The chasm between neuroscience and psychiatric practice

I know all of us here in New Bretten will have to struggle awhile to feel comfortable with mind-brain science research and its application. You can’t know how to think clearly about complex problems related to how our heads work until you have built up a good deal of knowledge and then spent lots of time playing with what you know. In the meantime, as we are learning more and more we also have to keep our guard up. We have to know when what we read is bull, or story telling in lieu of scientific knowledge. Much of this work I s fun so we enjoy what we are doing.

TKS was shocked at the article he brought to our discussion group. We sort of suspected that basic mind-brain science is way ahead of its application to mind-brain dysfunctions but that really came home to us, with a thud, after reading an article by Louis Menand published in the March 1, 2010 issue of the New Yorker. We discussed the implications of what is presented in that article and then broke up into small groups so that we could look at some of the background studies that were used to support the major point being made by Menand, namely the way Psychiatry is practiced today is not science. It is not science in how disorders are diagnosed or treated or theories about what causes minds to fray or break.

I was asked to summarize briefly what was in the article and the references sprinkled throughout the text. First of all many surveys estimate that there are apparently many millions of Americans who suffer from some disorder like depression (which by itself number 14 million). It makes us wonder whether perhaps everyone is nuts given the liberal use of diagnostic labels. So whatever is going on it sure means that we are looking at a problem that touches very many lives. It also means that identifying and treating millions of patients is big business.

Turns out that the diagnostic categories such as forms of depression and anxiety are slippery, vague, vaporous, and have been regularly redefined every few year. Many would argue that the diagnostic labels border on being useless. The problem of wording what is wrong with our minds is a related problem.  When should sadness or grief be labeled depression?  When is being edgy, scared, out of sorts, an example of symptoms of anxiety? None of this is clear in the world of diagnosis. Is shyness a disorder and should it be researched as such? I was particularly struck by findings from some old studies in which Psychiatrists were asked to diagnose a wide variety of patients and ended up with little agreement between them in the diagnosis of the same patients. Perhaps even more discouraging are the findings that demonstrated that Psychiatrist could not distinguish between hospitalized real patients and impostors acting like patients (a classic study by David Rosenhan entitled On Being Sane in Insane Places, 1973).

What can be said about treatments of psychiatric disorders?  It turns out that careful reviews of the research literature on drug therapies for psychiatric disorders like depression demonstrate that effects are barely distinguishable from placebo effects. It is therefore not surprising that drug treatments are often no more effective than forms of psychotherapy (with perhaps some small advantage evident for cognitively oriented therapies). If drugs are not effective in treating depression and the drugs were developed based on what we think we know about the neurochemistry of depression what does that then tell us about the state of our knowledge about brain chemistry dysfunctions in depression?

When it comes to the commercial possibilities of drug therapies we see big business that is growing and growing. Starting with Miltown in the mid 50’s and Librium and Valium in the mid 60’s drug treatment of real or imagined mind dysfunctions has grown exponentially. Since there is a huge pool of psychiatric patients out in our world, including those that have been diagnosed as depressed or anxious, then it follows that we have an enormous market that can be filled with prescriptions and a perspective that can be sold at the same time. Whatever the problem take a pill and maybe everything will turn out alright.

All I know is that as we build our New Bretten project applying mind-brain science to life we need to realize that we are often treated to marketing in the guise of science or clinical practice. We have heard about buyer beware and we are.