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Bets are being taken on the survival of psychiatry in the near future

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Angelo Barbato

 

In 1967 the provincial administration of Parma printed a small volume entitled "What is
psychiatry?", re-edited by Einaudi in 1973. Basaglia, in a brief introductory essay, gave a reply to this question that he defined controversial, outlining two possible definitions for the field of research in psychiatry: "either it deals with the mentally ill person, or only with the syndromes that imprison him.... if the mentally ill person is the only reality to be referred to, then the two sides that make up this reality have to be confronted: that of being an ill person, with a psychopathological problem, and that of being an outcast, a socially stigmatized person". At the end of the essay a positive dissolving of the discord between these two alternative possibilities was optimistically predicted: "from the moment the institutional world ceases to be enclosed within the borders of an artificial reality, it will come face to face with the external world that in turn, it will have to learn to accept, not having a place in which to relegate its own personal contradictions any more". The anti-institutional choice together with a social change, gave a chance therefore for the exoneration of science and the psychiatric profession. In this sense anyway Basaglia placed himself within the framework of psychiatry, distinguishing himself from the
radical critics who objected to it, positioning themselves outside of it and in opposition, from a historical-philosophical point of view such as Foucault, sociological such as Scheff and Goffman or phenomenological such as Laing and Cooper. Nevertheless the adhesive that held together the protests of criticism from within and without psychiatry was made up of a criticism of its
social function, that entered the sphere of the currents of antiauthoritarian and anticapitalistic thought that flowed into the melting pot of the movements in '68.

Nowadays little is left of the radical criticism of psychiatry of the sixties and seventies: its
contributions have been forgotten or are taken into consideration only as a curiosity of another period, at the most, an object for historical reconstruction. This oblivion is partly undeserved, due, up to a certain extent to the ostracism of the psychiatric establishment, but also brought about by objective reasons.

The sociological analysis of Goffman of the total institutions maintains its importance and The Divided Self by Laing is one of the most significant texts on the psychopathology of psychosis. Nevertheless the labeling theory of the sociologists turned out to be insufficient to capture the complexity of mental distress, while the phenomenological-existential approach of Laing and Cooper soon regressed towards a confused, superficial spiritualism, without any real significance for those who in practice, had dealings with mentally il people.

Above all, the criticism of psychiatry lost its foothold in the society, due to changes of the socio-cultural context, resulting in a decline in strong ideologies and the regression of those movements inspired by the political radicalism that had welcomed and supported anti-psychiatry.

Instead, from the beginning of the eighties, within the area of official psychiatry that seemed shaken and trapped in a corner by the attacks it received, great changes took place. The rallying of psychiatry was based on two aspects apparently in contradiction with each other: reductionism and expansion of the field of action. Reductionism materialized through the adoption of a diagnostic model of the categorial type imposed by DSM-III and by its successive branching out, based on the isolation of well-defined and separate diagnostic entities, each one in turn clearly defined from normality (that is absence of illness). In the area of this neo-kraepelinian model a reply was given to the criticism directed at the arbitrariness and the ambiguous significance of psychiatric diagnosis, establishing in DSM-III operational criteria for the definition of each diagnosis that corresponded to a detailed list of symptoms.
Psychiatric diagnosis, defined in this way, proved to be, unlike the old form of clinical diagnosis, sufficiently reliable, that is if two observers rigorously followed the criteria of DSM-III, they generally found themselves in agreement, applying the same diagnostic label to the same patient. The creators of DSM-III could proudly claim that psychiatric diagnosis had reached the same level of reliability as that of general medical diagnosis. Psychiatry had lost the uncomfortable characteristic of a borderline discipline and could present itself in accordance with the rules as a biomedical speciaity. DSM-III was a great and unexpected success, also on the editorial side, becoming a point of reference in the formation of psychiatrists the whole world over, in spite of transcultural problems deriving from its north-american origin. Despite its reductionist structure, the declared atheoretical background of DSM-III was useful for helping in its diffusion whatever the orientation of the psychiatrists using it. The categorial approach also favored the breaking up of the most extensive syndromes into a number of specific illnesses each one individually defined and potentially able to undergo treatment, making differential diagnosis an exercise requiring the untangling of long lists of symptoms. If making diagnosis legitimate was the first pillar of biomedical reductionism, expanding the use of pharmacological therapies was the
second.

First of all, research in pharmacology that had been dormant since the fifties, had an upswing thanks to the incentive of renewed investments by the pharmaceutical industry and led to the introduction on the market of new molecules in the sphere of the two main categories of psychotropic drugs: the antipsychotics and the antidepressants. These were presented as not only more effective than the old ones, but above all as safer and more acceptable for use, having less side effects.

The awareness, after decades, of real progress in the availability of drugs led to a renewed trust in psychiatrists for their therapeutic capabilities and reduced the feeling of inferiority
omnipresent in the category in respect to other medical specialties where innovations in treatment had followed one after the other at a fast speed during the last half of the century.

At the same time there was a change in the actual image of psychotropic drugs both in the commercial messages of the industry and in the attitude of the public. The introduction of innovative and modern methods of marketing shifted the portrayal of the drugs from a limited instrument of symptomatic control intended for a marginal minority of severely ill, incurable people to the royal road for improvement in the quality of life, well-being and, why not ?, complete recovery, adopting some of the characteristics of the smart drugs, above all in the case of the antidepressants. As mental disorders, from a biomedical point of view, were "illnesses like any other", the stigma associated with psychiatric therapies virtually began to fade and nobody had to feel ashamed at taking fluoxetine or olanzapine. An unexpected convergence took place between the commercial interests of industries, the diffusion of information that showed how mental disorders in the majority of cases were not treated, the need in terms of public health to facilitate the access to treatment, and the drive on behalf of everyone to share in the destigmatization of mental disorders. Even the downsizing of the large asylums for and the greater control by the law and public opinion of the authority given to psychiatrists was goodfor a renewed legitimacy of psychiatry, which then expanded its functions, acquiring a more technical and less custodial role, mitigating its obscure jargon and moving closer to the ordinary people.
The diffusion at mass level of psychiatric practices is testified by the exponential growth in all countries of prescriptions for psychotropic drugs, that covered groups of the population not previously involved, such as children and adolescents.

As what I have outlined has been the development of the last decades, being short and to the point I have had to ignore many subtleties, where are we now, more than forty years later after the essay of Basaglia mentioned in the beginning? In the last few years it has become more and more clear that psychiatry has expanded and grown like a giant with clay feet. The edifice of psychiatry, both as a discipline and as a profession, is tottering and appears to be undermined by a deadly illness growing inside it and fueled by the intrinsic contradictions generated by its own growth.

The following example shows one of the most resounding symptoms of this process: only a few months ago World Psychiatry, official journal of the world psychiatric association, played host to a heated debate opened by an article written by the Austrian psychiatrist Heinz Katschnig, with the eloquent title "Are psychiatrists endangered species ?". Katschnig, with the support of ample documentation, specified a number of challenges both internal and external to the psychiatric discipline that according to him, seriously called into question the existence of psychiatry as an independent profession. In the debate presented on the pages of the journal, psychiatrists of different orientation and geographical origin, in actual fact, refused this view, consequently in the end the president of the association Mario Maj concluded that the challenges mentioned by Katschnig were real, but the doubt he raised was exaggerated and the edifice of psychiatry seemed to him solid enough to resist, though needing a number of structural changes.

Nevertheless a close study of the whole matter leaves a very clear impression that Katschnig's questions had received only partial replies, ascribable more to a defense of position rather than careful reasonings. In any case the actual fact that a doubt of this importance had found a place on an official site, in itself assumes a significant meaning.
In reality the problem can be set in a more radical way than that of the Austrian psychiatrist, for the simple fact that the challenges of today are not aimed only at psychiatry as a profession but at the very conceptual foundations it's based upon and its operative instruments. With quite a significant difference regarding the strong disapproval of the sixties and seventies, what is put in doubt is not the social role of psychiatry or its repressive functions, even if these aspects maintain their importance, but its scientific status within the paradigm of medical science based on evidence. The union with the biomedical model that took place thirty years ago is turning out to be a kiss of death, in so far as it's the actual application of the most advanced methods of research particularly in the fields of epidemiology and clinical research, to psychiatric concepts and practices that highlights its fragility. The first critical aspect regards precisely the diagnosis, that is the framework created by DSM-III to guarantee the scientific correctness of the identification of the various syndromes as a base for the formulation of treatments. General population studies carried out in different parts of the world with epidemiologically correct methodologies have shown in the first place that the partitioning of mental disorders in specific diagnostic categories is false and doesn't reflect the distribution of the symptoms of psychological distress in the population, that are experienced along a continuum, resulting in an ample overlapping between categories, the difference between normality and illness becoming a problem of quantity that refers back to the choice of a threshold and not a problem of quality. In the second place, more surprisingly, it has emerged that psychopathological phenomena, such as hallucinations and thought disorders, believed to be indications of serious illnesses, can be present in sizeable subgroups of the general population, without necessarily being associated with a subjective distress or an impairment in social functioning. A simple clinical definition therefore, is not sufficient enough to explain the illness and even less the disability, whose development requires other contextual or subjective factors coming into play . The importance of subjective factors makes the role of the users and their knowledge emerge powerfully, fueling their demands to question the modality and the use of diagnostic procedure. The diagnostic categories of DSM-III are sufficiently reliable, but unfortunately have a limited validity that makes them of limited usefulness not only in planning a treatment or predicting the response to it, but also in the study of genetic risk factors or neurobiological variables.

The second aspect regards efficacy in the practice of pharmacological therapies and the continual expansion of their use. Recently, the realization of controlled clinical studies conducted with strict criteria and carried out on a vast number of representative samples, together with the publication of several summaries of all the information available from tens of studies, both large and small,l and carried out with accurate statistical methods, have opened the door to a critical reconsideration of the risks and benefits of pharmacological treatments in the two great diagnostic groupings of psychoses and mood disorders. Without going into the technical details of rather complex and not always easily comprehensible researches, conclusions of notable importance have emerged.

So far as antipsychotics are concerned, there is no difference in the efficacy between old
and new drugs, in spite of promises of the superiority of the former. As for side effects, in those who take the new drugs, conspicuous, disturbing and considerably unpleasant neurological symptoms are induced to a lesser degree, but they are associated with endocrinological and cardiovascular symptoms not always immediately evident over a short period, but responsible in the long term for considerable problems regarding physical health, with an increase in body weight and the risk of very serious, adverse outcomes such as diabetes, a heart attack or a stroke. On the whole the efficacy of antipsychotic drugs is well supported on positive symptoms, at least in the short term, but not on negative symptoms and it has therefore a relatively limited impact on the longitudinal course of an illness.

From a more general point of view the implications of research on antidepressants are
more important, in so far as they are prescribed for disorders that are much more widespread among the population compared to psychoses, so that the rise in prescriptions for psychotropic drugs was determined in large part by their use. It seems to be established that the efficacy of antidepressants is limited to the most serious forms of depression, that concern not more than 10% of the depressed individuals who gain access to treatment. In milder cases their effect is undistinguishable from that of a placebo. Moreover a group of North American researchers, taking advantage of a law that allows access to data coming from studies promoted by pharmaceutical companies but not yet made public, has made a comparison regarding various antidepressant drugs between published data and non published data and has verified that the latter gives an account of significantly lower efficacy. Lastly, for some groups of the population more involved in the rise in the number of prescriptions, such as children and adolescents, consistent doubts have been raised regarding the absolute necessity of their use in relationship to the risks.
If the results of research are compared to prescriptive practices and the diffusion of the use of the drugs by the population, it's clear to see how the increase in the last few years is justified only in part and how an indiscriminate use that doesn't take into account side effects has prevailed in spite of the indications of scientific evidence for a prudent, well aimed and contained use. The whole field of research and of psychopharmacological practice appears gravely undermined by conflicts of interest between academic psychiatry and industry, in a more relevant way than in other fields of medicine.
Official circles of psychiatry have generally acknowledged with embarrassment or made attempts to limit the importance of this information. In this regard, an episode that occurred in Italy is emblematic. One of the journals of the Italian Society of Psychiatry published a monographic issue dedicated to a thirty-year assessment of various fields of psychiatry, thirty years after the reform law of 1978. The pharmacologist Garattini, entrusted with giving a full picture of the developments in the psychopharmacological field, published an article in a considerably critical tone, sustaining that during these years psychopharmacology had produced very little of significance from the scientific point of view, that innovations had been dragged out more from needs of the market rather than by research and there had been on the part of prescription writing doctors an unreasonable shift of preference towards new and more expensive drugs without any advantage for the health of the patients. Finally, he hoped for a drive from the scientific community towards research for drugs with new mechanisms of action, instead of drugs more or less similar to those already available, that have given a false illusion of originality.

This article provoked a resentful and controversial reply, in the same journal, from a high profile exponent of Italian academic psychiatry, who accused Garattini of opposing the arid data of research with the problems of the daily treatment of patients, unfairly accusing psychiatrists of being in the pay of the pharmaceutical industries. A pharmacologist raising doubts about the use of drugs and a psychiatrist defending them at all costs: thirty years ago this debate would have occurred inverting the parts.

The case of psychotropic drugs is one of the aspects that regards the scarce adhesion of the psychiatric practice in general to the indications, conspicuously displayed on paper, of the guidelines based on the critical use of available evidence. The situation is even more serious as far as psychosocial interventions are concerned, unanimously recommended for different disorders,
such as, for example, family intervention in psychosis or brief forms of psychotherapy
in depression, that are offered to a very limited amount of users, even in countries like the United States that certainly don't suffer from a lack of resources. On the other hand, in cases where these interventions are offered by the health services, it's extremely doubtful that psychiatrists are capable of putting them into practice, seeing that their formation in recent years does not generally provide instruments in the vast area of psychotherapies and psychosocial rehabilitation, which appears to be entrusted more and more to other professional figures, from psychologists to social workers and various types of counselors and perhaps in the future, also to specially trained users. Psychiatric formation guarantees even less regarding the capabilities required to program, run and evaluate community services, which are now the area where 90% of mental health treatments are allocated. These problems appear even more relevant because the confrontation with organized users, which is more and more on the agenda in psychiatry, as moreover in other healthcare fields, puts many of the instruments of psychiatry in doubt and asks for replies that psychiatrists don't seem prepared to give.

In fact, if the formation of psychiatrists in substance covers diagnosis and pharmacology, the complete abolition of psychiatry gets to be on the agenda, as some begin to propose insistently, transforming it into "clinical neuroscience", a marginal and subordinate branch of neurology, incapable of explaining complex phenomena that sink their roots in the micro and macro contextual dimension. It remains to be seen how attractive a career with this connotation would be for doctors, seeing that there is already a worldwide crisis in the recruitment of young doctors for specialization in psychiatry.

Moreover it's clear that it would mean abandoning additional prospects exemplified by the biopsychosocial model (an increasingly empty word that many wouldn't even know how to
explain) and a fragmentation of the area of intervention in mental health, but it is extremely doubtful that psychiatrists, without a deep rethink of the present situation of their discipline and a decisive repositioning in the area of public health, can maintain a leadership in mental health services for long, if not in a formal and bureaucratic manner.

Because in the end, what is it that characterizes a professional field such as that of psychiatry (and here, after forty years we return to the question put by Basaglia): a set of qualifications, an identity within the health area and an institutional authority. If the first are reduced and the second becomes weaker, only the third area is left. At this point, we can recall the words of Antonin Artaud, repeatedly interned in French mental hospitals, in his striking Lettre aux médicins chefs des asiles des fous, written in far-off 1925. He urged alienists to recognize, regarding their own patients, "not having any other advantage than that of force". Force, that is the delegation by the state with of some forensic medical functions. Would this be enough to guarantee the survival of psychiatry? I don't think so and I would be really afraid of losing the bet that the title of this essay refers to, if someone asked me to gamble on it.

Bibliografia

1. Basaglia F (ed) Che cos'è la psichiatria ?, Einaudi, Torino, 1973.
2. Katschnig H Are psychiatrists endangered species ? Observations on internal and external challenger to the profession, World Psychiatry 9: 21-28, 2010.

 

 

 

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