Psychiatry in crisis? Back to fundamentals

H. Katschnig’s thoughtful and scholarly essay raises important and timely questions about the present state of the psychiatric profession and of psychiatry’s raison d’etre as a medical discipline. In many parts of the “developed” world, there is a slow but steady decline in the numbers of medical graduates who opt for specialist training in psychiatry. In most of the “developing” world, chronic shortage of psychiatrists continues to work against reducing (not to speak of closing) the “treatment gap” between need for, and supply of, even basic care for the majority of the world’s mentally ill. In countries such as the UK, Australia and the United States, public mental health services would face collapse without many immigrant doctors from low- or middle-income countries filling in the vacant positions 1. The public image of psychiatry continues to be tainted by stigmatizing stereotypes which, not uncommonly, are shared by some of our professional confreres in other medical disciplines. How deep is the apparent crisis of the discipline and profession, and what are the factors contributing to it? While agreeing with much of Kats- chnig’s diagnostic assessment, I would argue that the root cause of the problem is not in an inherent regression of the discipline of psychiatry, but in its relative loss of competitive edge when compared with other medical disciplines. The dramatic advances in the basic biological sciences have, in the last couple of decades, transformed whole fields of medicine and surgery, including cancer medicine, cardiology or clinical immunology. General medicine is becoming increasingly “molecular”, hence more attractive and intellectually challenging to young minds. This kind of transformation has not occurred in psychiatry. Hardly any of the recent advances in neuroscience, molecular genetics and genomics has translated into practical clinical tools, disease markers, treatments or novel conceptual paradigms in our understanding of the nature of mental disorders. Notwithstanding hyperbole and periodically appearing false promises of imminent breakthroughs, the gains in real knowledge of the genetic and neural basis of the major mental disorders have been modest, while the looming complexity of the task has become obvious. Thus, while the theory and practice of psychiatry cannot at present claim to have a firm anchor in either neurobiology or “psychiatric genetics”, it has, in recent decades, allowed its true “specialized and not easily accessible body of knowledge and skills” 2 to slip into relative neglect. That body of knowledge and skills includes psychopathology and clinical phenomenology, which have become an esoteric subject for many (if not the majority) of medical students and trainee psychiatrists. Intellectual curiosity, coupled with sound grasp of psychiatric semiotics, is being increasingly replaced in the training of psychiatrists by uncritical counting of DSM-IV diagnostic criteria. While eminently useful for specific purposes of communication, DSM-IV and ICD-10 criteria are no surrogate for clinical acumen. The belief that the adoption of quasi-operational criteria has once and for all resolved the problem of reliability of psychiatric diagnosis may turn out to be illusory, if the validity of symptom and sign ascertainment in actual clinical practice can be shown to be questionable. This trend of alienation of clinical psychiatry from its roots in psychopathology and phenomenology is reinforced by the increasing dominance of managerialism in the organization and evaluation of psychiatric care, making the daily practice of the profession intellectually and emotionally unrewarding, or simply boring. While much of Katschnig’s overview of the state of the profession, and my added comments, may seem to paint a rather bleak picture of psychiatry in crisis, I remain optimistic about its future. The way forward for us as a profession points to a need to reclaim assertively the solid “knowledge base” of psychopathology which combines the two perspectives of “understanding” and “explaining” 3 the phenomena of mental illness and is capable of dynamically integrating novel concepts, data and technological advances from the ever changing fields of neuroscience, genetics and population epidemiology. Moreover, to quote the late Professor L. Eisenberg 4, psychiatry remains today “the one medical speciality with a persistent interest in the patient as a person in an era increasingly dominated by organbased medical subspecialities”. What we need is a concerted effort to nurture a new breed of “clinician scientists”, able to bring back together those foundational strands of the discipline of psychiatry that in the last decades have drifted apart.