Questions regarding bio/neuro, medication and causality

[w1116]

Hello.

I am potentially interested in a career change to psychiatry but before I go any further with such a large decision I feel I need to be in agreement philosophically. The main topics I am interested in now is with regards to medication, as well as the relationship between biology/neurology and mental illness.

More specifically, I am interested in the following items, and hope you folks could point me in the right direction to books or journal articles.

1) What are some examples of proposed causal relationships between biology/neurology and mental illness (eg gene expression may lead to schizophrenia)

2) What are some proposed causal relationships between medications that are meant to treat mental illness and the mental illness themselves (eg Haldol can apparently cure psychosis).

3) How do pharmaceutical companies conduct research into new medications? Generally speaking, can we trust this research?

I recognize these are very very broad questions but they are the main ones I'm looking to get answered, considering that psychiatry is now heavily focused on the biological and neurological side of the human. As stated above, I need to be philosophically "on board" before I go further with any future decisions regarding my career.

As a side note, based on my current readings of the field of psychiatry, my main worry is an epistemological one. It seems to be the case that we don't know enough about why and how mental illness is caused, nor do we know exactly as to why certain drugs cure certain mental illnesses, yet we prescribe anyway because, statistically speaking, certain drugs do cure certain mental illness. Please correct me if I'm out of line here, but this is how I currently view the field of psychiatry and I must admit it is slightly scary. Again, I'm extremely new to the field in general so please pardon my ignorance.

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[MacDonaldTriad]

Hello.

It seems to be the case that we don't know enough about why and how mental illness is caused, nor do we know exactly as to why certain drugs cure certain mental illnesses, yet we prescribe anyway because, statistically speaking, certain drugs do cure certain mental illness.

This. "Cures" are almost unheard of. You should use the words treat, help, or control. Serendipity explains a lot of our progress, but that doesn't mean our field isn't fascinating. Required skills are a combination of inherent interpersonal abilities, and teachable techniques. If you have any discomfort with ambiguity, this isn't for you. (Or you can just read Dr. Stahl's book.)

 

[Shikima]

Just remember, the medications are only a splint. They work as long as you take them. Same goes for any other medications treating chronic diseases.

 

[splik]

More specifically, I am interested in the following items, and hope you folks could point me in the right direction to books or journal articles.

1) What are some examples of proposed causal relationships between biology/neurology and mental illness (eg gene expression may lead to schizophrenia)

2) What are some proposed causal relationships between medications that are meant to treat mental illness and the mental illness themselves (eg Haldol can apparently cure psychosis).

3) How do pharmaceutical companies conduct research into new medications? Generally speaking, can we trust this research?
.

1. gene expression does not lead to schizophrenia. There are no "genes for" mental illness. This is partly because there is no such thing in biology as "schizophrenia" (Kraepelin, who described dementia praecox cut nature at the joints to create this illness construct), and partly because mental disorders appear to be complex genetic disorders that are the developmental endpoint of genetic, environmental and stochastical factors. This is similar to most chronic diseases, except that mental disorders aren't diseases.

2. The relationship between medications and mental disorders is one of backward logic. For example the interest in the now largely discredited monoamine hypothesis of mental disorders (that posited that changes in monoamine neurotransmitters like serotonin, noradrenaline, and dopamine were responsible for depression, mania, and psychosis etc) came from a rudimentary understanding of the mechanisms of the drugs that were being used to treat these mental states rather than the other way around. The British psychiatrist Joanna Moncrieff argues that we have a "drug centered model" understanding mental illness rather than a "disease centered model". She actually goes further and argues that antidepressants were not developed to treat depression, but depression was created to market antidepressants. It seems an astounding claim but there is some truth to it! When Elavil (amitriptyline) came on the scene, Merck wanted it to be prescribed in primary care and they tried to convince people there was a condition called "depression" (that doctors hadn't really heard of) and really had to convince physicians there was an outpatient illness called "depression" that was not being recognized in their patients! Up until that time, melancholia, a very severe form of depression was treated by psychiatrists in the inpatient setting. Neurotic and nervous states were known to exist and the wealthy may have sought treatment, but it would not have been called "depression". Even terms such as "antidepressant", "antipsychotic" and "mood stabilizer" are marketing rather than medical terms though they have come rather perniciously to be used in this way.

3. I am not going to answer the first part this question because you can do your own homework. We have to take drug company statements with a grain of salt, but that usually means don't believe the written text, and look at the numbers. Usually the numbers don't lie (though studies have been buried in the past which is now all prospective clinical studies have to be registered and statistical analyses can sometimes massage figures) and you can work out for yourself whether someone is spinning a story. But the publications are damning enough. People will usually independently review the industry sponsored studies and there may be systematic reviews of the evidence or independent studies which we do have for antidepressants, antipsychotics, stimulants and so on. The drug pipeline for psychotropic drugs has been pretty dead, we've had no major advances since the 1950s really.

I'm not sure what you mean by career switch into psychiatry. You are clearly not in the medical field thus would have to do premed requirements and apply for medical school in the first instance if you want to do psychiatry.

 

[Jorje286]

Hello.

I am potentially interested in a career change to psychiatry but before I go any further with such a large decision I feel I need to be in agreement philosophically. The main topics I am interested in now is with regards to medication, as well as the relationship between biology/neurology and mental illness.

More specifically, I am interested in the following items, and hope you folks could point me in the right direction to books or journal articles.

1) What are some examples of proposed causal relationships between biology/neurology and mental illness (eg gene expression may lead to schizophrenia)

At the moment we are still at the stage of suggestions, one example is the glutamatergic theory of schizophrenia. Here's a nice and simple read: http://doctorsonly.co.il/wp-content/uploads/2011/12/2010_1_2.pdf

 

[thoffen]

First, Splik is being his hyperbolic self and should be ignored. A general distillation of his point should be that biological psychiatry is in its infancy and cannot be universally applied. We have no concrete pathologic understanding of mental illnesses that applies universally. Thus, they are "disorders" (based only on clinical description) not "diseases" (based on biologic description). That being said, many advances in psychiatry have been birthed from working backwards from known treatment to mechanism that have enhanced our understanding of a subset of individuals who meet criteria for a particular mental illness. In some cases, a very large subset. To answer your questions more honestly below:

1) What are some examples of proposed causal relationships between biology/neurology and mental illness (eg gene expression may lead to schizophrenia)

Many genetic associations have been found for some schizophrenias and bipolar disorders, as well as environmental factors, although none individually provides a very significant understanding of them, and to date no genetic underpinnings have lead to a significant advance in treatment. There are other studies investigating inflammation in depression and schizophrenia. There are many drugs being developed targeting specific neurotransmitter receptor subtypes with animal models suggesting targets for specific types of symptoms (e.g. cognitive symptoms in schizophrenia).

2) What are some proposed causal relationships between medications that are meant to treat mental illness and the mental illness themselves (eg Haldol can apparently cure psychosis).

Haldol can't cure psychosis. Haldol can treat psychosis. Haldol's principle mechanism of action is antagonism at the D2 subtype of Dopamine receptor. The main underlying proposed mechanism of schizophrenia developed from this is that dopamine excess in the mesolimbic pathway leads to positive symptoms of psychosis (e.g. hallucinations, delusions). There are other pathways effected, other receptors with models implicated in at least parts of or subsets of schizophrenia. Unfortunately, these models have been reverse engineered from the actions of drugs which were accidentally discovered to treat the condition; either that or psychoactive substances which are shown to induce analogous symptoms. The models seem valid, but only partially so. From these models, people have done things like knock out genes with mice to study new treatment targets on them. Nothing much has come from that, at least in our clinical library these days.

3) How do pharmaceutical companies conduct research into new medications? Generally speaking, can we trust this research?

Learning how to critical evaluate the available literature is an important skill in any medical field. Of course you can't universally trust the research, but that doesn't mean that it's bad research or their methods are invalid. They are just designed to increase the likelihood of producing the results they want. And unfortunately it's often the best or only clinical evidence we have.

To summarize:
1. Biological research into mental illness is very active, but at this time has not been able to reliably translate into clinical treatment
2. Lots of valid but incomplete models have been developed based on drug actions, but at this time have not been able to reliably translate into clinical treatment
3. Drug companies want to sell drugs. But if they didn't, then we wouldn't have drugs to treat illness

 

[w1116]

Thank you all very much for the in-depth replies. Splik, you're fine in my book, though I rolled my eyes at your last comment. I am aware of what it takes to become a psychiatrist, and I'm not sure what term I would use besides "career change". Regardless!

I will say this much: I don't know how many of you folks here follow academic psychiatry (assuming that's the correct term...perhaps metapsychiatry is more appropriate) but it's extremely fascinating. More specifically, I'm going through Ghaemi's The Rise and Fall of the Biopsychosocial Model and McHugh's Perspectives of Psychiatry. There seems to be a fair amount of turmoil in the profession with regards to how to press forward and make progress. Is this indeed the case? Given that I'm not in the profession I'm not sure how objective these books are, though Perspectives obviously has less of an agenda than The Rise and Fall.

Hey, at least I'm not reading Szasz or Laing yet

 

[w1116]

why not? All psychiatrists should read Szasz and Laing

I suppose I meant that comment to be sarcastic more than anything else. Considering my extremely limited knowledge of the field and considering the views of those two, I think I better save them until I get a better feel for how psychiatry is currently operating.

 

[OldPsychDoc]

I suppose I meant that comment to be sarcastic more than anything else. Considering my extremely limited knowledge of the field and considering the views of those two, I think I better save them until I get a better feel for how psychiatry is currently operating.

I wouldn't take Ghaemi or McHugh as a barometer of how "psychiatry is currently operating" either.
Academic philosophical debates have very little to do with our patient care or day to day practice.

 

[w1116]

I wouldn't take Ghaemi or McHugh as a barometer of how "psychiatry is currently operating" either.
Academic philosophical debates have very little to do with our patient care or day to day practice.

Thank you, and definitely noted. Un fortunately I am out of ideas as to how to get a taste of the profession. Other than reading these various books and volunteering (I've been at a suicide hotline), how do I get a taste of psychiatry? It seems nigh impossible to shadow a psychiatrist without already being in med schools.

 

[clausewitz2]

Thank you, and definitely noted. Un fortunately I am out of ideas as to how to get a taste of the profession. Other than reading these various books and volunteering (I've been at a suicide hotline), how do I get a taste of psychiatry? It seems nigh impossible to shadow a psychiatrist without already being in med schools.

Not saying it's necessarily something you should do, but you could always get a job as a mental health associate. Usually they will hire anyone with a pulse and no criminal record and it would at least expose you to some of the patient population.

 

[OldPsychDoc]

Thank you, and definitely noted. Un fortunately I am out of ideas as to how to get a taste of the profession. Other than reading these various books and volunteering (I've been at a suicide hotline), how do I get a taste of psychiatry? It seems nigh impossible to shadow a psychiatrist without already being in med schools.

This is probably the closest to "explaining psychiatry to an educated lay person", imho. At least I thought it was more realistic about the day to day stuff. Written by three Johns Hopkins residency alums.
Shrink Rap: Three Psychiatrists Explain Their Work