Are psychiatrists an endangered species? Observations on internal and external challenges to the profession

In the 2009 edition of the New Oxford Textbook of Psychiatry, where the discipline presents itself impressively on more than 2000 pages, P. Pichot, Past President of the WPA and a long-time authority on the history of psychiatry, devotes the last few paragraphs of his chapter “History of psychiatry as a medical specialty” to the discussion of a potential crisis in psychiatry. Psychiatry, as he concludes, is threatened by either being incorporated in other medical specialties or being deprived of its medical character 1. In psychiatric journals, the question is being discussed whether and how psychiatry will “survive into the second half of the 21st century” 2, and the presence of “considerable pessimism and a sense of foreboding among psychiatrists” is being described 3. In many countries, a shortage of psychiatrists is reported 4–5. The question has even been asked whether psychiatry should “exist” 6. And we are being advised by our neurological colleagues to abandon the term “mental illness” and replace it by “brain illness” 7. What is behind such messages? Are they indicating only personal views or local problems? This is improbable. Why should the WPA have recently launched activities and projects on such topics as stigmatization of psychiatry and psychiatrists, furthering the choice of psychiatry as a career by medical students, and improving the prospect for early careers in psychiatry 8–9? So, 200 years after its birth 10, is there something wrong with psychiatry? And, if so, what is it? In order to shed some light on this issue, I have listened around, looked back on my own forty years as a psychiatrist and searched the literature for signs of a crisis, including the literature on professions in general. Psychiatry as a profession can be looked at with the eyes of the sociology of professions, which analyses the relationship of professions with society at large. In times of crisis, this can usefully supplement the inside views of the professions themselves, which tend to focus on the relationship between a profession and its clients, including the professional value systems defining this relationship 11. From the viewpoint of sociology, professions in general are characterized by: a) ownership of a specialized body of knowledge and skills, which defines the field of competence and the scope of potential clients, including the demarcation from other professions; b) holding a high status in society (both through financial and other rewards); c) being granted autonomy (and thereby power) by society, e.g. in recruiting and excluding members; d) being obliged, in return for the above, to guarantee high quality standards in providing services (being “professional”) and following ethical rules 12–13. I will discuss here six challenges which are related to the first two of the above criteria: three challenges “from inside”, basically referring to the decreasing confidence about the knowledge base of psychiatry and to the lack of a coherent theoretical basis; and three “from out-side”, including client discontent, competition from other professions, and the negative image of psychiatry. There are certainly other challenges — such as increasing state and insurance interventions, asking for improved quality of care despite growing restrictions — but they mostly concern medicine as a whole and will not be discussed here. Disease categories and their classification are the pervasive organizing principle for most aspects of medicine, including psychiatry as a medical specialty. Diagnoses are meant to be used for making therapeutic decisions, for teaching purposes, for reimbursement, for defining patient populations for research, and for statistical returns. In psychiatry we have the confusing situation of two different internationally used diagnostic systems. In any member state of the World Health Organization (WHO), on discharge of a patient from hospital, a diagnosis from chapter V of the International Classification of Diseases (ICD-10) must be selected. However, for psychiatric research to be published in a high impact factor journal, it is advisable to use the Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association (APA). The parallelism of these two major diagnostic systems exists since nearly 60 years. In 1949, the sixth revision of the International Classification of Diseases (ICD-6, 14) included for the first time mental disorders (earlier versions covered only mortality). Three years later, the APA launched its own classification system (DSM-I, 15). We have now arrived at ICD-10 (1992) and DSM-IV (1994), and the next revisions of the “big two” are due in a few years (DSM-V in 2013; ICD-11 in 2014). There will thus be still two systems in parallel. Such parallelism is possible because of the very nature of the definitions of most psychiatric diagnoses: they consist of combinations of phenomenological criteria, such as signs and symptoms and their course over time, combined by expert committees in variable ways into categories of mental disorders, which have been defined and redefined again and again over the last half century. The majority of these diagnostic categories are not validated by biological criteria, as most medical diseases are; however, although they are called “disorders”, they look like medical diagnoses and pretend to represent medical diseases. In fact, they are embedded in top-down classifications, comparable to the early botanic classifications of plants in the 17th and 18th centuries, when experts decided a priori about which classification criterion to use, for instance, whether fruiting bodies or the shape of leaves were the essential criterion for classifying plants 16. The DSM-III approach of creating “operational definitions” (e.g., “2 out of 5 symptoms” of a list must be present) has certainly rendered the process of arriving at a diagnosis more reliable, in the sense that we can be more sure that, if different psychiatrists assess a patient diagnostically, they will, after evaluating symptoms and other criteria, come more often to the same result. But reliability is different from validity. Psychopathological phenomena certainly exist and can be observed and experienced as such. However, psychiatric diagnoses are arbitrarily defined and do not exist in the same sense as psychopathological phenomena do. This is not new. However, whereas psychiatric diagnostic classification systems and disease definitions have long been criticized, the character of the attacks has changed. Half a century ago, they came mainly from outside psychiatry (e.g., 17–18). Today, while these assaults continue 19, discussions about the validity of psychiatric diagnoses are also getting momentum within our profession (certainly fuelled by the imminent revisions of the “big two”) 20–21. It is no longer just the “usual suspects” who criticize psychiatric diagnosis and classification systems; the discussion has arrived at the heart of our profession. For instance, psychiatrists talk about the “genetic deconstruction of psychosis” 22, the lack of validity of psychiatric diagnoses despite their utility 23, and the poor diagnostic stability of psychiatric disorders 24. From psychiatric geneticists one hears that they have to use “star war technology on bow and arrow diagnosis”. Recently, a prominent psychiatric researcher commented: “It has been suggested that the debate is political. This is not the case however, as solid scientific evidence pointing to the absence of nosological validity of diagnostic categories that nevertheless invariably are subject to paradoxical psychiatric reification, lies at the heart of the argument” 25. The sociologist A. Abbott has observed that the control that professions have over their body of knowledge allows them to seize new problems and redefine their scope of interest 26. With this perspective in mind, it can be argued that, while some psychiatric disorders have some kind of “clinical validity” (e.g., bipolar disorder), the DSM has “fabricated non-validated psychiatric diagnoses out of the general human predicament” 27. Psychiatry “abandoned the island of psychiatric disease and was thus engulfed in the boundless sea of human troubles”, as F. Redlich has put it more than 50 years ago when referring to psychoanalysis (28, quoted in 17). The issue whether we are able to “differentiate between true mental disorders and homeostatic reactions to adverse life events” 29 is more pressing than ever. All kinds of rescue efforts are under way in relation to these threats to the diagnostic knowledge base of psychiatry, and a plethora of suggestions are being made: to identify “metastructures” 30, to supplement diagnostic categories with dimensional measures 21 or a “cross-diagnostic approach” 31, to use “epistemic iteration” 16, or to provide a “person-centered integrative diagnosis” 32. Recently, a group of psychiatrists has asked for the establishment of a conceptual working group for DSM-V, pointing out that in past DSM revisions conceptual questions were considered only on an ad-hoc basis by individual workgroups and the task force 33. Eve rything seems open. It has also been proposed to put more emphasis on the clinical utility of diagnosis, such as ease of usage, communication, and treatment planning 34. However, in clinical practice, the selection of medication is only vaguely related to diagnosis (e.g., antidepressants are used across a wide range of conditions) 35, and in community mental health services, diagnoses are mainly used for channelling resources, and different classifications are employed for dealing with clients in everyday work 36. The threatening bottom line of these discussions is that, if our diagnostic categories have not been valid until now, then research of any type – epidemiological, etiological, pathogenetic, therapeutic, biological, psychological or social — if carried out with these diagnoses as inclusion criterion, is equally invalid. We are living in the era of evidence-based medicine 37. Based on meta-analyses and systematic reviews of carefully selected methodologically sound studies, guidelines for practice are prepared and become prescriptive — we can no longer accept clinical experience alone. But how sure can we really be of our treatment decisions? When in 2008 a meta-analysis of antidepressant medication studies was published 38, with the main message that in mild and moderate depression antidepressants are no better than placebo, the result went around the world immediately — the special “kick” for the media being that the authors had included in their meta-analysis also those studies which had not been published (but submitted to the US Food and Drug Administration). A related study corroborated these findings 39, leading to some discussion within psychiatry 40. The fact that trials with positive findings are published more often and more quickly than those with negative findings has become a serious concern not only in psychiatry, but in the whole field of medicine 41. In a different development, the randomized controlled drug trials in schizophrenia had been criticized for their limitations, and “pragmatic” or “real world” trials had been proposed 42. When such real world pragmatic trials were carried out, the superiority of the second over the first generation antipsychotics could not be reproduced 43–44. It is evident that such results increase uncertainty, even more because — the lack of validity of psychiatric diagnoses and the in of — they do not that the studies were wrong and the new are When to evidence-based guidelines for clinical practice, we an in the of randomized controlled for validity to selected that the results be to the real while for a high of the study It has been suggested in this to have two of the evidence of of studies, and evidence the of results into the real world A related issue is that and combinations of are in clinical practice whereas most evidence is only for In to these the of interest from the relationship between and 50 are creating has recently as a issue, in the scientific community as as in the media and from we about and their our and the must about the of the that our professional work three psychiatrists and I have this in many from and health as an for I to them to psychiatric care and increase and are not in medicine, but do many different as in psychiatry. 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