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Psychiatry: the end of the timequake?

2014; Elsevier BV; Volume: 1; Issue: 1 Linguagem: Inglês

10.1016/s2215-0366(14)70265-2

2215-0374

The Lancet Psychiatry,

Health Policy Implementation Science

In Kurt Vonnegut's novel, Timequake, the universe suffers “a crisis in self-confidence”. After a brief period of indecision, it shrinks by a decade, forcing the world's populace to relive the past 10 years of their lives without the ability to change anything. When the timequake ends in 2001, individuals emerge stunned by the sudden return of their free will. Only one sentence is capable of breaking the indecision that would otherwise lead to societal collapse. “You were sick, but now you're well again, and there's work to do.” For psychiatrists, the past few years have felt like living through such an event. The furore surrounding the publication of the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (APA DSM-5) was felt far beyond North America. The criticisms of DSM-5 fell into two broad camps. Those of people such as Allen Frances were that although psychiatry was a valid scientific and practical endeavour, DSM-5 had “opened the floodgates to much more mislabelling and to drug company misleading marketing.” The now-superseded DSM-IV, whose task force Frances had chaired, had, he said, “tried (with only partial success) to stem the tide.” For others, it wasn't simply that DSM-5 was a regression from, or at least not an advance on, previous iterations: the arguments brought the very validity of psychiatry as a profession into focus. Psychotherapist and anthropologist James Davies told Psychiatric Bulletin that “psychiatry over the past 40 years, under the dominance of the medical or ‘technological’ model, has done a lot of harm in the name of helping vulnerable people.” Overall, the debate demonstrated that, in generating acrimony, psychiatry still leads the scientific field. This backlash might have led psychiatrists to question if their profession had made any progress at all in helping patients or justifying its worth to the sceptical, whether since DSM-IV in 1994, or, indeed, in the half-century since Thomas Szazs published The Myth of Mental Illness. “The common service models…had all been introduced 30 years ago. There have been no new antipsychotics, antidepressants or mood stabilisers that are clearly more effective than the drugs available at that time…All current major psychotherapy schools had already outlined their models”, wrote Stefan Priebe and colleagues in the British Journal of Psychiatry last year, adding that “achievements in fundamental research have led to no obvious breakthrough in better treatments.” It was therefore surprising that a mood of something approaching optimism was in the air at the APA meeting in New York, May 2014. Outgoing President Jeffrey Lieberman started his opening session speech with a joke: “I have a confession to make that may shock you to hear…I really have enjoyed being President of the APA”. While the more psychoanalytically inclined might suspect that this represented the employment of humour as a defence mechanism, it felt more like a genuine expression of delight and surprise. The scientific programme included innovative thinking in both science and service delivery. For example, a symposium about care for pregnant patients integrated clinical knowledge with profound legal and political awareness of the lamentable disregard for women's rights in many parts of the USA. As for DSM-5: if it is indeed the so-called Bible of psychiatry, then agnosticism, if not actual atheism, seems to be a growing movement. Several developments presented at APA are of particular interest. First, attendees heard about the Australian headspace initiative for young people, with its holistic model for support, rather than isolated psychiatric diagnosis. Second, the National Institute of Mental Health's research domain criteria, which aim to define basic dimensions of functioning, were mentioned frequently. Finally, work of both veteran scientists such Eric Kandel and rising stars including Karl Deisseroth suggested that the moment at which basic neuroscience finally translates into clinical benefit could, after the longest journey, be on the horizon. Even with acknowledgment of the barriers to translation that have dashed hopes in the past, exploration of the complexity of the human mind is a valid scientific endeavour in itself, and one in which psychiatrists have a crucial part to play. Putting these things together, might the way forward for psychiatry be taking shape at last: a specialty in which individuals experiencing mental distress are given not a label, but a personalised and collaborative programme based on their specific strengths and needs, in terms of their social, emotional, cognitive, and physical wellbeing? Psychiatry is not entirely well again, but we believe it can recover and flourish. There's work to do.