Institutional pressures in psychiatry

Lade Smith, outgoing President of the Royal College of Psychiatrists, has called on the UK government to address the “silent mental health pandemic” (see press release). The government has set up a review to examine what is driving rising demand (see previous post). The College, of course, emphasises the need for more funding, but doesn’t really talk about the need for change, apart from promoting the Community Mental Health Framework and neighbourhood hubs.

As I said in a previous post:-

The current Community Mental Health Framework for Adults and Older Adults to transform mental health services has been too non-specific in providing direction and there has been insufficient progress in its implementation. ... Community Mental Health Teams have become too large and need to be devolved so that there is one in every Primary Care Network (PCN). The PCN mental health teams also need to work alongside non-medical mental health hubs, one of which again should be in each PCN.

I’m not against increasing funding for services, but they do need to become more patient-centred. Psychiatry itself is partly responsible for the increased demand by fostering simplistic solutions to mental health problems. It misleads people about the nature of mental illness by encouraging them to see their problems in terms of brain abnormalities. There does need to be a change in the ideological position of psychiatry but Lade and the College don’t mention that in the press release. 

Conceptual understanding of psychiatric diagnosis

As I said in my last post, a paper that has been influencing the Future DSM Strategic Committee has been Hyman (2021). The abstract concludes that "scientific results demonstrate that psychiatric disorders cannot reasonably be understood as discrete categories—and certainly not as natural kinds".

Hyman reaches conclusions with strong implications for current psychiatric diagnostic systems, such as DSM. For example, he states that "The currently predominant categorical nosologies are fundamentally in error and are damaging to science". He sees psychiatric and neurological disorders as "groupings of disorders that exhibit some internal scientific and clinical coherence, but also have changing and permeable boundaries that are negotiated by interested professional groups". His argument is primarily against seeing any distinctions between disorders and non-disorders and between disorders as categorical in nature. To summarise in another quote:-

If by natural kinds we mean categories of things existing in nature that are well bounded and have stable, cohesive causal structures, as is the case for chemical elements, then the poorly bounded, etiologically and pathophysiologically complex psychiatric disorders are something else entirely. 

For me, Hyman, and the Future DSM Strategic Committee in general, could go further in their conceptual understanding of psychiatric diagnosis. They still seem to be too enamoured of the possibilities for "localising the mind" in the brain. Despite the lack of evidence for biomedical markers of mental illness, psychiatry remains paradigmatically committed to the idea that mental functions must be localised in the brain in some way (see eg. previous post). Of course the brain is the vehicle for meaningful experiences, such as functional mental illness. But the brain does not create meaning; it is people as a whole that do that. 

In particular, a new DSM needs to re-create the distinction between functional and organic psychosis, which was present in DSM-I, and was abolished by DSM-IV (see previous post). I am not arguing for Cartesian dualism, splitting the mind from the brain (see eg. another previous post). Mind and body are integrated in the organism. People are animate, embodied beings. But what needs to be made clear is that naturalistic explanations of primary mental illness are inadequate because of the need to take a holistic personalistic perspective of mental health problems. The evidence for the abolition of the distinction between organic and functional mental illness does not exist and the argument for doing so by DSM-IV was flawed (see yet another previous post).

Related to this, I suspect Hyman still wants to hold on to the idea that primary mental illness will be shown to have biological aspects to its causation. Of course there's a tautological sense in which this is true, because the brain is necessary to mediate mental illness. But in the same way as we can't, or at least shouldn't, talk about our 'normal' thoughts, emotions and behaviour as being caused by the brain as such, nor should functional mental illness be described in those terms. The whole organism is the condition of its parts, and is in turn realised by them. We may be able to understand some of the reasons for functional mental illness, but these cannot be proven in a natural scientific way (see eg. previous post). We can only hope to understand formative causal influences, not efficient causes (see eg. another previous post). By contrast, brain pathology is a necessary cause of organic mental illness, such as dementia or delirium.

It's unclear to be what the next stage of the DSM review process will be, but as I've always said, proper conceptual foundations for understanding psychiatric diagnosis are needed before progress can be made.

Whither DSM?

Scientific American reports that the American Psychiatric Association (APA) is optimistic that “DSM [Diagnostic and Statistical Manual] can be retooled to become more scientific” (see article). Maybe because of the current DSM-5, people may assume that APA means ‘scientific’ in the sense of natural scientific, implying that a biological cause of primary mental illness will be found. But the press release comes across as, at least potentially, more open-minded. And ‘scientific’ can be defined more in terms of the application of rigour to analysing data (see eg. previous post) than implying a positivistic understanding of mental illness. Science doesn’t have to be reduced to physics and chemistry or mere empiricism. It can make sense to say that psychiatry should be more scientific (see eg. another previous post). There is, in fact, a need to move away from so much of the pseudoscience of biomedical psychiatry (see eg. yet another previous post). A key paper influencing the Future DSM Strategic Committee is by Steven Hyman (2021), a former National Institute of Mental Health (NIMH) director and DSM-5 Task Force member, which makes the case that psychiatric disorders are not natural kinds (see eg. previous post).

DSM-5 failed because of its misdirected aspirations (see eg. previous post). The current DSM review committee has to accommodate a range of different views. But there are some hopeful signs in its paper on the ‘Initial strategy for the Future of DSM’. One of its four subcommittees is the Socioeconomic, Cultural, and Environmental Determinants of Mental Health Subcommittee, which the paper admits 

fills a gap in DSM given that despite the influence of socioeconomic, cultural, and environmental determinants of mental health on the development, progression, and treatment of mental disorders, they are not adequately addressed in DSM or in other psychiatric nosologies.

The overall committee also wants to avoid the problem of reification of psychiatric disorders (see eg. previous post). The idea of embracing “biology and environment and their interactions as key determinants of mental disorders” is said to be under consideration. The committee wants to find a pragmatic solution to psychiatric diagnosis “without abandoning the whole effort or eschewing improving current nosology”. Let’s see how this process develops.

I may be being overoptimistic about the initial publication of the Future DSM Strategic Committee. DSM may never properly incorporate the uncertainty of psychiatry. It may find it difficult to accommodate the inevitable unreliability of psychiatric diagnosis, considering the historical motivation of DSM-III to increase reliability (see eg. previous post). Psychiatric assessment has always been about differential diagnosis and aetiology, rather than a single diagnosis, often seen as having implied biological causes. I’ve never been one for wanting to completely abandon psychiatric diagnosis but modern psychiatry does overvalue it, particularly when it takes a biomedical approach (see eg. previous post and my 2002 article).