Keywords: Future of psychiatr, diagnosis, treatment, user and carer criticism, professional competition

Decreasing confidence about the knowledge base: diagnosis and classification

Disease categories and their classification are the pervasive organizingprinciple for most aspects of medicine, including psychiatry as a medicalspecialty. Diagnoses are meant to be used for making therapeutic decisions,for teaching purposes, for reimbursement, for defining patient populationsfor research, and for statistical returns. In psychiatry we have the confusingsituation of two different internationally used diagnostic systems. In anymember state of the World Health Organization (WHO), on discharge of a patientfrom hospital, a diagnosis from chapter V of the International Classificationof Diseases (ICD-10) must be selected. However, for psychiatric research tobe published in a high impact factor journal, it is advisable to use the Diagnosticand Statistical Manual (DSM-IV) of the American Psychiatric Association (APA).

The parallelism of these two major diagnostic systems exists since nearly60 years. In 1949, the sixth revision of the International Classificationof Diseases (ICD-6,14) included forthe first time mental disorders (earlier versions covered only mortality).Three years later, the APA launched its own classification system (DSM-I,15). We have now arrived at ICD-10 (1992)and DSM-IV (1994), and the next revisions of the “big two” aredue in a few years (DSM-V in 2013; ICD-11 in 2014). There will thus be stilltwo systems in parallel.

Such parallelism is possible because of the very nature of the definitionsof most psychiatric diagnoses: they consist of combinations of phenomenologicalcriteria, such as signs and symptoms and their course over time, combinedby expert committees in variable ways into categories of mental disorders,which have been defined and redefined again and again over the last half century.The majority of these diagnostic categories are not validated by biologicalcriteria, as most medical diseases are; however, although they are called“disorders”, they look like medical diagnoses and pretend to representmedical diseases. In fact, they are embedded in top-down classifications,comparable to the early botanic classifications of plants in the 17th and18th centuries, when experts decided a priori about which classification criterionto use, for instance, whether fruiting bodies or the shape of leaves werethe essential criterion for classifying plants16.

The DSM-III approach of creating “operational definitions”(e.g., “2 out of 5 symptoms” of a list must be present) has certainlyrendered the process of arriving at a diagnosis more reliable, in the sensethat we can be more sure that, if different psychiatrists assess a patientdiagnostically, they will, after evaluating symptoms and other criteria, comemore often to the same result. But reliability is different from validity.Psychopathological phenomena certainly exist and can be observed and experiencedas such. However, psychiatric diagnoses are arbitrarily defined and do notexist in the same sense as psychopathological phenomena do.

This is not new. However, whereas psychiatric diagnostic classificationsystems and disease definitions have long been criticized, the character ofthe attacks has changed. Half a century ago, they came mainly from outsidepsychiatry (e.g.,17-18). Today, while these assaults continue19, discussions about the validity of psychiatric diagnosesare also getting momentum within our profession (certainly fuelled by theimminent revisions of the “big two”)20-21. It is no longer just the “usualsuspects” who criticize psychiatric diagnosis and classification systems;the discussion has arrived at the heart of our profession.

For instance, psychiatrists talk about the “genetic deconstructionof psychosis”22, the lack ofvalidity of psychiatric diagnoses despite their utility23, and the poor diagnostic stability of psychiatric disorders24. From psychiatric geneticists one hearsthat they have to use “star war technology on bow and arrow diagnosis”.Recently, a prominent psychiatric researcher commented: “It has beensuggested that the debate is political. This is not the case however, as solidscientific evidence pointing to the absence of nosological validity of diagnosticcategories that nevertheless invariably are subject to paradoxical psychiatricreification, lies at the heart of the argument”25.

The sociologist A. Abbott has observed that the control that professionshave over their body of knowledge allows them to seize new problems and redefinetheir scope of interest26. With thisperspective in mind, it can be argued that, while some psychiatric disordershave some kind of “clinical validity” (e.g., bipolar disorder),the DSM has “fabricated non-validated psychiatric diagnoses out of thegeneral human predicament”27.Psychiatry “abandoned the island of psychiatric disease and was thusengulfed in the boundless sea of human troubles”, as F. Redlich hasput it more than 50 years ago when referring to psychoanalysis (28, quoted in17).The issue whether we are able to “differentiate between true mentaldisorders and homeostatic reactions to adverse life events”29 is more pressing than ever.

All kinds of rescue efforts are under way in relation to these threatsto the diagnostic knowledge base of psychiatry, and a plethora of suggestionsare being made: to identify “metastructures”30, to supplement diagnostic categories with dimensionalmeasures21 or a “cross-diagnosticapproach”31, to use “epistemiciteration”16, or to providea “person-centered integrative diagnosis”32. Recently, a group of psychiatrists has asked for theestablishment of a conceptual working group for DSM-V, pointing out that inpast DSM revisions conceptual questions were considered only on an ad-hocbasis by individual workgroups and the task force33.Eve rything seems open.

It has also been proposed to put more emphasis on the clinical utilityof diagnosis, such as ease of usage, communication, and treatment planning34. However, in clinical practice, the selectionof medication is only vaguely related to diagnosis (e.g., antidepressantsare used across a wide range of conditions)35,and in community mental health services, diagnoses are mainly used for channellingresources, and different classifications are employed for dealing with clientsin everyday work36.

The threatening bottom line of these discussions is that, if our diagnosticcategories have not been valid until now, then research of any type –epidemiological, etiological, pathogenetic, therapeutic, biological, psychologicalor social – if carried out with these diagnoses as inclusion criterion,is equally invalid.

Decreasing confidence about the knowledge base: therapeutic interventions

We are living in the era of evidence-based medicine37. Based on meta-analyses and systematic reviews of carefullyselected methodologically sound studies, guidelines for practice are preparedand become prescriptive – we can no longer accept clinical experiencealone. But how sure can we really be of our treatment decisions?

When in 2008 a meta-analysis of antidepressant medication studies was published38, with the main message that in mild andmoderate depression antidepressants are no better than placebo, the resultwent around the world immediately – the special “kick” forthe media being that the authors had included in their meta-analysis alsothose studies which had not been published (but submitted to the US Food andDrug Administration). A related study corroborated these findings39, leading to some discussion within psychiatry40. The fact that trials with positive findings are publishedmore often and more quickly than those with negative findings has become aserious concern not only in psychiatry, but in the whole field of medicine41.

In a different development, the randomized controlled drug trials in schizophreniahad been criticized for their limitations, and “pragmatic” or“real world” trials had been proposed42.When such real world pragmatic trials were carried out, the superiority ofthe second over the first generation antipsychotics could not be reproduced43-44.

It is evident that such results increase uncertainty, even more so because– given the lack of validity of psychiatric diagnoses and the difficultiesin obtaining homogeneous samples of patients – they do not imply thatthe original studies were wrong and the new ones are correct. When attemptingto establish evidence-based guidelines for clinical practice, we face an inherentcontradiction in the methodology of randomized controlled trials: strivingfor internal validity leads to highly selected samples, meaning that the resultscannot be easily generalized to the real world, while looking for a high representativenessof the study samples generates methodological biases45-46. It has beensuggested in this context to have two parallel assessments of evidence: theusual evidence of efficacy of intervention studies, and “corroborative”evidence assessing the transferability of results into the real world47-48.A related issue is that polypharmacy and combinations of treatments are commonin clinical practice49, whereas mostevidence is available only for monotherapies.

In addition to these problems, the conflicts of interest arising from therelationship between doctors and industry50 arecreating further doubts. “Ghostwriting” has recently receivedincreased attention as a “credibility” issue, in the scientificcommunity51 as well as in the mediaand from politicians52. If we addconcerns about psychotherapeutic interventions and their unintended side effects53-54,we, our patients and the public must get increasingly insecure about the trustworthinessof the proofs that our professional interventions work appropriately.

Lack of a coherent theoretical basis

“Ask three psychiatrists and you get four answers”. I haveheard this in many variations from politicians and health administrators,as an excuse for doing nothing, whenever I tried to get them to improve psychiatriccare and increase resources. Over-valued beliefs and nostrums are not uncommonin medicine, but perhaps nowhere do so many different ideologies flourishas in psychiatry.

It is a truism that psychiatry is split into many directions and subdirectionsof thought. Considering that a common knowledge base is a core defining criterionof any profession, this split is a considerable threat to the coherence ofour profession. Textbooks usually cover all aspects55, and integration is freely advocated, but not pursuedin any practical way. There are worldwide associations for biological psychiatry,psychotherapy and social psychiatry which all claim better patient care astheir main aim (often with strong relations to or cooperation with neighbouringdisciplines and professions). Each approach has its own body of knowledge,conferences and journals. The tone with each other is getting increasinglyirritated56-60, not the least also because of resource implications61.

After having lived and worked for some time with a specific mind-set, andseeing only restricted groups of patients, it is difficult or impossible tochange. This was true also for our forefathers, who developed their conceptsin specific settings – for example, E. Kraepelin working mainly withpsychotic patients in mental hospitals, and S. Freud working mostly with neuroticones in private practice, each of them with no or very limited experienceof the other setting – and so came up with completely different ideas62. It is indeed difficult to stay abreastof all aspects of psychiatry, although the professional associations (suchas the WPA) regularly organize congresses where all kind of professional knowledgeis available.

The danger of splitting or being absorbed by other professions1 is tellingly illustrated for US psychiatry by the dividebetween the “two cultures” of biological psychiatry and psychotherapyas described by a neutral scientist from outside63 andby the mutual stereotypes of “mindless” and “brainless”64. Guidelines usually stress the combinationof both approaches, but reimbursement systems do not favour such integration.

Client discontent

While criticism of psychiatry by professionals has been around for a longtime17-18 andstill continues today65, discontentwith our profession is been increasingly voiced also by our “clients”,the patients. Whereas criticism within a profession can be regarded as contrib-utingto its dynamic development, discontent of clients with a profession may bedetrimental.

Over the last few decades, I have seen several new terms coming up forour patients. First it was “client”, then “consumer”(implying that one claims one’s right to receive adequate services).Then “user” or “service user” appeared, a term whichis difficult to translate from English into many other languages, but seemsto be quite common nowadays in the English speaking world, also among professionalsand even in government documents. These names in themselves imply a changein the relationship between doctor and patient, with the traditional “asymmetric”paternalistic model being outlived by new, more symmetrical ones (like the“informative”, “interpretative” and “deliberate”models)66. Also, by replacing theword “patient”, these terms are indicating a distance to medicine.Finally “exuser”, “expatient” and “survivorof psychiatry” came on the scene, indicating complete detachment frompsychiatry.

“Discontent” covers a broad spectrum, from the “survivorof psychiatry” concept67, whichimplies that psychiatry should not exist at all, to other forms of discontent,criticizing psychiatry “as it is”68.Today the Internet allows persons having undergone psychiatric treatment toexchange their experiences. And there are quite a few negative experiences,in addition to positive ones, which are all made public in personal storiesworldwide (e.g.,69-70. Topics raised are manifold, and range from diagnosisto pharmacological treatment, from compulsory measures to neglect of qualityof life issues. Also family members (in the English speaking world now called“carers”) voice discontent with psychiatry, although often froma different perspective than the users.

Self-help organizations on mental health issues are established everywhere,organized by “clients”71 andby “carers”72. Such associationshave become relevant not only in terms of “empowerment” and “self-confidence”of their members, which is enacted also in conferences and in creating trainingand consultancy companies (e.g.,73,but also at the political level, where, depending on the cooperation of healthpoliticians and administrators, they can participate in the planning process.

Many user groups and organizations focus today on the concept of recovery74, which is increasingly advocated as theguiding principle for mental health policy in many English-speaking countries.Some experts claim this is only a “rhetorical consensus” and pointto the need of distinguishing “clinical” vs. “personal”recovery”75, and recovery as“outcome” vs. recovery as “process”. Also, misunderstandingsarise when the word is translated into other languages.

The focus on clients’ needs and inclusion is now supported by documentsof international organizations such as the Unites Nations76, the European Commission77,the Council of Europe78, and the WHO79. The psychiatric profession has also contributedto this perspective: for instance, guidelines for “better mental healthcare” have been produced, giving equal importance to “ethics”,“evidence” and “experience”, including the experienceof users80, and the quality of lifeissue has been taken up81. But clientcriticism continues.

Competition from other professions

As Abbott26 has observed, professions,in addition to defining their knowledge base and expanding their scope ofcompetence, are watchful against interlopers. In the post-modern era, withits growth of a culture of professional expertise82,there are more and more ”intruders” into the territory which psychiatryclaims for itself. And, unwittingly or wittingly, in order to attract patients,they often make use of the stigma associated with being treated by psychiatrists.

On the medical side, it is neurologists, general practitioners and doctorswho practice alternative medicine who compete with psychiatrists. For instance,in many countries, the volume of prescription of antidepressants is much largerin general practice than in psychiatry. Neurologists understandably claimorganic brain syndromes for themselves, but depending on the reimbursementsystem they also treat psychiatric patients in many countries.

Psychologists, psychotherapists and clinical social workers constitutefurther large professional groups who compete with psychiatrists. In Austriathere are around 10 times as many officially recognized clinical/health psychologists/psychotherapistsas psychiatrists. In the USA, by 1990, 80,000 clinical social workers wereactive in the psychiatric socio-psychological domain, a quarter of them inprivate practice1. Psychologists donot only compete in the psychological and psychotherapeutic sector: in theUSA, for instance, according to the APA, since 1995 bills to grant prescribingprivileges to psychologists have been considered one hundred times in 23 differentstates. They have been defeated 96 times, but New Mexico, Louisiana, Wisconsinand Oregon have enacted relevant legislation83.

There are also more systematic challenges, such as the “ImprovingAccess to Psychological Therapies” programme in England, where 3,600“psychological therapists” are being trained in cognitive behaviouraltherapy84. Also, a government documentin England on “New Ways of Working”85 givespsychiatrists more of a supervising role, while upgrading other professionsin the mental health services with regard to direct patient contact. Giventhe lack of psychiatrists in developing countries, this is exactly proposedfor them86. This proposal createsa dilemma, expressed tellingly by an English psychiatrist as follows: “Psychiatristsmust continue to see patients, also in the first line and not just as supervisor.If we, as consultant body, see a small number of cases, while supervisingothers who are seeing vastly more people than ourselves, it is only a matterof time before we lose respect, credibility and competence”87.

How do we respond to these developments? How to keep the balance betweenour own identity and the identity of other professions, in a field where overlapis common and increasing? How can cooperation be organized in a satisfyingway? Fundamental issues come up here, such as private enterprise vs. publicemployment, single handed vs. group practices, responsibility and risk management,as well as hospital vs. community treatment. Team work warrants special attention88.

Negative image

I think of myself as a rather average looking and behaving person. In socialcontacts with new people outside my professional milieu, it becomes unavoidableafter some time to disclose my profession. And I often meet with disbelief:“You are a psychiatrist!?”. I am not always sure what people meanby this, but I have come to take it as a compliment. What on earth, do theythink a psychiatrist looks like and behaves?

Every psychiatrist knows it and has experienced it: there is somethingspecial about our profession, in terms of how people view us. The portrayalsof psychiatric treatments in films are rarely positive89 and a number of stereotypes circulate about us, not leastin jokes, such as the “nutty professor”, the “analyst”and the “aloof interrogator”68-90. Some of these stereotypes might go backto a time when psychiatrists were still mainly working in large mental hospitals,away from normal life, and it was deemed that by this they become strangepersons themselves and not very different from their patients91.

It has been suggested that such image factors may play a role in the decisionof medical students not to choose psychiatry as a specialty92 or for early drop-out from a psychiatric specialty trainingcareer93: doctors who had starteda training career as a psychiatrist in England, but had broken it off, agreedmost frequently with the statement that psychiatry had a poor public imageand that they were not sufficiently respected by doctors in other disciplines.

Concerning patient contacts with psychiatry, a case vignette-based generalpopulation study in Germany found that only a minority of interviewees recommendedto see a psychiatrist as the first choice94.Similar results were reported in Austria and Australia95. Probably people fear that, after having been in contactwith us, they might be stigmatized and discriminated, if this becomes known.There is a considerable desire in the general population for social distancefrom people with mental disorders96,and stigma and discrimination are well documented97.This is known by anyone who develops psychological problems and considersto ask for professional help. Also, people might assume that psychiatrists(in contrast to psychologists and psychotherapists) will treat them mainlywith medication, and the majority refuses this: in the Austrian survey, thelarge majority recommended primarily psychotherapy, even for dementia, wherethis percentage amounted to 73%95.

The “stigmatization” of psychiatrists is under-researched98, if compared to the stigmatization ofour patients. There might also be a more complex relationship between thesetwo topics. It has been suggested that the members of the psychiatric professioncan simultaneously be stigmatizers, stigma recipients and powerful agentsof destigmatization99. With so manyopen questions, it is understandable that the WPA is currently funding a researchproject on “stigmatization of psychiatry and psychiatrists”9.

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