Mental health awareness and reducing stigma are in the news at higher rates as the public tries to understand the toll untreated illnesses take. I read a headline yesterday, “Are We Entering A Golden Age of Neuroscience Research?” It would be nice to think so. For me as a psychiatrist, sometimes the options for treating the most complex patients seem bleak. What we can offer now in mental health is simply inadequate. I don’t try to hide that fact from my patients. We work together and do the best we can to alleviate psychic pain and restore well-being, but the treatments we offer fall short of curing suffering in human minds.
Psychiatric diagnosis, medication, or understanding of disease- these are all not exactly accurate.
Diagnosis
Mental health diagnosis is still made checking off symptoms from a list. The checklists were developed decades ago to make sure doctors were describing the same illnesses when they used words like “depression” and “schizophrenia.” But it has never been proven that the checklist for depression (or for any other illness) actually captures a single disease. Maybe the symptoms we call “depression” can be produced by seventeen different causes requiring as many different treatments. And maybe the list fails to capture everyone in need of treatment. Even if we identify all the right people, checking off all the items from the list says nothing about why a patient has the symptoms or whether the symptoms can successfully be treated.
Treatments
When patients ask how psychiatric medications work to treat their symptoms, the most honest answer a doctor could give is, “We really don’t know.” Although PET, SPECT, and fMRI scans and chemical tests of brain neurochemistry show us what changes in the brain after taking a medication, we have never proven that the changes we can measure are why the medications help. The same is true for talk therapies and other treatments. Researchers can predict what percentage of patients will improve, but they cannot explain why one person will improve and not another, or whether a given patient will fall in the good-responder or the poor-responder group (or somewhere in between).
Evidence-based care
Throughout the medical field, there is a push for more evidence-based care. Rather than acting on intuition or basing treatments on experience, physicians are urged to study the scientific research and choose treatments based on the evidence. However, in mental health care, there is often not enough evidence to guide physicians.
Experts within the psychiatric field are divided on the best ways to solve the mental health crisis. Leaders in the field argue how to conduct the research and about the strength of the scientific evidence.
Robert Whitaker wrote in his blog (at madinamerica.com) about scientific findings showing that some of our standard practices, defended by medical and psychiatric professionals, don’t really work. He referenced a research study by Wunerink, which found that the accepted practice of leaving schizophrenic patients on medication long term is not effective. Whitaker notes, for psychiatry to truly “follow the evidence,” standard treatment should have changed after that study but it didn’t. Leaders in the field are emerging against the practices as usual- people like Allen Frances and Thomas Insel, but the general practices are not changing even with these “high-ranking voices of dissent.”
Whitaker also raises concerns about inaccurate teachings on “chemical imbalance,” “serotonin deficiency,” “curable illnesses” in mental health, and even the basic ways mental illnesses are diagnosed with checklists of symptoms forming supposed “illnesses.” He notes that these ideas have all been discredited, but are still being practiced routinely. He believes many of the practices are being maintained simply because of tradition or fear of change- or worse, conflicts of interest.
Joanna Moncrieff wrote in her blog about genetic research in schizophrenia, “We will likely never be able to fully account for why some people experience extreme mental states, but we know that poverty, unemployment, insecure attachments, familial disruption, low self-esteem, abuse etc. play a role for many. We would be better concentrating on how to eliminate these from our society if we really want to reduce the impact of mental disorder, rather that pouring more money into the bottomless pit of genetic research.”
Dr. Deuter is a psychiatrist who specializes in the care of emerging adults.