Are psychiatrists an endangered species?

It may be true that psychiatrists are becoming an endangered species, as stated in H. Katschnig's paper introducing the Forum of this issue of the journal 1. What we must do is to catch the essence of the problem and turn the possible risk into an opportunity for growth. There are indeed different theoretical orientations in psychiatry, but this should be viewed as an unavoidable reflection of the biopsycho-social complexity of mental disorders, which requires an equally complex biopsycho-social approach. Other neighbouring professions may have a clearer identity and appear less divided than we are, but one of the reasons for this is that their vision and approach are more unilateral, thus being not sufficient to address the biopsycho-social complexity of mental disorders. The existence of a biological, a psychological and a social component in our discipline is not a weakness, but an evidence of its peculiar integrative nature, and should be perceived, presented and promoted as such. Rather than denigrating and fighting each other, the proponents of the different approaches should look for synergy and cross-fertilization. Dialectics is welcome, but destructive fanaticism should be actively discouraged (rather than applauded, as unfortunately is often the case). There is indeed a continuing debate in psychiatry on what is a disorder, on the relationship between disease and functional impairment, on the role of values vs. evidence in the diagnostic process 2–6. I am not convinced, however, that this discussion is just a sign of the weakness of the theoretical foundation of our discipline. If I were an internist, I would follow this debate with great interest. Psychiatry may be just forerunning a discussion which in the future will involve medicine as a whole. It is true that diagnostic criteria for mental disorders change from time to time, and that we have two competing diagnostic systems. But, is this really shacking the foundations of our clinical practice? I do not think so. I do not believe that clinicians are currently disoriented about what is schizophrenia or depression, or that they are eagerly waiting for the new edition of the two diagnostic systems in order to learn what they are. The main diagnostic concepts in psychiatry have shown a remarkable stability over the decades: considering that they are just “arbitrary conventions”, they have done remarkably well (and many thousands of patients have benefitted from their delineation). This does not mean, of course, that these concepts should not be refined, and many clinicians will certainly welcome future opportunities to make their diagnostic assessment more articulated and personalized 7–9, and will be pleased to witness that “renaissance of psychopathology” which has been repeatedly invoked in recent years 10–11. There is indeed an ongoing discussion about the effectiveness of antipsychotics and antidepressants 12. It is very unfortunate that this debate is being so heavily influenced by financial and non-financial conflicts of interests (on the one hand, by the financial relationships of some researchers to drug companies; on the other, by the ideological prejudice, sometimes bordering to fanaticism, of several people outside and within our profession). But it would be foolish to even contemplate the idea that antipsychotics and anti-depressants do not work, that they are just a placebo. The empirical foundation of their use is very solid, and this use has stood the test of time, in an environment which was completely unfavourable. They have changed and will change to the better many thousands of lives. Of course, if used properly, as well-trained specialists in psychiatry are able to do. We have to create, however, a mechanism ensuring that, for each newly introduced antipsychotic or antidepressant, at least one trial be conducted by an entity which is independent from the company producing the drug. Yes, we psychiatrists are stigmatized, mainly due to our past professional image. What we have to do is to refine our new image and promote it. Many of us treat competently a broad range of mental disorders which are very common in the population. We provide our counseling in prisons, in the workplace, in schools. We are asked by colleagues of other medical disciplines to provide our advice for the emotional problems of their patients. We interact on a continuing basis with user and carer organizations. This new reality of our profession is not well known, and probably not sufficiently developed in several regions of the world. We have to build up this new image and make it public. At the same time, we have to ensure that psychiatric practice worldwide match up to this new image 13–16. I like H. Katschnig's paper, but I do not share its underlying pessimism. If psychiatry is in a crisis, this is, in my opinion, a development crisis. Our future is in our hands, more than in those of our clients or of politicians. Let's stop blaming ourselves and struggling with each other, and let's work together to upgrade the reality and the image of our profession.