Sunday, December 15, 2013

Getting psychiatry to see the blindingly obvious

An article in Acta Psychiatrica Scandinavica, giving a wake up call to European psychiatry, starts quite well:-
The DSM-5 was published in May 2013. Its publication has been associated with increasing controversy about some specific diagnoses but is not a ‘paradigm shift’. Furthermore, US psychiatric leaders want to ‘sell us’ the belief that the future integration of neuroscience with psychiatric diagnosis will ‘cure and prevent’ mental illness. In 100 years, these words will seem as laughable as similar statements Kraepelin made when he was marketing his Research Institute.
This author proposes that the DSM-5 is a dead end for the historical process initiated in 1980 with the publication of the DSM-III, which was an important step in the history of psychiatric vocabulary. ....
This article proposes that the DSM-III put European psychiatry to sleep; it now must wake up and establish a 21st century language of psychiatry .... to advance its scientific development and practical utility.
The article may lose its way a little later, but makes the essential point that:-
... when psychiatric symptoms are related to 'semantics’ (communication between human beings), a neuroscience approach and methods such as brain imaging make no methodological sense, because these symptoms can only be understood, in the sense of Jaspers, and not explained by brain disturbances. These relatively simple concepts are bad news for psychiatric researchers. 
Jaspers, of course, emphasised the distinction between understanding and explanation. If this is the way of getting the message through about why DSM-5 has failed, then so be it. As I've said in previous posts (eg. Stop thinking about DSM-6), there needs to be a proper conceptual understanding of mental illness before progress can be made. I agree with the author of the article that DSM-5 needs to be recognised as a dead end in the history of psychiatric vocabulary. Holding out the hope of an integration between psychiatric understanding and neuroscience is an illusion. True, psychiatry has always had this wishful hope but DSM-5's failure may have made this basic situation starkly obvious.

Friday, December 13, 2013

Exploiting the antidepressant placebo effect

Stuart Jessop, a patient with depression, in response to a BMJ article, says patients don't care whether antidepressants are merely placebos. He seems to suggest that the placebo effect shouldn't be "explained away". He even suggests GPs should prescribe herbal medicines, presumably even if these remedies have not been shown to be better than placebo.

I do agree with his motivation to avoid patients with mild depression being sent away "empty handed". But is Jessop really encouraging doctors to deceive their patients? I agree the value of the placebo effect shouldn't be minimised and the relationship between doctor and patient is important. But using dummy drugs and other phoney interventions is unethical (see my BMJ letter). Placebos (and antidepressants if they are merely placebos) should not be used to exploit patients.