1 Boring Old Man

While I bandy about the trinity of trendy paradigms [evidence-based medicine, translational medicine, and personalized medicine], I’m not really being precise about the nature of my complaints. Like all of us, I get caught up in the obvious – the profit motives of the pharmaceutical industry that pervade modern psychiatry and its academy, the overgrowth of fuzzy science that finds its way into our journals, the power dynamics of our specialty’s organizations, our chronic inferiority complex in the hierarchy of medical specialties, and our frustration with the elusive and confusing conditions that ended up on our plate. I suppose there’s another thing that clouds my clarity, my own story – always a major piece of anyone’s opinion.

I was meandering through my life aiming towards a career as a research scientist. I guess it was my version of the post-sputnick science-is-all world I grew up in. I was kind of good at it so I was shepherded along the right path by some very helpful mentors. But there came a forced interruption about the time I was thirty, and my launch was delayed by a stint in the Air Force as a regular old practicing Internist on a base of largely healthy soldiers and dependents – a far cry from the laboratories of my NIH fellowship or the life and death front lines of the southern charity hospital where I received my medical training. To my amazement, I liked it – a lot. It wasn’t the Internal Medicine. Internal Medicine in an Air Force hospital overseas is fairly routine, – in the range of boring. And I quickly learned that unlike the emergency world of a Memphis Charity hospital, most of the people I was referred weren’t medically ill – their symptoms pointed to some tangle in their lives [75% by my count]. I had nothing but time, so I got into trying to help them untangle. That’s the part I liked, and so I came back and trained in psychiatry and later psychoanalysis. I had no illusions of finding a cure for Schizophrenia or Bipolar Disorders. I retrained to learn how to be a better untangler. If I was going to be a doctor after all instead of finding the hidden secrets of medicine, I preferred helping people deal with their own secrets over worrying about their blood pressure. I still prefer that, and I’m more than glad to have figured out what I was for at only thirty. When the modern movement of psychiatry turned chemical, I just kept doing what I had set out to do. Tangled lives were little changed by the revolution, so plenty of them found me and occupied my time.

^{If you … in all of history, ever had to have the misfortune or have a loved one have the misfortune of suffering from a mental illness, there’s no better time in history than now. The quality of care, the level of knowledge, the acceptance in society, they’re nowhere near where they need to be but they’re better than they already ever have been. There still exists a kind of a disparity between psychiatric medicine, mental health care in other areas of medicine.}
^{Well, why is that? Well, that’s existed historically for a number of reasons. First, I think psychiatry has kind of been the stepchild of medicine for a long time. And it’s really only been in the last century, with the advent of neuroscience, modern imaging methods, genetics, molecular biology that psychiatry has been established on the same scientific basis, or comparable scientific basis to every discipline in medicine. So psychiatry … has had to play catch-up. But it’s done so in amazingly swift time and has built up tremendous momentum and head of steam. Another reason why it exists with some kind of disparity to other disciplines in medicine is the fact that we’re dealing with the brain. So every discipline in medicine, whether it’s neurology, whether it’s cardiology, whether it’s gastroenterology, whether it’s OBGYN, deals with a certain sort of disease, set of diseases, or a target organ. And the brain is the target organ for psychiatry and neurology…}

Another paradox is psychiatry’s abandoning the medical model of disease while espousing it’s centrality. The medical model essentially teaches us that the signs [abnormalities we can see or measure] and symptoms [reprted complaints from our patients] may be experienced as dis-ease [feeling bad], but the first order of business, if possible, is to find the underlying cause [disease as noun] and treat it if we can. Symptomatic treatment comes afterwards. If my daughter shows up in a distant emergency room with right lower quadrant pain, I want her doctor to look into the state of her appendix before giving her pain medication. Likewise, if she reports to a psychiatrist depressed, I’d like for someone to ask about her life to see if she’d gotten herself into a tangle she can’t handle before giving her an SSRI for her symptom. Looking back, thus far I know of no compelling evidence that the antipsychotics or antidepressants are anything more than symptomatic treatments. We’ve had any number of hypotheses along the way that have attempted to link the actions of the drugs to theories of cause, but they don’t seem to have panned out. While such linkages might be made in our yet unrealized future, that actually relates to another paradox [below]. So, more or less, modern scientific, psychopharmacology is preoccupied with symptoms, and the Clinical Trials business is measuring them right and left in symptom diagnosed [DSM] subjects using symptom list improvements [rating scales]. "I think psychiatry has kind of been the stepchild of medicine for a long time. And it’s really only been in the last century, with the advent of neuroscience, modern imaging methods, genetics, molecular biology that psychiatry has been established on the same scientific basis, or comparable scientific basis to every discipline in medicine." There’s something to be said for a science of symptomatic treatments, but the essence of the medical model – causality – seems to  have been lost in translation.

The other paradox to me is the "future-think" of modern psychiatry. A title search of PubMed for articles with "psychiatry" in them reveals: new [3995], future [1321], novel [817], trend [648], emerging [250], directions [249], recent advances [122]. That’s hardly a scientific survey, but the point is solid. These people have lived in their dreamed-of future since they showed up thirty plus years ago. Futurethink is fine, the stuff of discovery, but it’s not daily bread. To me, what’s worse is that they believe in their projected future, just like they believed in the SSRIs, believed in the antipsychotics, believe in personalized medicine. Most of the harm they’ve done is by believing in against a gradient of increasingly conflicting evidence. Science is not about believing in. A lot of people believed in prefrontal lobotomies too. Their great criticism of psychoanalysis was that analysts believed in Freud. It was a valid criticism. Perhaps they could consider their own version of the same problem.