Tuesday, 25 September 2007


Who should do psychiatry?

A mature and sensible anaesthetist (she was a physiologist before training to be a medic) believes that psychiatry is just very complicated neurology. If you're a proponent of biomedical psychiatry it becomes quite a compelling argument.

A psychiatrist who taught me when I was a junior doctor believes that many psychiatric conditions, like severe depression, are too serious to leave to psychiatrists to treat. Although truly biopsychsocial in outlook, the "bio" bit was important enough for him to feel that "social psychiatrists" focussing on psychosocial problems were mistreating many of their patients by ignoring pathological neuroendocrine biological processes. "In 10 years time," he said, "physicians will be the ones treating depression, not psychiatrists . . . it's too serious a condition for us to play with."

Taking this views on, who should treat them? Their points both suggest that "sitting down and talking about it" is wrong and a more active management is warranted. And in many ways they're right.

We know that depression is bad.

The consequences of depression are serious. We know research shows that being stressed for protracted periods of time is damaging since the hormones released aren't meant to be sustained at high levels for any length of time. A "fight or flight" response is great if a lion is chasing you but to have surges of catecholamines like adrenaline is, we know, neurotoxic.

This means each and every day that someone's being there, fraught and frazzled, stressed and depressed, they're poisoning their brain and killing off brain cells. Much badness.

The original comments referred to this, meaning that patients deserved prompt and effective treatment to address the neuroendocrine elements of their distress. They felt that depression was too serious an illness for "social psychiatry" to treat and physicians (or maybe neurologists) should be treating such folk. My mentor said this over 10 years ago; his vision hasn't come to pass.

I think this is a good thing.

I believe that good mental health services can address the biochemical elements of illness expediently but, critically, can generate a holistic and cohesive careplan that's broader (and better) than simply getting the right drugs prescribed at the right time.


Mousie said...

Good mental health services you say?

You may have to explain that concept to me as I have yet to come across such a thing; it's sadly lacking in my part of the world... :o(

PhD scientist said...

I'm with you, Shrink. Surely antidepressant treatment is one available "intervention" for people with depressive illness? The drugs are a pretty blunt instrument, especially given their various downsides.

I would have supposed that sometimes drug therapy would be the best intervention available, based on severity of the illness, need for speed of treatment, availability vs other interventions, chance the patient will accept the therapy, likelihood of real underlying neurochemical changes etc etc.

The idea that it is ALL neurochemical will make the PharmaCos happy, and cut consultation times, but seems a touch “biochemically determinist”...!

Isn't what your friend was saying really justifying why psychiatrists might need to have enough general medical / neurological training and experience to spot the interfaces of the psychological and the physiological?

The above, BTW, would reflect both my personal experience as a patient (couple of times on SSRIs) plus that of sundry friends (I seem to know a lot of depressed academics and doctors), as well as Mrs PhD's as a physician. After many years in general medicine (including seeing a good few “psych” cases who had previously missed underlying / contributory medical problems), and a couple in gassing, Mrs PhD now works in Occy Health. Loads of the people she sees who report inter alia "work stress", back pain, chronic fatigue, "RSI" etc show signs of depressive illness and somatization - often in an unhelpful spiral - as a response (psychological and psychophysical intertwined) to working conditions they are finding they can't cope with. The treatment of choice is usually talking to them and getting them to recognize this as a possible element of their problems.

PS In case anyone reading doesn’t know - cue historical aside:

The idea - then new and shiny - that mental illness was all a result of biochemical abnormalities was what led so many 50s physicians to tinker with things like psychedelics as potential therapies. In fact, the effects of things like mescaline and LSD on perception convinced a lot of doctors that "endogenous LSD like" compounds must exist as a cause of hallucinations. What I find particularly fascinating is that a lot of the people who later ended up as the alternative "you can treat mental illness with vitamins and nutrients" crew started off in this camp, e.g. Abram Hoffer.


- or in his own words:


Sorry, that’s enough random rambling, I'll shut up now.

The Shrink said...

My, you're a clever chappy :-)

And yes I'm wholly with you that medication is part of a solution for some folk in helping effect change but typically is not the "cure" in and of itself.

That's why we need community mental health teams, and even though I'm the first to admit that medics are the least important in that team, we still do have a valid and helpful role to play.

Mousie, you prompted a whole new post :-)

PhD scientist said...

Shrink wrote: "My, you're a clever chappy :-)"

Oh dear - this means I've been lecturing again. Apologies. Call it an occupational hazard of being an ageing academic.

I really will get a proper blog of my own together one of these days so I can rant away to myself and stop cluttering up your comments.

*Slinks out looking sheepish*

The Shrink said...

". . . stop cluttering up your comments."
No no no!

Your comments are most welcome - I like clever - I like being mentally stimulated and having my rudimentary ramblings advanced.

All is good :-)

The MSILF said...

I believe that good mental health services can address the biochemical elements of illness expediently but, critically, can generate a holistic and cohesive careplan that's broader (and better) than simply getting the right drugs prescribed at the right time.

-- Shouldn't that be all health services?