the future of psychiatry?

[Manicsleep]

double post.

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[Manicsleep]

Manic sleep - My posting was to convey that most advances in health generally and the global lessoning in the burden of disease in the last 150 years are due to better sanitation and better nutrition. With respect that point is beyond all doubt. Technology has played a minor role by comparison.

I understand what you are trying to say with the sanitation point. My point is that this is about the future and not the past.
Just because we understand germ theory doesn't mean cleanliness will solve everything. They certainly have little to do with DM and Cancer. The top killers of today and tomorrow are will not be solved because of sanitation.

Pakota's idea that bio, bio, bio is not the answer is only partially correct. Because it is a big part of the answer. The more we understand the more we can do with the biological aspect of psychiatry. Humans are 100% bio. If we can understand the psychosocial in a bio context then so what. The problem is that you are equating what people are doing today to what will happen tomorrow.

I think it is absurd not to embrace what is happening. That does not mean doing SPECT scans for 3000 dollars as part of some crazy visit to solve all your problems (i will mention no names of psychiatrists who may work at UCI) but being realistic. It just means that doing the best based on the evidence based medicine but understanding that the technology is advancing rapidly and it will be integrated. The mind is the last frontier but it will be conquered. That doesn't mean instant, overnight cures for anyone but eventual cures are absolutely in sight.

 

[HMSPSYCH]

I hope I’m not the only one that finds these posts nauseating, particularly the last one...classic argumentum ad hominem.

Frankly, it's frightening that a mental health professional would attempt to undermine an argument by attacking the speaker instead of addressing the argument, and evermore so when doing so by questioning the speaker's mental health.

Reviewed all the posts and I'm with the others. Sounds like the pot calling the kettle black here.

It is more frightening and shocking reading what you and Ibid have written.

 

[HMSPSYCH]

Ibid's post is absurd. He feels that most medical treatment is only due to sanitation and an improved diet? By that absurd logic, if your child gets diabetes or cancer or any number of genetic diseases that have nothing to do with diet or sanitation, you will clean them and give them fruits and vegetables?

Do you even remember what was routinely available for scanning the brain in 1990? How many people got MRIs in 1990? Even CT technology has advanced greatly. Can you imagine a world without spiral CT?

You will be saying the same thing in 20 years about gene therapy, nanomachines and organ transplant/cell transplant. Schizophrenia may be a syndrome, a lot of diseases that present similarly or perhaps a lot of disease states that cause similar damage to the brain. You can treat the underlying cause or the damage but hiding in the corner and closing your eyes wont do anyone any good. It is very likely that the mind is that last thing to be treated but before that we will see real cures for the body, then the brain and then the mind.

The idea that imaging is ONLY for predicting outcomes is not true. It will be for targeting. Gene therapy is progressing at an amazing rate. They are already growing cells, organs and nanomachines. Gene therapy has been use to "cure" mice of diabetes. These things are still in their infancy but give it a decade or 2.

 

[Ibid]

Manicsleep

I do understand what you are saying.

My point is that this is about the*futureand not the past

I on the other hand am simply using the past as a general guide and positing that it potentially tells us something useful about the likely future.

Pakota's idea that bio, bio, bio is not the answer is only partially correct. Because it is a big part of the answer. The more we understand the more we can do with the biological aspect of psychiatry. Humans are 100% bio. If we can understand the psychosocial in a bio context then so what.

What you have posted above (apologies for the italics, I’ve not got the hang of multi quoting) contains the knub of our differing opinions, I think….

Of course I’m not suggesting we are not 100% bio and for the time being I’m setting aside spiritual questions so as not to muddy the water. How ever just stating that we are all 100% bio does not move us much further along. In the specific context of mental distress it doesn’t differentiate between mental distress with an environmental determinate and those with out. I’m sure you are familiar with this theory http://www.imperial.ac.uk/college.asp?P=7349
I’m sure you understand I’m not supporting that theory, just illustrating a point. Again with genetics as a possible bio bio bio explaination for all kinds of things, for instance child abuse runs in families but it doesn’t mean that the propensity to child abuse has a large genetic component. That would be to muddle up correlation with causation. There are other examples that, forgive me, escape me at the moment that would have appeared to have a large genetic component until the correct environmental causation was found.

After that slight diversion what is really at the heart of the difference between us is a difference of emphasis. I am positing that the biology of human distress needs to understood with in its social context and a persons biographical history. Of course you will say this has always been the case but to me it’s the matter of emphasis that is critical. Above you just say so what? That I believe misses the point because as I have said I believe it is critical.

I appreciate your clarification. Thank you.

 

[Manicsleep]

After that slight diversion what is really at the heart of the difference between us is a difference of emphasis. I am positing that the biology of human distress needs to understood with in its social context and a persons biographical history. Of course you will say this has always been the case but to me it’s the matter of emphasis that is critical. Above you just say so what? That I believe misses the point because as I have said I believe it is critical.

I appreciate your clarification. Thank you.

I agree that there needs to be integration and in todays world attention should be given to biological, psychological and social. As psychiatrists that is our job and it is what we are trained to do better than anyone else. But the final goal is only the cure and nothing more.

As far as human distress being understood in the social context and biographical history, I think thats great. For example if you have a patient with cancer who is elderly, perhaps they can't live by self for a while after having curative surgery and family must be involved or they need a SNF etc. But if its a healthy person, youre cutting out a skin lesion...they dont need anything else other than a follow up on the cancer.

Lets say a blood test for diagnosing schizophrenia is developed with excellent sensitivity and specificity. With it a 100% effective cure is developed as well. Are you really going to sit around and try to incorporate psychosocial aspects of treatment in someone who has not had symptom onset yet or would you cure them and let them go on their merry way?

At that point I would place very little emphasis on the person's psychosocial situation or biographical history unless there was some other reason for it. The problem with your statement is that you are same with the people who see bio as the only way to go.

We have a skillset and we should use the skills that are the most appropriate. To place emphasis on certain skills is wrong, plain wrong. In today's world you are right but your ideas will be incorrect at some time in the not so distant future. Perhaps you have a spiritual aspect that is coloring your views (you have hinted at it) or you can't see a place where cures are possible. Whatever the case, when the time comes for biolgical cures, the psychosocial will be secondary at best while in other arenas, the psychosocial will be more important. So what if one trumps the other as long as the patient is treated optimally?

 

[Ibid]

Manicsleep

Thank you for your answer. I will try and clarify my position. I have put your words in italics as I have not got the hang of the multi-quote function.

I agree that there needs to be integration and in todays world attention should be given to biological, psychological and social. As psychiatrists that is our job and it is what we are trained to do better than anyone else. But the final goal is only the cure and nothing more.

Forgive me but psychiatrists are educated and absorb an abstract body of knowledge. Training is what plumbers do.

As far as human distress being understood in the social context and biographical history, I think thats great. For example if you have a patient with cancer who is elderly, perhaps they can't live by self for a while after having curative surgery and family must be involved or they need a SNF etc. But if its a healthy person, youre cutting out a skin lesion...they dont need anything else other than a follow up on the cancer.

The analogy you present I accept as far as it goes but I am suggesting that all of what is described as mental illness is best understood as human distress which takes place in a social and biographical context,not as a disease. This being the critical difference between psychiatry and the rest of medicine.

Lets say a blood test for diagnosing schizophrenia is developed with excellent sensitivity and specificity. With it a 100% effective cure is developed as well. Are you really going to sit around and try to incorporate psychosocial aspects of treatment in someone who has not had symptom onset yet or would you cure them and let them go on their merry way?

I’ll indulge the prospect as this is about the future. To answer with an illustration. What if the person who took the test is a forth generation shaman living in central Africa, who has a valued role in their community because of their perceived ability to communicate with the spirit world. Are you going to take that away from them? Granted an extreme example but so is yours.

Why a blood test? Why not posit a genetic test? What will you do now, especially with all the people you identify as homozygous recessive? Are you going to cure them as well? Would this notional blood test work for say post natal depression?


At that point I would place very little emphasis on the person's psychosocial situation or biographical history unless there was some other reason for it. The problem with your statement is that you are same with the people who see bio as the only way to go.

I am sorry I thought I made it clear I am suggesting a change of emphasis not recommending throwing the baby out with the bath water.

We have a skillset and we should use the skills that are the most appropriate. To place emphasis on certain skills is wrong, plain wrong. In today's world you are right but your ideas will be incorrect at some time in the not so distant future.

Thank you. I will happily change my mind if new evidence comes to light.

The trouble with what I call a jam tomorrow approach is that it has negative consequences today ust as it has in the past. For the sake of a hypothesis that may or may not be right(in Scottish law the verdict would be unproven) it lumbers the very same people one desires to help with the notion that they have something biologically wrong with them that needs to be put right. I am sure you can see how this is distorted in to the prejudice and stigma that people who experience mental distress experience all the time and in quite a different way to people with cancer or skin lesions. This is a point that imo traditional psychiatry fails to address. Its is an epistemological certainty in the biological paradigm that pushes these the unintended consequences of the biological approach into the back ground as its easier to ignore the irrefutable rather than be honest and face it head on.

Perhaps you have a spiritual aspect that is colouring your views (you have hinted at it) or you can't see a place where cures are possible.

Infact I was trying to eliminate spirituality temporarily from the discussion because it tends to obscure things in this sort of conversation as we are quite far from a common understanding.

I think I am as capable as any one at separating a personal view from an objective analysis of any issue that is to hand. Although I am not so arrogant as to assume that somehow the evolutionary pressure that has led to our human predisposition for spirituality is something I have somehow managed to ellude by want of some freak of nature. I am sure you don’t either, unless of course you are claiming to be one of Nietzsches Ubermensch. How ever plenty of people do want their experiences to be understood in the context of a spiritual experience and that is huge challenge for traditional psychiatry.

For arguments sake, if you found the gene for spirituality would you recommend drug therapy or psychosurgery or gene replacement therapy for that matter? That would be consistent with the line you are taking.

I would say that no one is immune from taking account of their personal experiences. Is that not what clinical experience is all about, the very thing that allows a deviation from evidence based medicine when it seem appropriate?

Consider for a moment Schrödinger’s cat, waiting in its box for a gun to go off as a radio active isotope decays. I assume you are familiar with this thought experiment. The variation where one considers ones self to be in the position of the cat with a magnificent human brain is instructive regarding the dangers of epistemological certainty.

Btw it’s interesting that nuclear physicists as a breed tend to be rather open minded and comfortable with ambiguity, rather like the best psychiatrists.

Whatever the case, when the time comes for biological cures, the psychosocial will be secondary at best while in other arenas, the psychosocial will be more important. So what if one trumps the other as long as the patient is treated optimally?

The difference between us is that I am hopeful that ways of ameliorating human distress will continue to be refined and I am suggesting that the best way to do that is to disinvest in the lanquage of pathology and the fruitless quest for biological markers that don't exist. You are suggesting the equivalent of searching for a safe way to eliminate people with the autosomal recessive trait that leads to hitchhikers thumb when you don’t yet and can not yet know, what the future utility of that trait might be.
Sure, science can set you free but it can also bind you in ways you didn’t expect.

To make myself clear I am not denying psychosis or trying to romanticise it but I am posting a different paradigm that I believe will continue to bear fruit.

Thanks for the response; as you are as intellectually wedded to your position as I am to mine, I can only wish you well. Sticking to the one partner has many benefits I am sure. May your bio bio bio lover serve you well and if they turn out to have a much more attractive sibling, no fault divorce is rather common these days I understand.

In the mean time I look forward in a few years time to the publication of your magnus opus and if instead it ends not with some pious notion about further investigation leading to the betterment of mankind, but with the phrase quad erat demonstrandum I will salute you.

 

[Manicsleep]

Ibid what are you exactly? I am not sure you have an understanding of psychiatry or medicine in general.

I agree that there needs to be integration and in todays world attention should be given to biological, psychological and social. As psychiatrists that is our job and it is what we are trained to do better than anyone else. But the final goal is only the cure and nothing more.

Forgive me but psychiatrists are educated and absorb an abstract body of knowledge. Training is what plumbers do.

That must be why residency programs are also known as training programs and why physicians refer to their residencies as "where I trained."

The analogy you present I accept as far as it goes but I am suggesting that all of what is described as mental illness is best understood as human distress which takes place in a social and biographical context,not as a disease. This being the critical difference between psychiatry and the rest of medicine.

Not true. Schizophrenia is not simple human distress distress, delirium and dementia is not simply distress, mania is not just distress. Mood disorders, psychotic disorders, sleep disorders, dementias and deliriums can occur with relatively little 'social and biographical' context. These are disease states as much as cardiovascular disease is a disease state.

You are wrong.

Lets say a blood test for diagnosing schizophrenia is developed with excellent sensitivity and specificity. With it a 100% effective cure is developed as well. Are you really going to sit around and try to incorporate psychosocial aspects of treatment in someone who has not had symptom onset yet or would you cure them and let them go on their merry way?

I’ll indulge the prospect as this is about the future. To answer with an illustration. What if the person who took the test is a forth generation shaman living in central Africa, who has a valued role in their community because of their perceived ability to communicate with the spirit world. Are you going to take that away from them? Granted an extreme example but so is yours.

Why a blood test? Why not posit a genetic test? What will you do now, especially with all the people you identify as homozygous recessive? Are you going to cure them as well? Would this notional blood test work for say post natal depression?

Your first example makes no sense. Does this shaman have a disease? Are you implying that they are schizophrenic?

As far as blood test vs a genetic test. You understand that blood contains genetic information or no? But either way is fine we do genetic testing for many things already. As far as homozygous recessive, I dont understand what you are trying to say (not sure that you do either). What does that mean as far as disease penetrance?

A blood test COULD be developed for anything in theory. A test for schizophrenia would not work for post partum depression...most likely.

The difference between us is that I am hopeful that ways of ameliorating human distress will continue to be refined and I am suggesting that the best way to do that is to disinvest in the lanquage of pathology and the fruitless quest for biological markers that don't exist. You are suggesting the equivalent of searching for a safe way to eliminate people with the autosomal recessive trait that leads to hitchhikers thumb when you don’t yet and can not yet know, what the future utility of that trait might be.
Sure, science can set you free but it can also bind you in ways you didn’t expect.

Right. No markers for any disease state have been found. Next time I meet someone who had breast surgery without cancer because they had a "fruitless marker" and a few deaths in the family to breast cancer I will tell them that they made a horrible mistake because who knows what that breast could have done.

The really annoying thing is you actually have the nerve to talk of epistemological certainty in the context of schrodinger's cat when illustrating your point. If you really believe all you say give up all that science has provided and live in the wild then as a hunter gatherer.

 

[Ibid]

Manicsleep

Don’t be annoyed and casting aspersions is undignified. Now before you spit your dummy out again, yes, the dumbing down of the English language is a pity and trained is the common parlance but that does not make it correct. Strictly one reads a subject. Perhaps you have not been burdened with a classical education.

Now, saying not true in a loud voice adds nothing to your argument. I have posited that schizophrenia is not best understood or helped by naming it as a disease. You are getting muddled up when you try and equate mental distress with true illness like cancer. That is my whole point and why we are so far apart.

In this case and in every case it is up to the hypothesiser to demonstrate the worthiness of their case. In this instance you need to find the biological marker for schizophrenia. Its no good getting upset because you can’t find it. That’s your problem. I don’t think it exists and so far all the evidence is on my side sunshine, not yours. Forgotten Carl Popper so fast have we? How convenient for you.

I did think we were making progress but I see that you have wilfully disregarded the point I made about your fantasy paradigm having real life negative consequences for people now. Well keep you head in the sand and bio-bable away to your hearts content. The tide of history is against you. Psychiatry is not like the rest of medicine despite what you like to think.

I think the lab is probably the best place for you as even contact with people on the internet seems to be all rather to much for you. God knows what you would be like with patients in the flesh.

 

[Manicsleep]

With all your 'classical education' you failed to understand my simple words. I will ask again.

Ibid. Are you a physician?

 

[Ibid]

Manicsleep

Why are you trying to make this personal and about me?

You have not answered my questions either. In fact your are purposefully avoiding the issues that I have raised. I have given my view to each and every point you have made. You have not done the same in return.

 

[snarfer]

With all your 'classical education' you failed to understand my simple words. I will ask again.

Ibid. Are you a physician?

Great question. I think many of us would like to know as well.

 

[Evidence Based]

In this case and in every case it is up to the hypothesiser to demonstrate the worthiness of their case. In this instance you need to find the biological marker for schizophrenia. Its no good getting upset because you can’t find it. That’s your problem. I don’t think it exists and so far all the evidence is on my side sunshine, not yours. Forgotten Carl Popper so fast have we? How convenient for you.

Paint me confused, but there are biological markers for schizophrenia. Yes, schizophrenia is polygenetic, and yes, no person with the disease is exactly alike. A biological predisposition is influenced by the psychological and sociological context, no one (I presume) would argue with this. But there are plenty of biological markers for the disorder. There are common genetic mutations and changes in the brain (to both grey and white matter) that have been found to be prevalent in people with this diagnosis. Do all people have every marker? No, because schizophrenia is so polygenetic that clinical presentations vary widely from one person to the next.

So schizophrenia is not a single gene autosomal recessive disorder, but neither is, say, diabetes. Diabetes (let's take type 1 for simplicity) is marked by a genetic predisposition, but inheriting said genes does not mean you will necessarily inherit the disorder. Such a thing is influenced by the environmental context. This does not mean, however, that the biological markers don't exist, or that genetics and biology do not play a very strong role in the course of the disease.

The same thing goes with schizophrenia. Or bipolar disorder. Or depression. Biology is not destiny. But neither is it irrelevant.

 

[snarfer]

Manicsleep

Why are you trying to make this personal and about me?

.

Because you have personally insulted anyone who disagree with your views. The pot is calling the kettle black here as another poster wrote.

 

[Ibid]

Snafer how nice to see you again. Another one who likes to play the man and not the ball.

I would remind you that this is a student network, not the Nobel Prize winners after party.

So far between you and Manicsleep you have singularly failed to post anything that someone with a high school attendance certificate wouldn't grasp.

 

[Ibid]

Evidencebased

Well put but what you are saying is still ultimately conjecture. I do understand what you are saying and why I read the latest Copy Number Variation studies with interest with the caveat that traditional early work found zip. I don’t want to start swapping journal refs but just to say that is my interpretation of them.

I do think the stress vulnerability model you allude to has had its day. I would like to see something closer to a working model that incorporates the latest evidence but for the time being the SV model is rather crowding out anything that doesn’t fit with it.

 

[snarfer]

I would remind you that this is a student network, not the Nobel Prize winners after party.
.

True. So are you or aren't you?

A lot can be said for proper education or lack thereof.

 

[Ibid]

Snafer, sweetheart, go away and take a few deep breaths with your head in a paper bag and come back when you can deal with the issues at hand.

I won't be swapping biographical details, OK sweetie.

 

[Doc Samson]

<Gruff Moderator Voice>

Play nice - all of you. The core issue here is getting lost amongst all the posturing. Find it quickly or you'll find this thread locked.

 

[Ibid]

With that ticking off, I certainly apologize if I have offended anyone.

 

[Manicsleep]

I think I will go with :troll:
I will just ignore him and would ask others to do the same. (If you think I am the troll, don't respond to me).

Anyways.
The future of psychiatry is going to be modulated by several factors. Here are a few that I can think of.

Ever increasing stressors due to greater population density and paradoxical concomitant isolation that humans suffer.

Increased awareness of mental illness as well as fluctuating stigma.
i) I think overall the stigma is decreasing even with the scientologists and other fringe groups.
ii) there is going to be an upswing in the forensic aspect I think. It has already happened to a degree and if more events like VT happen, it will get worse for the severely mentally ill. The pendulum is starting to swing the other way.

The new health care system. Who knows what that will bring but it will be a game changer. This can be bad in the short run but ultimately I think it will be good for the patients and psychiatrists.

Technological and scientific advances. Psychiatry and Neurology are both primed for major breakthroughs and I think we are going to come full circle where the two specialties start to merge again. The countdown has begun, its time for liftoff.

 

[maranatha]

I think I will go with :troll:
I will just ignore him and would ask others to do the same. (If you think I am the troll, don't respond to me).

Anyways.
The future of psychiatry is going to be modulated by several factors. Here are a few that I can think of.

Ever increasing stressors due to greater population density and paradoxical concomitant isolation that humans suffer.

Increased awareness of mental illness as well as fluctuating stigma.
i) I think overall the stigma is decreasing even with the scientologists and other fringe groups.
ii) there is going to be an upswing in the forensic aspect I think. It has already happened to a degree and if more events like VT happen, it will get worse for the severely mentally ill. The pendulum is starting to swing the other way.

The new health care system. Who knows what that will bring but it will be a game changer. This can be bad in the short run but ultimately I think it will be good for the patients and psychiatrists.

I really hope you're right on this. The current health system is getting very frustrating to work in. And I'm still in training! Let's just hope it will ultimately provide better access for patients and cut down on paper work!!!

and scientific advances. Psychiatry and Neurology are both primed for major breakthroughs and I think we are going to come full circle where the two specialties start to merge again. The countdown has begun, its time for liftoff.

I'm very excited about the possibilities of utilizing technology and scientific advances in psychiatry, especially as we learn more about the brain and mind. However, I have a hard time seeing the benefit of merging neurology and psychiatry. Although we both are treating the same organ, the skills and training are so different. How would that look with things like therapy training?

 

[Manicsleep]

Yeah that paperwork aspect is a burden but I don't see it getting better. With more government, I anticipate more paperwork not less. At least in the early stages.

I'm very excited about the possibilities of utilizing technology and scientific advances in psychiatry, especially as we learn more about the brain and mind. However, I have a hard time seeing the benefit of merging neurology and psychiatry. Although we both are treating the same organ, the skills and training are so different. How would that look with things like therapy training?

I don't see the two disciplines becoming the same but I do see a much greater crossover. A blurring of the lines in many areas.

I don't see psychiatrists treating stroke but I can see interventional psychiatry or psychoradiology as distinct subspecialties. On the other hand you may have multispecialty fields where many specialties are needed and as a result you have a blending of specialties. One field that psychiatry already does that with others is sleep medicine. When these crossovers start to happen you end up doing a lot more than originally intended. I hadn't planned on treating OSA with CPAP, reading EEGs/PSGs/MSLTs, performing detailed oral exams (without saying much at all ) when I started psychiatry residency. I didn't expect to have my sleep CBT 'supervisor' be a neurologist either.

I think therapy is still therapy but you may find neurologists doing more of it. When I found out my sleep CBT supervisor was a neurologist I laughed, not because she wasn't good, but because she had been my senior when I was an intern and she had always said she didnt want to deal with 'mental' patients and that was why she was going into sleep. She did a behavioral sleep fellowship along with a regular fellowship and was excellent. The TD let the psychologists train the pulmonary/neurology people because he knew I already knew CBT and because it was this attending's first year. We had a great time.