Psychiatrists shall prevail
Authors: FELICE LIEH-MAK
Journal: World Psychiatry (2010)

H. Katschnig has to be commended for presenting a very thorough assessment of the challenges facing psychiatry. My answer to his question as to whether psychiatrists are an endangered species is an unqualified no. This answer is not some Panglossian fantasy. Psychiatry has been firmly embedded as a specialty in medicine for more than 200 years. In the course of its history there have been repeated Jeremiad prophecies on its demise. To paraphrase Mark Twain, the rumours of the death of psychiatry have been greatly exaggerated. The need for psychiatrists is great. The World Health Organization estimates that at any given time 450 million people suffer from some form of mental or brain disorder 1. Twenty to 30% of medical patients suffer from a psychiatric disorder and physical diseases are prolonged by psychological factors. Katschnig couched the problems in terms of challenges. This is a positive approach, since challenges are a call for action. As psychiatrists we have to take arms against this sea of troubles. The strategies are varied and most will need a longterm consistent and coordinated approach. Of the five characteristics of a profession mentioned by Katschnig, only three can be regarded as essential: the ownership of a specialized body of skills and knowledge, an obligation to guarantee high quality standards of services, and ethical conduct. Autonomy in determining standards for accepting or excluding members and being accorded a high status in society are the products of the preceding three. Political scandals, the degradation of the environment in the name of progress, the perceived failure of the globalization of trade to help the disadvantaged and the economic crisis that cast doubts on the establishment's ability to manage the economy all act in synergy to fuel the rise of populist sentiments in South America, Europe and North America. The very nature of populism is antielitism. In this context professionals are viewed as elites with special status and powers who deprive the sovereign people of their rights, identity and voice. Thus, professionals are made convenient scapegoats for local personal concerns. Medical journals give preference to the publication of positive results. The media prefer to disseminate bad news. After all, bad news has more currency than good news. In the current zeitgeist, it is not surprising to see that all professional groups, including psychiatrists, are under attack. These are painful times and some professionals may try to compromise by diluting their ethical standards or disavow their specialized body of knowledge. This is not only a shortsighted but also a counterproductive approach, which should not be taken by psychiatrists, otherwise we will lose our professional status irretrievably. This is the time to hold steady to the essential properties of our profession, since populism is a political storm that will pass with time. In the meantime, we have to live to fight another day. The majority of the psychiatric diagnostic categories are not validated by objective tests. This is a severe limitation, but it should not preclude us from making the most stringent use of phenomenological information. It is rather unfair and simplistic to label the DSM and the ICD as topdown exercises. The categories in both systems are the product of decades of careful observations and documentation by clinicians. They are in turn subject to field studies and further research and refined accordingly. The disorders included in the DSM and the ICD are not dogmatic. They are subject to the Popperian test of falsifiability. The number of scientists engaging in research in genetics, neurosciences and psychopharmacology is impressive. We see the beginnings of the uncovering of the neurobiological and genetic basis of some psychiatric disorders. There is increased knowledge of the mechanisms by which psychological and social factors interact with genetic, biochemical and structural ones. Whilst it is difficult to predict the nature of the next paradigm shift, this is unlikely to lead to the demise of psychiatry. The discovery of the Helicobacter pylori has not led to decline of surgeons specializing in gastroenterology. The invention of the endoscopy has caused the physicians and surgeons to develop their own expertise. There is always some degree of overlap between different medical specialties in terms of the patients they treat. The paradigm shift in psychiatric disorder need not be a zero sum game between the neurologists and the psychiatrists. There is enough work for all. There is no shortage of critics of modern medicine. The eminent social philosopher of medicine T. McKeown 2 contended that medical intervention had little effect on mortality rates and minor consequences for morbidity. The social polemicist I. Illich 3 declared that “the medical establishment has become a major threat to health. The disabling impact of professional control of medicine has reached the proportion of an epidemic”. The studies on the mechanism of heart attacks suggested that increasingly popular aggressive treatments like bypass surgery, angioplasty and the insertions of stents might be useless, as well as dangerous. It is, therefore, not surprising that doubts have been raised on the effectiveness of psychotropic medications. These criticisms should not cause psychiatrists to retreat into a state of frozen helplessness. The reality lays in the fact that psychotropic medications have helped to improve the lives of many psychiatric patients. Research on new pharmacological interventions will continue. Clinicians should continue to adhere to good practice in psychopharmacology by establishing proper diagnosis, identifying medicationresponsive target symptoms, monitoring effectiveness and avoiding the use of polypharmacy. I will conclude this commentary by paraphrasing W. Faulkner: we psychiatrists will not merely endure; we will prevail, because we have a spirit that is capable of compassion, sacrifice and endurance.