1 Boring Old Man

In writing about evidence-based medicine, I’ve run across or been sent a lot of interesting information. One such article was in Wired [Inside the Battle to Define Mental Illness]. It’s really good, and has a lot of information I hadn’t run across. Of particular interest – the part about Al Francis, Editor of the DSM IV, who now thinks they blew it and has been vocal about the coming DSM V. The article speaks for itself and I’ll leave you to it with hearty recommendations from me. The thing I want to mention is a couple of paragraphs from the article:

The DSM-5 battle comes at a time when psychiatry’s authority seems more tenuous than ever. In terms of both research dollars and public attention, molecular biology — neuroscience and genetics — has come to dominate inquiries into what makes us tick. And indeed, a few tantalizing results from these disciplines have cast serious doubt on long-held psychiatric ideas. Take schizophrenia and bipolar disorder: For more than a century, those two illnesses have occupied separate branches of the psychiatric taxonomy. But research suggests that the same genetic factors predispose people to both illnesses, a discovery that casts doubt on whether this fundamental division exists in nature or only in the minds of psychiatrists. Other results suggest new diagnostic criteria for diseases: Depressed patients, for example, tend to have cell loss in the hippocampal regions, areas normally rich in serotonin. Certain mental illnesses are alleviated by brain therapies, such as transcranial magnetic stimulation, even as the reasons why are not entirely understood.
Some mental health researchers are convinced that the DSM might soon be completely revolutionized or even rendered obsolete. In recent years, the National Institute of Mental Health has launched an effort to transform psychiatry into what its director, Thomas Insel, calls clinical neuroscience. This project will focus on observable ways that brain circuitry affects the functional aspects of mental illness—symptoms, such as anger or anxiety or disordered thinking, that figure in our current diagnoses. The institute says it’s “agnostic” on the subject of whether, or how, this process would create new definitions of illnesses, but it seems poised to abandon the reigning DSM approach. “Our resources are more likely to be invested in a program to transform diagnosis by 2020,” Insel says, “rather than modifying the current paradigm.”

So now we read, "Depressed patients, for example, tend to have cell loss in the hippocampal regions, areas normally rich in serotonin. Certain mental illnesses are alleviated by brain therapies, such as transcranial magnetic stimulation, even as the reasons why are not entirely understood." Exciting! Emerging! Novel! Advances in …! It sounds like the titles to the review articles that have filled our literature for years [Corlux [RU-486], VNS, Transcranial Magnetic Stimulation, Deep Brain Stimulation]. We’re well aware of this kind of neuroscience cheer-leading, often from the ranks of some of our least-reliable colleagues. Unfortunately, NIMH Director Tom Insel isn’t exactly free from their taint himself. Consider his recent walk down the road with Charlie Nemeroff, head cheer-leader extraordinaire.

^{In this commentary, we argue that psychiatry’s impact on public health will require that mental disorders be understood and treated as brain disorders.}
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Where to Go From Here?
The 1990s were identified as the "decade of the brain" with major new insights into brain circuitry and function. The current decade may be recognized in retrospect as the "decade of discovery," during which many of the major candidate molecules, cells, and circuits for normal and abnormal brain function will be identified for the first time. A goal of the Decade of Discovery must be the description of the basic pathophysiology of each of the major mental disorders [Figure 1].

Currently, patients with mental disorders are treated episodically with medications that are focused on symptoms and not on the core pathology. The available treatments are slow, incomplete, and can be limited by adverse effects. In mental disorders, just as in the rest of medicine, better understanding of pathophysiology should yield diagnosis based on biomarkers and treatments based on rational designs targeting the pathophysiology. It is critical to realize that clinical neuroscience does not entail designing exotic technologies for a few privileged patients. The ultimate goal is personalized or individualized care for a broad spectrum of patients with mental disorders. Recently a better understanding of pathophysiology has led to a strategy for individualizing treatment of cancer. Currently in psychiatry, specific treatments for any given patient are largely developed empirically. With more knowledge about the pathophysiology of mental disorders, treatments should become more specific, more effective, and ultimately more accessible.

Clinical neuroscience can now look forward to an "era of translation" with more accurate diagnoses and better treatments as well as very early detection and prevention. Early detection will require a thorough understanding of risk, based on a comprehensive understanding of genetics and experience. For example, preventive interventions might be available to prevent a first psychotic episode in an adolescent at high risk for schizophrenia.

Conclusion
At the intersection of an age of discovery in the neurosciences, behavior, and the complexities of human mental life, psychiatry should emerge once again as among the most compelling and intellectually challenging medical specialties. This promise of the future will depend on psychiatry’s incorporation of the insights and tools of modern neuroscience, integration into the mainstream of medicine by focusing on the public health needs of those with mental disorders, and retention among the medical specialties of a unique focus on the contribution of human experience and behavior to health and disease.

I’ve encountered lots of exciting things in my days in Psychiatry. When I understand a connection between a person’s biography and some current dilemma, and that understanding helps them undo a knot or two, I feel excited. When I see a young psychotic person with Schizophrenia and instead of sending them off to an institutionalized life, I give them a medication that controls the psychosis, I feel excited. When I meet someone whose life is consumed by obsessive compulsive rumination relieved with medication, I feel excited. When I help a person connect a previous trauma with the symptoms that have doomed them to misery and begin the "untangling" process, I get excited. Psychiatry has been full of excitements for me.

But we’ve had enough of the "exciting" fantasies of the enthusiastic neuroscientists. They have a strong place in the Psychiatric cosmology. But  Psychiatry as Clinical Neuroscience? Not on your life. What we’ve gotten from that talk is an infusion of Pharmaceutical Industry influence that has actually done a hell of a lot of harm. We’ve also gotten some fairly shaky science, some outright corruption, and some un-necessarily toxic medications. If anything, the complaints are actually directed at neuroscientists and their irrational exuberance. To Insel, I would suggest that neuroscience is too important to Psychiatry to have misbehaved at this level, and that it’s not a very good time for him to say Psychiatry is Neuroscience, sounding like a clone of his friend in Miami. Psychiatry will become Clinical Neuroscience if and when it actually is a Clinical Neuroscience, not because of his wishes or excitement.