Psychiatry's Catch 22, Need For Precision, And Placing Schools In Perspective

Blueprint for an Indian nobel laureate in psychiatry

There are a number of spoofs and light-hearted writings in blogs, journalistic pieces and book form (even from former Nobel Laureates), which attempt at ‘understanding’ the secret of getting a Nobel. This is not one of them. It is more pedantic without necessarily being dry. It first analyses the meaning of the concept, ‘the greatest benefit of mankind’, which is the crux of the Nobel Will and the overarching requirement for a Nobel in Medicine. Further discussion in the paper is divided into 5 parts:

(1)

General qualities for a Nobel: The need to be really bright is a given; what is necessary is to be sufficiently crazy about a research topic to make it an obsession; be ready to forgo many creature comforts for long stretches of time; and after all this, be ready to accept that the Nobel may never happen, yet continue to do a type of research solely because it is intrinsically worth doing.

(2)

Nobel in Physiology or Medicine: Here, the key is to do fundamental/basic research to answer persistent, nagging, unanswered questions of medicine which others neglect because they are discomforting. Or, find treatments that change the whole manner a disease has been hitherto treated.

(3)

Nobel in Psychiatry: There are many Nobels waiting to be won, provided: (a) The branch becomes more precise; (b) Science, quantitative study and biology remain its bedrock; and (c) There is an almost obsessive preoccupation with unravelling the mysteries of the brain. One has to choose wisely where to put in efforts, e.g., fields like fundamental research into the causes of psychiatric disorders, especially schizophrenia, depression, bipolar disorders. Or their definitive treatments. Or, work at the cellular or molecular level of the neuron and brain; or, the glandular or genetic level of the systems connected with psychiatric disorders; or, in brain radio imaging. If other, or allied, fields are chosen, to work with finding quantitative data and attempt to pinpoint their precise biological correlates.

(4)

Indian Nobel in Medicine: There is first the need to give up the colonial mindset that everything trend-setting in science comes only from the West. As also, for Departmental Heads, to protect and nurture those with research excellence rather than the mediocre and the sycophants. For governments, to set up an autonomous Research Excellence Council to expressly and exclusively cater to promoting research excellence, with a sizeable fund to put this into practice.

All these four points are summarised as four rules.

(5)

Indian Nobel in psychiatry: Practical suggestions are presented in the form of an 11 Point Action Plan based on 1-4 above.

Medicine and Mind-Body Dualism: A Reply to Mehta's Critique

Neeta Mehta recently advanced the thesis that medical practice is facing a crisis today. In her paper “Mind-body dualism: a critique from a health perspective” she attributes the crisis to the philosophy of Descartes and set out to understand why this dualism is still alive despite its disavowal from philosophers, health practitioners and lay people. The aim of my reply to her critique is three-fold. First, I draw attention to a more fundamental problem and show that dualism is inescapable—scientifically and commonsensically. I then focus on the self-conscious emotions of shame, guilt and remorse, and argue that the self is not identical with a brain. The third section draws attention to the crisis in psychiatry and stipulates some of the main reasons why this is so. Contrary to Mehta's thesis, the health profession faces a crisis because of physicalism and biological reductionism.

Shrug ambivalence and disagreement; search commonalities in psychiatric phenomena(**)

Holistic understanding is necessary to study intimate nuances of psychological/psychopathological processes; also, individual manifestations and individual approach are laudable goals in treatment and approach. But we cannot forget that major therapeutic advances result when we are able to delineate commonalities and stable symptom clusters that cut across geo-cultural boundaries and are amenable to study and intervention. Even though the purpose and approach of psychiatry, as of all medicine, has to be humane and caring, major therapeutic advancements and aetiologic understandings result only from a scientific methodology that stresses and figures out the commonalities of psychopathological phenomena.

It is a mistake to stress individuality so much that commonalities are obliterated. Although stress on the individual's needs has helped psychiatry at times become more humane, it has hurt the task enormously by making some very bright minds question the very scientific basis of psychiatry and its status as a medical discipline.

Hence, even as it is necessary to promote holistic and individualistic caring, it is equally necessary to shrug ambivalence and crippling disagreements that can result if individualism in therapy is carried beyond limits.

Psychiatry's tradition, and field, will always allow for diversity in its practice, even in its theorising. For, psychopathology has both a personal, deep inner dimension — due to biogenetic and personality factors - and social, manifest/unmanifest, outer dimension — due to the environment. And the practice, and theory, of both are likely to be different, although we do try to amalgamate them in our ‘bio-psycho-social’ model. Such differences are only manifestations of an intricate network of influences that make for the human condition in health and disease.

Psychiatry is the one branch which realises this diversity the most, but equally important for it is to stress its unity:

Of purpose – that of reducing individual and social psychopathology;

Of goals – that of unravelling the aetiopathology of psychiatric disorders; finding precision in diagnostics and investigative tests; finding biomarkers; and finding precise therapies for precise disorders that control such disorders; and not just control, but finally cure them; finding methods of primary prevention; of moving from mental disorder to mental health; and, further, of progress to individual actualisation and personal and collective well-being with longevity;

Of practice – a) in therapy: By synergising psychopharmacology/somatic therapies with psychotherapy/therapies, social therapies and pharmacogenetics; b) in diagnostics: By identifying the phenotype-genotype-endophenotype axis; and (c) by promoting such therapy and diagnostics as brings about control, and finally, cure/primary prevention of psychiatric disorders.

The future course for psychiatry involves a goal oriented forward movement - while allowing for diversity in practice and theory, stressing on unity of purpose, goals, and practice.

The Task before Psychiatry Today Redux: STSPIR*

This paper outlines six important tasks for psychiatry today, which can be put in short as:

Spread and scale up services;

Talk;

Science,

Psychotherapy;

Integrate; and

Research excellence.

As an acronym, STSPIR.

Spread and scale up services: Spreading mental health services to uncovered areas, and increasing facilities in covered areas:

Mental disorders are leading cause of ill health but bottom of health agenda;

Patients face widespread discrimination, human rights violations and lack of facilities;

Need to stem the brain drain from developing countries;

At any given point, 10% of the adult population report having some mental or behavioural disorder;

In India, serious mental disorders affect nearly 80 million people, i.e. combined population of the northern top of India, including Punjab, Haryana, Jammu and Kashmir, Uttarakhand and Himachal Pradesh;

Combating imbalance between burden of demand and supply of efficient psychiatric services in all countries, especially in developing ones like India, is the first task before psychiatry today. If ever a greater role for activism were needed, this is the field;

The need is to scale up effective and cost-effective treatments and preventive interventions for mental disorders.

Talk: Speaking to a wider audience about positive contributions of psychiatry:

Being aware of, understanding, and countering, the massive anti-psychiatry propaganda online and elsewhere;

Giving a firm answer to anti-psychiatry even while understanding its transformation into mental health consumerism and opposition to reckless medicalisation;

Defining normality and abnormality;

Bringing about greater precision in diagnosis and care;

Motivating those helped by psychiatry to speak up;

Setting up informative websites and organising programmes to reduce stigma and spread mental health awareness;

Setting up regular columns in psychiatry journals around the globe, called ‘Patients Speak’, or something similar, wherein those who have been helped get a chance to voice their stories.

Science: Shrugging ambivalence and disagreement and searching for commonalities in psychiatric phenomena;

An idiographic orientation which stresses individuality cannot, and should not, preclude the nomothetic or norm laying thrust that is the crux of scientific progress.

The major contribution of science has been to recognize such commonalities so they can be researched, categorized and used for human welfare.

It is a mistake to stress individuality so much that commonalities are obliterated.

While the purpose and approach of psychiatry, as of all medicine, has to be humane and caring, therapeutic advancements and aetiologic understandings are going to result only from a scientific methodology.

Just caring is not enough, if you have not mastered the methods of care, which only science can supply.

Psychotherapy: Psychiatrists continuing to do psychotherapy:

Psychotherapy must be clearly defined, its parameters and methods firmly delineated, its proof of effectiveness convincingly demonstrated by evidence based and controlled trials;

Psychotherapy research suffers from neglect by the mainstream at present, because of the ascendancy of biological psychiatry;

It suffers resource constraints as major sponsors like pharma not interested;

Needs funding from some sincere researcher organisations and altruistic sponsors, as also professional societies and governments;

Psychotherapy research will have to provide enough irrefutable evidence that it works, with replicable studies that prove it across geographical areas;

It will not do for psychiatrists to hand over psychotherapy to clinical psychologists and others.

Integrate approaches: Welcoming biological breakthroughs, while supplying psychosocial insights:

Experimental breakthroughs, both in aetiology and therapeutics, will come mainly from biology, but the insights and leads can hopefully come from many other fields, especially the psychosocial and philosophical;

The biological and the psychological are not exclusive but complementary approaches;

Both integration and reductionism are valid. Integration is necessary as an attitude, reductionism is necessary as an approach. Both the biological and the psychosocial must co-exist in the individual psychiatrist, as much as the branch itself.

Research excellence: Promoting genuine research alone, and working towards an Indian Nobel Laureate in psychiatry by 2020:

To stop promoting poor quality research and researchers, and to stop encouraging sycophants and ladder climbers. To pick up and hone genuine research talent from among faculty and students;

Developing consistent quality environs in departments and having Heads of Units who recognize, hone and nurture talent. And who never give in to pessimism and cynicism;

Stop being satisfied with the money, power and prestige that comes by wheeling-dealing, groupism and politicking;

Infinite vistas of opportunity wait in the wings to unfold and offer opportunities for unravelling the mysteries of the ‘mind’ to the earnest seeker. Provided he is ready to seek the valuable. Provided he stops holding on to the artificial and the superfluous.

Welcome biological breakthroughs, supply psychosocial insights

Human behaviour, emotions, and cognition are complex to understand and explain. It is even more difficult to understand the basis for abnormal behaviour, disturbed emotions, and impaired cognitions, something mental health professionals are trying for long. In these pursuits, psychiatry has traversed through eras of humours, witchcraft, spirits, psychoanalysis, and gradually deviated from other medical specialities. Now, with recent biological breakthroughs like advances in psychopharmacology, neuroimaging and genetics, increasingly more emphasis is being given to the biological model of psychiatric disorders. These new biological models have given a more scientific appearance to the speciality. It has also revolutionised the management strategies and outcome of many psychiatric disorders. However, this rapid development in biological understanding of psychiatry also leads to a new wave of reductionism. In an attempt to deduce everything in terms of neurons, neurochemicals, and genes, can we neglect psychosocial aspects of mental health? Patients' personality, expectations, motives, family background, sociocultural backgrounds continue to affect mental health no matter how much 'biological' psychiatry gets. Biological and psychosocial approaches are not mutually exclusive but complementary. Integrating them harmoniously is the skill psychiatry demands for comprehensive understanding of mental and behavioural disorders.

Speaking to a Wider Audience about the Positive Contributions of Psychiatry

We live in a world that is increasingly complex, intense, and stressful. Most people, at some time or other in their lives, can make good use of psychiatry as they map their course and steer their way through it. While this holds true, there also exists a very disturbing trend. No other branch of medicine suffers a similar, constant criticism, scrutiny and quite often downright vehement protest. Even the service users, who have been greatly benefitted, choose to stay mum for fear of stigmatization that may follow if they admit to have undergone therapy. The onus lies on both, the service users and providers alike, to take the positive contributions of psychiatry to the masses at large. All of us, especially medical professionals, need to consider our own attitudes and awareness. The recognition that anyone will break down if mental stress is high enough should help free us from a 'them and us' attitude. Reading about people's own experience of mental illness can promote understanding: Examples include a successful actress and a prize-winning author. For mental health practitioners, enabling service users to influence service development is another strong anti-stigma move. A cognitive behavior therapy approach can help individuals overcome the stigma felt and also cope better with discrimination. Also, we need to stand up against mental health discrimination wherever it is encountered.