the future interrupted…

Posted on Tuesday 26 February 2013

"Ten or 20 years from now, we will be sending our patients to the laboratory to characterize them in terms of genetic polymorphisms and/or to an imaging laboratory. Then based on those findings, and on the clinical presentation of the patient, we will be able to do what we can’t do right now, which is to answer the question—of all the treatments that are effective for depression, what is the best one for this particular patient?… This is where the future of psychiatry is going. The task before us is very large because each of these subtypes of depression is biologically distinct and will have different predictors of treatment response. But there is no doubt that what we will be able to do is end this interminable trial-and-error method that all of us are stuck with treating depressed patients."[link] May 2010
"Unfortunately, I don’t think we’re far enough so that in that fifth iteration, the work we’re doing with biomarkers or some of the other work will actually make it. In DSM-6, I think we’re going to see a very different creature because in DSM-6, what we’re going to be able to do is say ‘Oh, that form of depression that people are having, that’s ___’s form of depression – that’s a ___ mediated form of depression,’ or they’re going to go, ‘Oh, this other form of depression we have is similar to what ___ was describing, and it’s actually one that’s treatable by an intervention where we use things like ___.’ But I think that’ll be DSM-6 rather than DSM-5 that we’re going to be able to make those sort of biological correlates actually part of what we do. But the good news is that’s coming and that’s going to come fast, because unlike DSM-IV, DSM-5 is going to have a very short half life because our field is changing so rapidly. And, because of ___’s work, we’re beginning to understand the commonality between anxiety disorders and what the disruption among the circuits are, and we’ll know the changes in the different parts of the brain, particularly the Amygdala, and what’s causing those disorders."[link] October 2011
There are times for looking forward and dreaming of what can be done in the future. There are other times when looking backwards is the important compass point, taking stock of the past, identifying and correcting prior misadventures. Both of these speakers take the former approach, familiar for the last thirty years in psychiatry. I call it future-think because it’s always about what’s coming up ahead, not what’s currently available. But it’s more than that. It’s assuming a medically modeled psychiatry in which mental illness is conceptualized as the product of actual organ dysfunction [brain] analogous to other physical diseases. Here’s some of what the authors have to say in in the Journal of the American Medical Association about their DSM-5 coming out in a few months [DSM-5 – The Future Arrived]:
Many of the revisions in DSM-5 will help psychiatry better resemble the rest of medicine, including the use of dimensional [eg, quantitative] approaches. Disorder boundaries are often unclear to even the most seasoned clinicians and underscore the proliferation of residual diagnoses [ie, “not otherwise specified” disorders] from DSM-IV. But a large proportion of DSM-5 users will not be psychiatrists; most patients, for instance, will first present to their primary care physician — not to a psychiatrist — when experiencing psychiatric symptoms. The use of definable thresholds that exist on a continuum of normality is already present throughout much of general medicine, such as in blood pressure and cholesterol measurement, and these thresholds aid physicians in more accurately detecting pathology and determining appropriate intervention. Thus DSM-5 provides a model that should be recognizable to nonpsychiatrists and should facilitate better diagnosis and follow-up care by such clinicians…

The classification system should be able to incorporate future advances in the neuroscience and genetics of psychiatric illness. DSM-5 is intended to be readily updatable as relevant knowledge is accumulated in neuroscience, cognitive science, genetics, and in clinical practice. DSM-5 also will include a third major section following the introductory materials and the descriptions of the fully validated categorical disorders. This third section is intended to provide future directions for DSM-5 that will lead to its subsequent editions. Section III will guide clinicians and researchers in examining measures and criteria sets that emerged during the process of developing the manual but were deemed in need of further study before official inclusion in the nomenclature. This section will include criteria sets for potential new disorders, including a new approach to the assessment of personality disorders, a listing of the dimensional assessments that were included in the DSM-5 field trials, and assessments related to culture-specific formulations of the DSM disorders.

The most important next challenge is identification of DSM-5 criteria of particular relevance to specialties outside of psychiatry. Even though the criteria for the most common DSM disorders were written with the general medical practitioner in mind, the American Psychiatric Association is developing a collaborative approach to identifying the disorders most frequently seen in primary medical care settings and the particular way in which those disorders are likely to present in such settings — an emphasis to make the DSM-5 of greater value to all of medicine… [link] February 2013
In these presentations [by two psychiatry chairmen and the DSM-5 Task Force leaders], there’s a common refrain – the music of the forced paradigm shift that replaces the etiological non-commital stance of Drs. Spitzer’s and Frances’ DSM-III/DSM-IV series with a new DSM-5 definition of mental disorder: "a behavioral or psychological syndrome that reflects an underlying psychobiological dysfunction." Thus, the release of the DSM-5 is a formal statement [or perhaps belated confirmation] that Neuroscience is the official language of academic and organized psychiatry.

The DSM-5 [formerly known as the DSM-V] set out to certify this paradigm shift by including the neurobiological findings along with the behavioral descriptions in the Manual itself. That undertaking totally failed. The DSM-5 proposed adding a dimensional approach to diagnosis. For more reasons than there’s space for, the APA itself rejected those efforts outright. The DSM-5 was going to firmly embed psychiatric diagnosis in the mainstream of medical diagnostic tradition, but rather than the warm embrace of the rest of medicine, it feels more like being left at the altar. But the hardest thing of all to understand is how the APA, having failed on each count, can expect anyone to read the rhetoric in that JAMA blurb and feel anything but pity? or listen to the pronouncement about personalized medicine and not laugh because so many non-responders end up on all the antidepressants at once and still don’t respond? or seriously entertain the notion that immunology or deep brain stimulation [they go in those blanks up top] are going to make a dent in the oft-mentioned world-wide burden of depression. And what are we to say when we’re hearing about the wonders of the DSM-6 before the DSM-5 has even been released? If the DSM-5 is going to be so short-lived, why even release it? The future-think has gone on for far too long to make it through another round, and it sure hasn’t arrived!

I chose those three quotes because each one seems to me to be an attempt to perpetuate an illusion. The question of  note: "Is there a sustainable psychiatry beyond illusions?" Some people would answer that question "No" based on their own negative experiences. I would suggest that the most intense criticisms aren’t generated by people who are angry about the limits of psychiatric medications or other treatments. Those things are just what they are. Rather, the most biting criticisms are from people who were offered an illusion rather than a straight assessment of the realistic upsides and downsides of any medication being offered, or were enrolled in a psychotherapy without an up-front assessment of what could actually be achieved or expected – in short, people who felt lied to, tricked. When I read each of those quotes I started with, I felt that I was being tricked.

To be honest, I don’t even know what psychiatry is myself anymore, until I’m seeing a patient – then I remember. Otherwise, I spend my time writing about what it’s not. No patient cares much about the future of psychiatry. They care about what can be brought to bear on their problem in the present. The future they care about is their own. That’s what we should care about too…

    February 26, 2013 | 9:46 PM

    Classic cargo cult cant!

    berit bj
    February 27, 2013 | 4:46 AM

    Psychiatric treatments have done more harm than good all the time, enormous amounts of harm, EXCEPT TALKING THERAPIES, as the practice of medicine until doctors learnt to wash their hands properly, still problematic, till the discovery of lemon against scurvey was taken into use, years after James Lind’s discovery, then, in our age, pencillin and antibiotics.
    Remember Benjamin Rush, “father of American psychiatry”, bleeding George Washington to death, according to Roy Porter’s massive history of medicine, The greatest benefit to mankind, ironically named, I tguess. Bleeding any ailment. Today it’s pharmacology, promising to be more scientific than lobotomy, marketing ever new brands of snakeoils to the young, the poor, the suffering and the gullible, without assessing or taking responisibility for the damage they’re doing, unless fought all the way through the courts.
    Are the benefits greater than the damage when we count in all the dead, the damaged, the contamination of soil, water , animals? I think the contamination of our thinking is by far the greatest danger. Honest talking is what’s most needed – many more honest talking therapist-writers. Thank you!

    February 27, 2013 | 7:20 PM
    Influence of initial severity of depression on effectiveness of low intensity interventions: meta-analysis of individual patient data
    BMJ 2013; 346 doi: (Published 26 February 2013)
    Peter Bower and about 20 co-authors

    Conclusions The data suggest that patients with more severe depression at baseline show at least as much clinical benefit from low intensity interventions as less severely depressed patients and could usefully be offered these interventions as part of a stepped care model.

    February 28, 2013 | 6:30 AM

    You may appreciate this talk on DSM-V as delusion, from the gifted Gary Greenberg. Indeed he has a book, ‘The Book Of Woe’ to be published shortly which explores this very topic.

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