Is classical psychiatry in crisis?

Madness is an old companion of humanity. The Code of Hammurabi, written 3,700 years ago, refers to it as the clothing that men wear when the gods abandon them, and the ancient Greeks went so far as to classify it, discerning between “mania,” “melancholia,” and “insanity.” However, psychiatry has only dealt with it for a little over a century and a half. In all that time, research and treatment have not been enough to prevent mental illness from resisting our efforts to trace their origins or ease the suffering they entail. “For the present, we need to be honest about the dismal state of affairs that confronts us rather than deny reality or retreat into a world of illusions,” writes Andrew Scull, historian of psychiatry, in the preface of his recent book Desperate Remedies, Psychiatry and the Mysteries of Mental Illness, in which he reviews the past, the present and peeks into the, in his opinion, uncertain future of the discipline.

We cannot deny that “some progress” has been made, he states, but we also cannot ignore “the price that is sometimes paid for such relief as psychiatry can now provide.” As for the reasons for this situation, they must be sought in “the depths of our ignorance about the etiology of mental disturbances.” A professor of sociology at the University of San Diego, Andrew Scull speaks from outside the medical profession, but as an expert on the historical and current reality of a specialty that, to him, is facing a crisis, a lack of new ammunition against mental disorders and the growing competition of psychology regarding minor disorders. Scull refers not only to classical psychiatry, which has historically sought to treat illness, but also to the alternate trend that is more focused on the patient and their social environment, as both lack, in his opinion, effective remedies against severe mental disorders.

José Luis Carrasco, professor of psychiatry at the Complutense University of Madrid and head of the psychiatry unit at the San Carlos Clinical Hospital, flatly denies that the profession is in crisis. Psychiatrists are more necessary than ever, he argues. “What defines psychiatry, like medicine in general, is the patient; people with ailments that need a solution,” he says. After all, the challenge of this specialty is enormous, given the complexity of the human being. Carrasco acknowledges that much remains to be learned, but that does not overshadow the progress that has been made. “The life of a person with schizophrenia is infinitely better today than it was 50 years ago. And a person with severe major depression can lead an almost normal life, when half a century ago they would have been incapacitated or even taken their own life.”

Jordi Artigue, clinical psychologist and president of the Spanish Association of Neuropsychiatry, agrees. The brain indeed still contains many mysteries, “but progress has been made, thanks to follow-up studies of patients from childhood to adulthood, in understanding what we call the risk factors that precipitate the onset of a mental disorder, even the most serious ones, such as schizophrenia and psychosis.” He also denies that psychiatry is in crisis. Maybe the role of the isolated psychiatrist is, he admits, but not that of the one who works as part of a team with other mental health professionals.

Seen from a historical perspective, this situation could be understood as the loss of hegemony of a medical specialty born with the purpose of curing madness and that has exercised absolute authority in this field for decades, testing all kinds of remedies on its patients, many of them aberrant, which Scull recounts in his book. Suspecting that the disease could have its origin in simple infections, an American psychiatrist tried removing the tonsils, spleen, ovaries and even the teeth of his patients. Injections of insulin and other substances were also used to cause artificial comas in an attempt to rid patients of their conditions. Electroshock therapy was born in Italy, a practice that immediately spread throughout the world, and Egas Moniz, a Portuguese psychiatrist, received the Nobel Prize in Medicine in 1949 for devising a supposedly miraculous surgical intervention that turned out to be a tragic fiasco: the lobotomy.

Meanwhile, psychoanalysis – the cure by words – had already conquered a large sector of psychiatrists. However, the real revolution would come in the 1950s with the appearance of psychotropic drugs, which allowed for the opening of the doors of the so-called asylums. But these drugs have not been a panacea either. “Neither the antipsychotics nor the antidepressants were psychiatric penicillin,” writes Scull. “These drugs were in fact no more than Band-Aids, sources of symptomatic relief that often carried with them a heavy price in side effects.”

British psychiatrist Joanna Moncrieff, who is very critical of the official line, has studied the subject extensively. In her book A Straight Talking Introduction to Psychiatric Drugs she warns that there is a lack of research on the impact that the prolonged use of these drugs can have on the neurons.

Shortcomings and all, so far psychopharmaceuticals have been an essential resource in psychiatry. But their future is uncertain. Reasons like lawsuits or more profitable trials have led the big pharmaceutical companies to leave the field. In the past 10 years, writes Scull, GlaxoSmithKline has closed its psychiatric labs, AstraZeneca has dramatically reduced in-house psychopharmacology research and Pfizer has drastically cut research funding in this field. Carrasco confirms this and acknowledges that new preparations have not been marketed for a long time, although he attributes this to some specific failures and is convinced that the trials will continue.

The role of these drugs continues to be important because, as Jordi Artigue points out, the goal today is to improve the quality of life of patients, achieving what medicine has done with diabetes or asthma, chronic diseases that one can live with thanks to medication.

What qualifies as an illness?

“We don’t talk about illness, but about mental disorders,” Artigue clarifies on behalf of a broad sector that rejects the term. Moncrieff even avoids referring to “patients” or “treatments.” “The thing is that we are not even clear about what illness is,” says Javier Álvarez, a retired psychiatrist who used to be the head of the psychiatry service at the General Hospital of Leon, in Spain. He expresses serious doubts regarding the medical diagnoses, especially in the mental field, “because there are no objective pathological markers, but rather a statement of symptoms established by the American Psychiatric Association in its Diagnostic and Statistical Manual of Mental Disorders, of which there have been five revisions since the first version, published in the 1950s. While the first one lists 105 disorders, the most recent (from 2013) already lists 350.” Under the umbrella of this latest APA manual, new syndromes flourish. And the prescriptions of psychotropic drugs multiply for a population that, says Artigue, demands pills even to overcome an emotion as normal at certain times as sadness. This “psycho-pathologization” of life is responsible, in part, for the excessive consumption of antidepressants, believes the psychologist.

Perhaps the fault does not lie on the individual, but in an increasingly complex and demanding social mechanism that is unbearable for many people and leads them to saturate mental health consultations. Nel González Zapico, president of the Spanish Mental Health Confederation, an NGO that brings together numerous associations of patients and their families, attributes part of the suffering of psychiatric patients to the social inability to accept difference. “The way to approach these disorders is not biological, but rather one of deep respect for human dignity and human rights,” he argues.

But many psychiatrists, such as José Luis Carrasco, are aware of the biological aspects of the disease, even if they consider essential the findings of psychiatric epigenetics that study the impact of diet, the emotional warmth received in childhood, or hate, or the mistreatment that may have been suffered. “All of this is expressed in the genes and forms the brain,” says Carrasco, who emphatically rejects the possibility of speaking, as is sometimes done within the profession, of biological or social psychiatry. Scull himself is convinced that the ultimate explanation for these disorders has to be biological and biographical, although in the end the dilemma may be meaningless, because the innate and the acquired get mixed up in an organ as plastic as the brain.

What Carrasco and Artigue complain about, like many of their colleagues, is the essential problem of public health in the mental field: lack of time, and a system that turns psychiatrists into mere prescribers of psychoactive drugs. What is there to do when there are too many patients and the doctor can only see them for 10 minutes? “Well, you give them medication to improve their mood a little bit,” says Carrasco, “and you send them to a psychologist, who will see them in five months and once a month.”

Artigue speaks with admiration about an ambitious exercise carried out in Finland by Jaakko Seikkula. In 1985, this psychologist devised a psychiatric care approach called “open dialogue” that allows people suffering from an acute crisis to be treated in their own home. When someone experiences such an episode, a full team of mental health workers (psychiatrist, psychologist, nurse and social worker) go to the affected person’s home. They treat them and devote the necessary time on successive visits until they consider them recovered. “According to the statistics they publish, they have achieved a decrease of 80% in cases of schizophrenia and the same in psychotic episodes,” says Artigue.

For this psychologist with psychoanalytic training, any therapy is good — whether cognitive, gestalt, family or psychoanalytic — depending on the duration of the sessions. Time is also key for Carrasco, who attributes many of the mistakes of the past to haste. Perhaps we will not see it, but he is convinced that “dynamic” psychiatric research will someday provide the answers that we seek.

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