Friday 24 November 2017

Analyse this: there are a lot of fads in psychiatry

A new book by an eminent Canadian psychiatrist challenges our medical approach to many disorders

The great message of In My Room for patients and their families is that recovery from mental illness is possible
The great message of In My Room for patients and their families is that recovery from mental illness is possible

Patricia Casey

In 1957 a courageous book, 'Fads and Fallacies in the Name of Science' by Martin Gardner, explored some of the pseudosciences and cult beliefs that were fashionable at the time. These included scientology and homeopathy among others as well as critiquing the personalities behind them. It found a ready market and led to the establishment of the scientific scepticism movement.

Now another work, this time focussing on psychiatry, has just arrived in the bookshops and online.

To describe it as a stimulating read is an understatement – it is simply superb. 'Fads and Fallacies in Psychiatry' is written by Canadian psychiatrist Joel Paris and published by RCPsych Publishing, London. Not only is he editor of the 'Canadian Journal of Psychiatry 'but he is also an eminent academic and consultant psychiatrist at McGill University, Montreal.

Anybody, whether a mental health professional, a patient or an interested member of the public, whether sceptical or affirmative of psychiatry, should read this book. The reader can dip into it at will. Each chapter stands alone in what is a slim volume of 124 pages of text.

The passion that drives this book is not any hostility to psychiatry. In his 40-year career he says he has seen more than 25,000 patients, wryly observing that diagnosis gets easier after the first 25,000!

He challenges those psychiatry sceptics who claim that the specialty consists of no more than fads and fallacies and argues that we are at least as good as physicians and other branches of medicine in helping our patients, notwithstanding the gaps in our knowledge. Yet he has a particular concern that the fads in psychiatry are not coming from the fringes, as is the case in other areas, but from the mainstream.

His thesis is that if you want to practise scientific medicine you have to be humble and embrace doubt. And it is this which causes him to deconstruct the current and past edifices of certainty.

Describing that fads and fallacies that were part of the past, he begins by pointing to the hegemony of the psychoanalytic approach in the 1960s, both in academic psychiatry and clinical practice. He describes the plausible explanations for all kinds of psychological symptoms and the analysts' confident assertions that their methods worked, even in the absence of any evidence. And when it didn't work it was explained by therapy that was too brief or not conducted with sufficient skill. The consequence was relentless psychoanalysis.

This was replaced in the 1970s by an excessive focus on biological psychiatry which even now embraces a narrow biological model. From this perspective, mental illnesses are regarded as brain disorders and drug treatments are ascendant. He says of the swing from the psychoanalytic to the pharmacological approach that one is talking without a clear purpose while the other is not talking at all.

The fads that he tackles include over-diagnosis and over-treatment. He describes these as serious and deals with them in relation to depression, bipolar disorder, ADHD, autism and so on. He expresses concern that many diagnoses are simply medicalising the human condition since clear boundaries between normal human emotions/behaviours and those that are abnormal have not been defined with any clarity. He also discusses the uses and misuses of medication and current psychotherapies.

There are core conditions that Paris believes require medication and these include melancholic depression and schizophrenia. These are the starting point for him. Except for these and some others such as manic depression, he argues for further research that may show a biological basis for some disorders, or may not.

As well as studying the biological underpinnings of psychiatric disorders we must also examine the interaction between the environment and our biology. Meanwhile, we must be cautiously conservative in our practice.

He places his faith in research and in the evidence that this will adduce. Fads and fallacies cannot withstand the power of evidence and those that are current will fall under its weight. This he believes will provide the answers as to the nature of mental illness and its various manifestations. It will guide treatment and thus benefit our patients. This is a book that gives cause for optimism to psychiatrists and to our patients alike.

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