1 Boring Old Man

^{Genomics and neuroscience, 2 areas of science fundamental to psychiatry, have undergone revolutionary changes in the past 20 years. Yet methods of diagnosis and treatment for patients with mental disorders have remained relatively unchanged. Indeed, during the same time, the public health burden of mental disorders has grown alarmingly. Mental disorders are now among the largest sources of medical disability worldwide and, like AIDS and cancer, they are urgent and deadly.}



^{The recognition that mental disorders are brain disorders suggests that psychiatrists of the future will need to be educated as brain scientists. Indeed, psychiatrists and neurologists may be best considered clinical neuroscientists, applying the revolutionary insights from neuroscience to the care of those with brain disorders. The study of unconscious processes, motivation, or defenses, while at one time the sole province of psychoanalytic therapies, is now also in the domain of cognitive neuroscience.}
^{Psychiatry as a Clinical Neuroscience Discipline, Tom Insel Director of the NIMH, 2005}

The Plague

In this piece, Dr. Insel references the World Health Report, 2002, an absolute gold mine for the some of the psychopharmacology literature of the era:
^{Major depression is now recognized as a highly prevalent, chronic, recurrent, and disabling biological disorder with high rates of morbidity and mortality. Indeed, major depression, which is projected to be the second leading cause of disability worldwide by the year 2020, is associated with high rates of mortality secondary to suicide and to the now well-established increased risk of death due to comorbid medical disorders, such as myocardial infarction and stroke. Considerable strides have been made over the past 2 decades in the development of safe and efficacious antidepressants.}
^{Despite efficacious and widely available antidepressants and psychotherapeutic interventions, the psychosocial and medical burden of depression is increasing. In fact, the World Health Organization projects that depression will continue to be prevalent, and by the year 2020, will remain a leading cause of disability, second only to cardiovascular disease). Although we do not know with certainty why rates and disability associated with depression are increasing, it is likely that this mood disorder continues to be remarkably under-recognized and under-treated. Depression frequently occurs in the context of chronic medical illness, and it is only relatively recently that the research community has turned its attention to the relationship between depression and chronic medical conditions. However, there is much work yet to be done.}
These two examples were from medical writer Sally Laden written for guest-authors, but examples peppered our literature [like from Insel above] – a call to arms for biological and drug research:
^{"…the public health burden of mental disorders has grown alarmingly. Mental disorders are now among the largest sources of medical disability worldwide and, like AIDS and cancer, they are urgent and deadly."}

^{Indeed, psychiatrists and neurologists may be best considered clinical neuroscientists, applying the revolutionary insights from neuroscience to the care of those with brain disorders.}
I hate to be a rain-storm-in-a-parade, but the revolutionary insights from neuroscience that he’s referring to don’t come immediately to mind. What’s revolutionary, perhaps, are the available technologies that have  entered the picture – brain imaging, genetic sequencing and gene identification, biochemical assay techniques, etc. Promising avenues? yes. Fascinating reading? yes. Applications? not so much, at least in the present.

I recognize that choosing this article by Dr. Insel, obviously written to be a vision or mission statement for the NIMH, could be seen as an example of using the Straw Man Fallacy that I often preach against. But it’s not just that. The FutureThink of modern psychiatry is so ubiquitous that it literally characterizes the specialty today. It’s entirely appropriate for a Director of the NIMH to talk about the challenges of the future. However, his graph is a bit over the top. A 10 year plan to discover the causes of the mental illnesses? A 20 year plan that ends with the word "cure"? Bold stuff! But it’s not the boldness of his goals that particularly bothers me, it’s that he thinks he knows the path to get there [the vertical axis called Technology]. Who knows what those technologies might yield? I sure don’t, and I’m sure that Tom Insel doesn’t either.

It has worked for decades, this talk of the glorious discoveries just around the corner, new treatments in the pipeline, promising this-and-that on the horizon [Mifepristone comes to mind]. "Advances," "Innovations," "Future Directions," "Novel Treatments," "Promising," have become chronic tag lines in our literature. We live in a fictitious future realm where revolutionary insights from neuroscience and personalized care already exist, where unconscious processes, motivation, or defenses… is now also in the domain of cognitive neuroscience has already become solid fact, where genetics and brain imaging are already useful clinical tools.

On that graph, we’re just three or four years shy of treating core pathology. Well, that’s certainly news to me. I’d love for that to be true too, but it isn’t. And it wasn’t going to be true in 2005 when this article was written. It was the collective wish of a subset of psychiatrists who have dominated the field for the last three decades.

From Dr. Insel’s article:
^{We also recognize that psychiatry presents to the rest of medicine a unique blend of interpersonal skills and behavioral expertise that will be increasingly needed in this era of care dominated by technology. The challenge will be to incorporate neuroscience without losing the discipline’s sophisticated understanding of behavior and emotion.}
and another:
^{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.}
The Psychiatry of the pre-DSM-III era was heavily influenced by the Psychoanalysts, a group that is technically outside of and separate from the medical specialty of Psychiatry, though at that time, its membership was close to 100% psychiatrists. The dramatic change in Psychiatry in the 1980s was, in large measure, a move to solidify the separation of psychoanalysis and psychiatry.

There were other trends in psychiatry whose roots were elsewhere, probably tracable to a Swiss immigrant, Adolph Meyer, who was a dominant force in American Psychiatry. He championed an approach that involved detailed clinical interviewing and the biopsychosocial model – looking at mental illness in the broad context of his named three dimensions. Unlike Freud, Meyer wasn’t much of a theoretician. He was more case focused – one case at a time. Another name that fits in this story is Harry Stack Sullivan, a master of the clinical interview and the case focused approach. As the psychoanalysts arrived in the country, there was a lot of crossover with the Meyer/Sullivan tradition, and what emerged was something unique to American psychiatry – an amalgam of these trends into clinical interviewing, detailed case study, and something called dynamic psychotherapy. It was certainly not psychoanalysis proper, but it was influenced by selected psychoanalytic ideas. It’s what Insel is talking about when he says, "the discipline’s sophisticated understanding of behavior and emotion" or "unconscious processes, motivation, or defenses."

There’s another cog in this wheel – Cognitive Behavior Therapy – originated by Aaron Beck, originally a psychoanalyst who went in another direction. In looking at the dreams of depressed people, he noted that they had a kind of thinking he called depressive cognition – gloomy thought. He came up with an approach that took the concept of behavior therapy from the psychologists and applied it to thinking – thinking as a behavior. His therapy involved identifying depressive thinking and modifying it using techniques of learning theory. It’s an effective treatment, extensively validated in depression. It’s what Insel’s talking about when he says, "… along with the use of evidence-based, nonpharmacological treatments (from psychoeducation to cognitive behavioral treatments) will be the tools of the effective healer in the future as much as in the past." The term "evidence-based, nonpharmacological treatments" is code for Cognitive Behavior Therapy and not psychoanalysis.

The psychiatric revolution of 1980 sent psychoanalysis packing to the halls of its own institutes [and academic departments outside of medicine] and embraced the Cognitive Behavior Therapy of Beck. As a psychoanalyst, I can see why that was necessary and have no complaints about either of those things. But as a psychiatrist, I have a big worry about jettisoning the piece of psychiatry that’s hard to name – the Meyer/Sullivan/touch-of-Freud focus on clinical interviewing, case history study, and learning to hear the music behind the words in an interview – a way of approaching a single case that is not in opposition to making a "diagnosis," but is looking broadly rather than constrained by "the manual." It’s the essence of the case of chicken little. It’s a clinical skill that can and has been written about, but is really learned by the example of others who have been at it for a while and know how and where to listen. It’s a true clinical skill just like learning how to hear the subtle differences in heart murmurs or see the deeper meanings of the squiggles in an EKG or an EEG. It’s the psycho and the social in the biopsychosocial model. And it’s the "baby" in the "bathwater" that is threatened when Tom Insel and friends get so lost in their love affair with biology and neuroscience that they forget that practicing psychiatrists see patients one at a time in the present, not in some made up future, fighting a mythologic plague of mental illness, armed with as yet undiscovered drugs and technologies.