Psychiatry in a Slump

A brief commentary by Henry A. Nasrallah, M.D. in the, with all due respect, throwaway journal Current Psychiatry strikes a chord. Entitled "Is Psychiatry in a Recession?", the piece examines the field's setbacks, with respect both to publicity and to substance, in recent years.

Psychiatry may have suffered more than other disciplines from the medical and cultural backlash against the marketing tactics, the profitability, and the faulty products of pharmaceutical companies. The uniquely malleable nature of psychiatric diagnosis has invited therapeutic creep (or perhaps therapeutic rush is more like it), whereby antidepressants and antipsychotics are used for an increasingly broad array of mental ailments. And psychiatrists, perhaps owing to their perennially modest stature and income among medical specialists, have arguably shown an unseemly eagernesss to ally themselves with drug companies.

We constantly hear about breathtaking advances in neuroscience, but as yet none of these have led to major consensus, either philosophically or scientifically, with respect to the nature and boundaries of mental disorders. So as the field looks forward to (perhaps braces for would be more apt) the DSM-V within a few years, there seems to be no more agreement than ever about such fundamental entities as ADHD or bipolar disorder. For those invested in psychiatry becoming a twin of neurology, this is bad news; for those drawn to psychiatry precisely because of its ambiguous and eclectic nature, this may be strangely reassuring.

As Nasrallah mentions in general terms, on a practical level psychiatry has met with disappointment over the past decade. The SSRI's, once seen as the vanguard of future generations of increasingly effective and well-tolerated antidepressants, have stalled out, plagued by concerns over sexual and suicidal side effects (yes, an odd pairing) and limited efficacy. Atypical antipsychotics, while arguably better tolerated in a subjective sense than older drugs, have their own major problems of expense and metabolic side effects. Once seemingly cutting edge treatments such as vagus nerve stimulation and transcranial magnetic stimulation, while still potentially helpful for individual patients, have not transformed the treatment of depression as once hoped. It speaks volumes that the single most effective treatment for acute depression remains electroconvulsive therapy, which is 70 years old.

This concern over morale in psychiatry speaks to the unique cultural valence of the field. It's hard to imagine nephrologists, for instance, fretting over the status of their discipline (kidney failure is kidney failure, period). The best antidote for abstract debates is to remain focused on patients, to realize that beneath academic considerations of the socially constructed nature of social anxiety or whatever, there really is a vast pool of suffering and psychopathology out there. Like the ocean, it is exhaustively documented, yet arguably our ignorance of it still dwarfs our knowledge. It may seem like I refer to it as a good thing; it's not--if it ever dried up, I could finally justify going back to graduate school.