Friday, June 7, 2013

Psychiatry Leadership: Uneasy Lies the Head that Wears a Crown

Last Friday's Science Friday broadcast included a segment titled Bad Diagnosis for New Psychiatry "Bible", which featured 3 guests: Dr. Jeffrey Lieberman, the current president of the American Psychiatric Association, Dr. Thomas Insel, the director of the National Institute of Mental Health, and Gary Greenberg, author of the Book of Woe: The DSM and the Unmaking of Psychiatry. It's a fascinating half-hour, well worth listening to.

What is most remarkable to me about the segment is just how much more cogent and articulate Gary Greenberg was in making his arguments, compared to the two leaders of the field of psychiatry. Greenberg argues that though the DSM was a sincere effort at classifying mental illness, its disorders are man-made constructs, not real diseases, and this is a real problem when the DSM's diagnoses underlie psychiatry's authority and influence scientific research. Despite his sharp criticisms of the DSM, he is by no means anti-psychiatry or against the use of psychiatric medications. He hopes that psychiatrists can acknowledge that not all human suffering is pathological and needs to be treated with a medication, and that we can be more transparent about the fact that we don't know how the drugs work, and that they treat symptoms instead of actual diseases.

David Brooks makes a similar argument in his Heroes of Uncertainty column:
The problem is that the behavorial sciences like psychiatry are not really sciences; they are semi-sciences. The underlying reality they describe is just not as regularized as the underlying reality of, say, a solar system.
All of this is not to damn people in the mental health fields. On the contrary, they are heroes who alleviate the most elusive of all suffering, even though they are overmatched by the complexity and variability of the problems that confront them. I just wish they would portray themselves as they really are. Psychiatrists are not heroes of science. They are heroes of uncertainty, using improvisation, knowledge and artistry to improve people’s lives. 
Meanwhile, Dr. Lieberman, in defending psychiatry's lack of progress, said [at the 8:11 mark], "The brain is a tough organ, and the behavioral and mental functions of the brain represent the most evolved aspects of the human organism, and in all of the animal kingdom." He says essentialy the same thing in a letter to the editor in response to the David Brooks op-ed: "The brain has proved to be infinitely more complex than any other organ in the human body, and the functions that mediate behavior are the most highly evolved in the animal kingdom." Does he even understand evolution? What does it mean to be "most evolved" or "highly evolved?" Every other animal on this planet is the result of their ancestors having been able to survive and transmit their genes over billions of years; their behaviors have evolved just as much as ours have. The view that somehow there is an animal kingdom hierarchy with humans at the top is so anthropocentric, it's no better than the medieval view that the earth is at the center of the universe.

Dr. Insel, meanwhile, said something equally ridiculous when he talked about [at 10:34] "finding a way to deconstruct these classifiers, and to say hey, yes, this is what we currently call schizophrenia, this is what we currently call autism spectrum disorder, but perhaps that's not one problem, but multiple, 5, 6, 7, 8, different diseases, that are contributing." Does he realize that, in all likelihood, hundreds, if not thousands of different genes contribute to autism and schizophrenia, and that environmental influences can shape the expression of those genes as much as any biological factor? To think that the NIMH will eventually "discover" a handful of "diseases" underlying schizophrenia or autism is pure future-think fallacy.

When Gary Greenberg and David Brooks make more sense talking about psychiatry than the two supposed leaders of the profession, something is deeply amiss. At the 8:24 mark of the SciFri broadcast, Dr. Lieberman said, "Gary's argument is so philosophical, and abstruse, and so minimally relevant to clinical practice." When the head of the American Psychiatric Association can't understand why Gary Greenberg's arguments are critically relevant to all psychiatrists, our patients, and their families, I can only marvel at how far removed he must be from the day-to-day concerns of practicing clinicians and ordinary people.

Listening to the debate, I felt that Drs. Lieberman and Insel were somewhat uncomfortable in discussing the lack of progress in biological psychiatry over the years. I hope that this unease leads to some self-reflection about the fundamental flaws in biological psychiatry, rather than repeating the same platitudes and mistakes over and over again.