Psychiatry and the psychiatrist have a great future.

Abstract

Reminiscent of Szasz 1, Katschnig argues that psychiatry is under threat, either of not standing up to scrutiny as a medical discipline or of being highjacked by non-medical professionals. I believe that: a) psychiatry is going through what other disciplines have gone through in the past, coming out much stronger; b) psychiatry and the psychiatrists are not threatened, and c) it is up to psychiatry to confront stigma. Despite the apparent parallelism between DSM and ICD, there has been an increasing though incomplete convergence between successive versions of the two classifications. They have been demonstrated to serve the purpose of specific descriptions of disorders on the basis of which appropriate interventions are determined and carried out. There are numerous historical examples suggesting that we should not despise the little we know at any given time. The rudimentary 17/18th century botanic classification has over the years evolved into the complex classifications of today. What Hippocrates said about epilepsy more than 2,000 years ago was authenticated only in recent times and the same applies to Alzheimer’s disease and many other physical disorders, thanks to the ever increasing technology. We are not always able to differentiate between true mental disorders and homeostatic reactions to adverse life events. This is more pressing than ever, but applies to both mental and physical conditions, e.g. cardiovascular diseases, immunological disorders, diabetes, etc., in relation to stress. The sociological paradigms of professional autonomy 2 cannot wholly apply to any single medical discipline, given the unlimited availability and access to information, the right and demand to know by patients and their relatives, the increasingly popular shifting to non-physicians of tasks traditionally undertaken by physicians 3, and the ever increasing choice for alternative medicine practiced by non-physicians. Psychoanalysis as practiced by S. Freud and his contemporaries, unmodified electroconvulsive therapy, routine carotid angiogram for stroke etc., have all been replaced by the more evidence-based approaches practiced today, which may in turn be obsolete in the near future. This is all evidence for increasing confidence about the dynamic knowledge base for therapeutic interventions. Concerning ethical issues, psychiatry has not subjected itself to conflict of interest more than other medical disciplines, especially in relation to the pharmaceutical industry. The World Health Organization’s definition of health provides a coherent multidisciplinary theoretical basis for all branches of medicine. The increasing sub-specialization in psychiatry mirrors the same increase in all other medical disciplines, reflecting increase in knowledge base. New terms have been introduced to both psychiatry and physical medicine. “Survivor user” has been introduced by antipsychiatry pressure groups. “Client” has the positive connotation that the patient has a role to play in getting better. The term “consumer”, used in all medical disciplines, is appropriate in that it emphasizes that all medical services should be in the best interest of the patient. Unable to meet all the demands, all disciplines of medicine, without giving up on efforts to increase their human resource base, have sought the inputs of related but non-medical professionals who come under different names, e.g. clinical psychologists in psychiatry, and physio-therapists, EEG and laboratory technicians in physical medicine. It is true that psychiatry is one of the disciplines most affected, but the WPA is making attempts to address the matter. More in psychiatry but also in some other areas of physical medicine, stigma is an impediment which has to be confronted, just as happened in the case of HIV/AIDS. The WPA is at the forefront in this effort 4-5. These challenges are opportunities to improve. I cannot say more about the future of psychiatry than Kraepelin did nearly 100 years ago: “The nature of most mental disorder is now obscured. But no one will deny that further research will uncover new facts in so young a science as ours; in this respect the diseases produced by syphilis are an object lesson. It is logical to assume that we shall succeed in uncovering the causes of many other types of insanity that can be prevented – perhaps even cured – though at present we have not the slightest clue” 6. One hundred years down the line, we know exponentially much more, and we continue to make almost daily discoveries. Psychiatric disorders and in particular depression are fast creeping to the top of the leading causes of disease burden, overtaking communicable diseases, metabolic diseases, cancers and cardiovascular diseases 7. The knowledge base has been enhanced by the exponentially increasing technology (genotype/phenotype matching, imaging, etc.) and concerted multidisciplinary efforts. Psychiatry has a future. The psychiatrist has a secure place in that future.