatry, if and when it becomes scientifically sound, must always be delivered within the context of the doctor-patient relationship. Computer-generated genomic analyses, neuromodulation, deep brain stimulation (DBS), new drug delivery mechanisms, and perhaps someday, stem cell therapy, to name but a few, all require the participation of a physician. (With respect to DBS and FDA scrutiny over rogue stem cell therapy clinics, initial excitement has given way to mixed findings and resultant physician ambivalence and caution lest we oversell this technique as well.)
Promises of scientific advances often appear to downplay the value of the psychiatrist’s subjective understanding of patients. And, of course, there is the yearly plethora of studies each of whose findings is so obvious that I refer to them as “duh” articles. For example, an endless number of studies each year substantiate the impact of bad things happening to good little people. Does any clinician doubt that maltreatment and other adverse childhood experiences produce psychological vulnerability? Does anyone not believe that a disorganized attachment style has a profound effect on development throughout the life cycle? Have we not accepted the concept of intergenerational transmission of unresolved trauma in mothers?
A final point to be made is the enduring dismissal of psychotherapy either as a monotherapy or in conjunction with medication. When will the field embrace this proven therapeutic intervention for the treatment of our patients? Can we stop the self-defeating infighting about efficacious psychotherapy treatments?
→ Roy-Byrne P, Dubovsky S, Yager J. When genetic testing is unproven: the case of depression treatments. NEJM J Watch. August 31, 2017. https://www.jwatch.org/na44895/2017/08/31/when-genetic-testing-unproven-case-depression-treatments. Accessed November 15, 2017.
This article highlights the myth of precision psychiatry, that, in my opinion, has insufficient scientific support at present. It alerts us to be cautious and thoughtful about jumping on a bandwagon that favors adopting approaches that are not ready for prime time.
Dr. Kay is Emeritus Professor, Deparment of Psychiatry, Boonshoft School of Medicine of Wright State University, Dayton, OH, and Clinical Professor of Psychiatry, Tulane University School of Medicine, New Orleans, LA.
1. Bhugra D, Tasman A, Kay J, et al. The WPA-Lancet Psychiatry Commission on the Future of Psychiatry. Lancet Psychiatry. 2017;4:775-818.
2. Kay J. Psychotherapy by psychiatrists: why choose a bugle when you can play the trumpet? Acad Psychiatry. 2017;41:24-29.
3. Jones KL, Croen LA, Yoshida CK, et al. Autism with intellectual disability is associated with increased levels of maternal cytokines and chemokines during gestation. Mol Psychiatry. 2017;22:273-279.