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Psychiatry, at this moment anyway, remains blood-test and imaging-free. It offers the last frontier of semi-free thought to the thinking person who wishes to enter medicine. More in this opinion piece.
We at Psychiatric Times are proud to deliver a publication that provides a voice to a wide range of perspectives and opinions, including my own. Nonetheless, there are some comments in this provocative commentary that seem to malign our profession, with inaccuracies. First, I do not agree with the thesis that “Psychiatrists have an inferiority complex.” Second, although the piece may have meant to be tongue-in-cheek, psychiatry is not a pseudo-science, but rather a young and exciting field of science with a mission of furthering our understanding of the brain/mind continuum with the goal of decreasing human suffering by understanding and providing evidence based treatments related to the brain. Third, psychiatry has established its place in the center of medicine, as ultimately the mind/body complex is an interconnected and interdependent system.
Every field of science is a “work in progress,” which does not negate the science that is known at a particular time. In physics, the general theory of relativity was believed as concluded dogma until Albert Einstein introduced us to special relativity. In psychiatry, a competent clinician will utilize many medical diagnostics to arrive at the most likely diagnosis that will inform a treatment. These include a thorough physical and history, vital signs, substances use, MRI and CT scans, EEGs, serum drug levels, and a range of lab tests to name just a few. Twenty years ago acute psychosis with delusions and hallucinations ultimately diagnosed today as NMDA-receptor autoimmune encephalitis would have been treated with antipsychotic medication, with a poor response. Today, we treat this rare etiology to acute psychosis with plasmapheresis, high dose steroids, and intravenous immunoglobulin with rapid improvement. The science of any specialty begins with fragments of information that over years, decades and centuries continue to evolve into a greater understanding.
John J. Miller, MD
Editor in Chief, Psychiatric Times
“Dude,” the medical student said with an informal millennial drawl, “do you even like psychiatry?”
He stared at the books that line my office shelves. Mixed among the Freuds (both Sigmund and Anna), the Jaspers, and the textbooks are any number of works by Foucault, Laing, and Szasz. Between my Anti-Oedipus and Helter Skelter is my first edition of Psycho. Next to my copy of Junkie is a rare copy of My Lobotomy. I have a number of books on philosophy, history, and scientology. This particular student finally picked up the nearly extinct first American edition of I, Pierre Rivière, having slaughtered my mother, my sister, and my brother…
“Dude, why?” he asked semi-innocently.
“OK,” I said to him. “I’ll let you in on the dirty, little, ill-kept secret of psychiatry.”
He leaned in and I, looking shiftily left then right, confessed in a stage whisper, “Psychiatrists have an inferiority complex.”
Psychiatry–and do not let its more blustery practitioners kid you–is a pseudo-science. A fact that makes some neuroscientists, historians, sociologists, and generations of Freud-haters dance almost gleefully. A fact that makes some practitioners in the field tomato-faced and defensive. I never quite understood why. Frankly, this uncertainty–and the impossibility of certainty–is the reason I went into the field. In fact, I would counter that most of medicine today at best remains pseudo-scientific, relying on an "evidence-base" that changes on a near-daily basis1, very frequently contradicts itself2, and is easily manipulated by any number of industries. At worst, it is dogmatic–think Al Capone, “It’s right because I say it’s right”–and this makes for far more potential danger.
But more to the point, I would wager that more than half of the patients in any given general hospital at any given time are there for vague somatic symptoms with no known medical illness. Or, if there is a medical issue, it is not one that would typically require acute stabilization. Instead, the issues are either directly related to, or exacerbated by, underlying psychiatric issues.
The bottom line is that pseudo-scientific psychiatric treatments are no less effective than any scientific treatments in medicine.3
But–especially in these end of days–there are many psychiatrists who do so desperately wish to be neuroscientists. They do so want to be “real” doctors. They call themselves neuropsychiatrists, establish departments of neuropsychiatry, and even hide behind journals titled Neuroscience.4 They want to point to an MRI with confidence and say, “See. There. We have isolated the source of your self-loathing to the right frontal cortex. A simple excision, and you’ll be fine.”
Witness the current bandwagon of interventional and neuromodulatory psychiatry.5 The parade includes the tried and true ECT along with the shinier, newer transcranial magnetic stimulation, side by side with the rebranding of the old deep brain stimulation, psychosurgical ablations, vagal nerve stimulation, IVIG, and ketamine infusions. All of which are potentially well and good, if not nearly as miraculous as once hoped or advertised, except that these techniques mislead both patient and psychiatrist away from the heart of the patients’ problems. That is, they lead once again toward neurology and away from psychiatry, ignoring the inconvenient fact that what ties psychiatry and neurology together is that neither field can offer lasting cures.
Perhaps better put, like every other American specialty, what psychiatry wants more than anything is corporate respectability. Case in point: The National Institute for Mental Health has inaugurated a multi-billion dollar enterprise called the “Research Domain Criteria” (RDoC).6 There is a complicated website, well-disguised in untranslatable jargon, in an effort to subsume psychiatry under neurology.
No real definition of the project is provided anywhere on the website. As of this writing, the best I can find is a description of their framework. In their words, at least as of this writing, it is a matrix, or matrices, I suppose, that “represent specified functional constructs . . . characterized in aggregate by the genes, molecules, circuits, etc (sic) used to measure it. Constructs are in turn grouped into higher-level domains of functioning.” These domains are as follows: negative valence systems, positive valence systems, cognitive systems, systems for social processes, and arousal/regulatory systems.
This model was proposed just before the founder of this enterprise abruptly up and took off for the artificially greener pastures of Silicon Valley. Initially accepting a job offer from Google Life Science (now Verily), he has since hightailed it yet again, to a start-up ominously called Mindstrong. There he designs mental health apps7, an endeavor now boosted by the ethically questionable volunteering of his time as mental health czar of California.8
The founder’s personal peregrinating issues aside, billions of dollars have now been devoted in these recent years to exploring what amounts to various euphemisms: molecular psychiatry, genetic psychiatry, translational psychiatry, all subheadings of the grander movement toward so-called biologic psychiatry.
What is the grander motive? (Or, perhaps more appropriately, what was the motive, as the guru has since jumped ship.) Whatever the tense, the answer remains: potential procedural dollars on par with other specialties. Never mind that for all the investment not a single meaningful new treatment has emerged, and never mind that few have suggested at least some of that money be diverted toward social or educational or vocational programs for the severely and chronically mentally ill, programs that have a proven track record of efficacy; the bureaucratic foundation has been laid. Another inquisitorial framework is in place, and Lord help the poor shrink who points out the obvious: that psychopathology, at bottom, remains a social disease.9
“Embrace it!” I cry from my lonesome perch here in the wilds of suburban Boston.
The fact that psychiatry is so openly out there as a pseudoscience is the beauty of psychiatry.
Psychiatry, at this moment anyway, remains blood-test and imaging-free. It offers the last frontier of semi-free thought to the thinking person who wishes to enter medicine, to try to understand people, to try to understand really what makes people sick, to understand their need or desire to be sick. Hence my eclectic collection of books, and my ongoing admonition to my students–those who actually wish to understand their patients better–to continue to read as widely and broadly as they can.
Psychiatry is also, it should be noted, the only specialty with a political and social movement specifically directed against it. The so-called anti-psychiatry movement10 was initiated and has been maintained over the years, for the most part, by none other than psychiatrists themselves, with healthy assists, of course, from the legal trade, Hollywood intellectual heavyweights, and the ludicrously well-funded scientologists. How cool is that?
And, well, that at least makes me feel, however ineffectually, somewhat like a resistance fighter.
So is it time to do away with psychiatry?
For one thing, where would all the hopeless cases go? Because believe me, there is no clamor from the other side to subsume psychiatry.
Dr Martin is director of Medical Psychiatry at the Newton-Wellesley Hospital in Newton, MA, and a clinical assistant professor of psychiatry at Tufts University School of Medicine in Boston.
1. Little M. Book Reviews: Miriam Solomon, Making Medical Knowledge, Oxford University Press, 2015. Kennedy Inst of Ethics J. November 10, 2015. https://kiej.georgetown.edu/miriam-solomon-making-medical-knowledge-oxford-university-press-2015/
2. Ioaniddis JPA. How Many Contemporary Medical Practices Are Worse Than Doing Nothing or Doing Less? Mayo Clin Proc. 2013;88(8):779-781. https://www.mayoclinicproceedings.org/article/S0025-6196(13)00403-5/fulltext
3. Dubovsky S. How Well Do Psychiatric Treatments Work? NEJM Journal Watch. May 21, 2014. https://www.jwatch.org/na34660/2014/05/21/how-well-do-psychiatric-treatments-work
4. Mass General Neuroscience. Massachusetts General Hospital. Accessed September 17, 2020.https://www.massgeneral.org/neuroscience
5. Williams NR, Taylor JJ, Kerns S, Short EB, et al. Interventional Psychiatry: Why Now? J Clin Psychiatry. 2014;75(8):895–897. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4221242/
6. Research Domain Criteria (RDoC). National Institute of Mental Health. Accessed September 17, 2020. https://www.nimh.nih.gov/research/research-funded-by-nimh/rdoc/index.shtml
7. Rogers A. Star Neuroscientist Tom Insel Leaves the Google-Spawned Verily… For a Startup? Wired. May 11, 2017. https://www.wired.com/2017/05/star-neuroscientist-tom-insel-leaves-google-spawned-verily-startup/
8. Sheridan K. California names former Google scientist as the state’s ‘mental health czar.’ Stat News. May 22, 2019. https://www.statnews.com/2019/05/22/tom-insel-california-mental-health-czar/
9. Horwitz A. Social Constructions of Mental Illness. In: Harold Kincaid, ed. The Oxford Handbook of Philosophy of Social Science. Oxford, Oxford University Press; 2012. https://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780195392753.001.0001/oxfordhb-9780195392753-e-23
10. Desai N. Antipsychiatry: Meeting the Challenge. Indian J Psychiatry. 2005;47(4):185–187. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921130/