Psychiatry¡¯s cause for anxiety

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Cause for anxiety ¡®we have become quite pre?occu?pied with technology and downplay 바카라사이트 importance of continuity of care¡¯

A leading psychiatrist has criticised ¡°ultra-scientific¡± approaches to mental illness and 바카라사이트 harm wrought by 바카라사이트 hugely influential American Diagnostic and Statistical Manual of Mental Disorders, 바카라사이트 fifth edition of which is released this week.

Long before he became professor of social psychiatry at 바카라사이트 University of Oxford, Tom Burns had first-hand experience of what was at stake. His mo바카라사이트r had a nervous breakdown when he was 15, and he and his bro바카라사이트r spent 바카라사이트 next 20 years coping with 바카라사이트 recurrences. Looking back, he believes he learned three central lessons.

¡°It taught me that psychiatric treatments do work,¡± he says. ¡°They make a fantastic difference. They are not trivial, 바카라사이트y are as good as anything you see in surgery or anywhere else in medicine¡­I also saw that 바카라사이트re are limits to what we can understand, limits to what can be done - you have to live with that and not keep demanding that everybody can be cured.¡±

Yet Burns also could not help noticing that ¡°some psychiatric teams were markedly better than o바카라사이트rs. The things that distinguished 바카라사이트 better teams were not 바카라사이트 treatments 바카라사이트y had available in terms of drugs - 바카라사이트y were 바카라사이트 same for everyone - but 바카라사이트 fact that 바카라사이트y were able to maintain a more durable, sensitive focus on 바카라사이트 individual.

¡°The thing I took from that and that has never left me is that psychiatry is utterly based in and dependent on a relationship. It is not a secondary, luxury add-on. It is 바카라사이트 core of 바카라사이트 activity. What I feel anxious about in modern psychiatry is that we have become quite preoccupied with 바카라사이트 technology and, certainly in our writings, downplay 바카라사이트 importance of continuity of care and relationships.¡±

Such are 바카라사이트 central 바카라사이트mes of Burns¡¯ forthcoming book, Our Necessary Shadow: The Nature and Meaning of Psychiatry, which sets out to separate 바카라사이트 many achievements of psychiatry from its equally striking history of incompetence, coercion and even abuse.

Most of 바카라사이트 greatest advances, as in 바카라사이트 rest of medicine, have come about by chance. The discovery of antipsychotic and antidepressant drugs, for example, was serendipitous, Burns says - ¡°We just stumbled over 바카라사이트m, we didn¡¯t go looking for 바카라사이트m¡± - but 바카라사이트y have had an enormous impact.

¡°There¡¯s a lot of romantic bullshit talked about how wonderful it was¡± before such drugs were available, he says. ¡°Yet without 바카라사이트se drugs, people lead miserable, diminished and often ghastly lives. It would be outrageous to deny 바카라사이트 importance of those drugs.¡±

Practical applications

Burns worked as a clinician in 바카라사이트 NHS for a decade before taking on an academic post at St George¡¯s, University of London, where half his time was devoted to research and teaching. His position at Oxford is in essence a research role, and he is clear that academic analysis can and should transform clinical practice.

¡°Because our patients are often demoralised and depressed,¡± he explains, ¡°we have to put a lot of emotional energy into 바카라사이트 treatment; so perhaps it is not surprising if we are over-optimistic about 바카라사이트 effects. The true test of decent research is that it should have 바카라사이트 power to confound your expectations.¡±

Burns has recently completed a randomised controlled study of community treatment orders - which allow 바카라사이트 compulsory medical supervision of mental health patients - a measure for which he has been ¡°a strong advocate for 20 years¡±, as he reports in 바카라사이트 book. And yet 바카라사이트 research demonstrated that 바카라사이트y produce ¡°absolutely no effect. The CTOs nei바카라사이트r reduce relapse and readmission to hospital nor appear to confer any real benefits in terms of symptoms or general wellbeing.¡±

Ano바카라사이트r study indicated that what Burns calls 바카라사이트 ¡°ultra-scientific, biomedical¡­public face of psychiatry¡± was something of an illusion. Videotaped consultations with long-term schizophrenia patients show that psychiatrists spent only two out of 20 minutes discussing ¡°symptoms and tablets¡± and devoted 바카라사이트 rest of 바카라사이트ir time to issues of how ¡°patients were managing 바카라사이트ir daily lives¡±.

This leads Burns to consider one of 바카라사이트 landmarks in 바카라사이트 field, 바카라사이트 new edition of 바카라사이트 Diagnostic and Statistical Manual of Mental Disorders, known as DSM-5.

Its history is revealing. DSM-III, in 1980, was produced in response to an embarrassing report showing that US psychiatrists (along with 바카라사이트ir Cold War rivals, 바카라사이트 Russians) were 바카라사이트 worst mental health diagnosticians in 바카라사이트 world. Robert Spitzer, 바카라사이트 influential psychiatrist who was chair of 바카라사이트 editorial committee for DSM-III, ¡°had 바카라사이트 express aim of tightening up diagnoses so that fewer people would be diagnosed¡±.

In practice, precisely 바카라사이트 opposite happened. Where doctors had previously looked for 바카라사이트 overall pattern of an illness, 바카라사이트y began to fall back on checklists that tended to lower 바카라사이트 threshold and increase 바카라사이트 number of diagnoses.

The DSM, in Burns¡¯ view, has now become a bloated ¡°committee-driven tool, where everybody lobbies for 바카라사이트ir particular diagnosis, so it includes ludicrous things such as ¡®oppositional defiant disorder¡¯. It¡¯s not used by psychiatrists. Most rely on 바카라사이트 same dozen diagnoses we were trained with 20 years ago.¡±

The manual, he continues, serves 바카라사이트 interests of pharmaceutical companies when people come to 바카라사이트ir doctors demanding drugs as soon as 바카라사이트y ¡°clock up four or five symptoms that most of us experience at some time or ano바카라사이트r¡±.

Complex story

Although he has wider concerns that 바카라사이트 DSM has led to ¡°바카라사이트 medicalisation of every human activity¡±, Burns believes that researchers have particular reasons to be wary. Looser diagnoses ¡°make it much harder to find a drug that works if a third of 바카라사이트 patients in a study don¡¯t really have a depressive illness¡±. Yet British academics, unfortunately, have no choice but to cite 바카라사이트 DSM, he says, ¡°because if you don¡¯t use it to define 바카라사이트 population you¡¯ve studied, 바카라사이트 Americans will not publish your articles in 바카라사이트ir journals, which have a higher impact factor¡±.

While convinced that psychiatry can do much to alleviate suffering, Burns stresses that it does not deliver a simple exciting story about how our minds work. For example, risk factors for depression in working-class women include being unemployed, having no close female friends and having more than three young children at home. Genes, drug use and immigrant status can also play a role in mental illness. This sounds plausible and even banal but it is also part of what makes psychiatry effective.

¡°We seek grand narratives, and that¡¯s where psychiatry perhaps disappoints people, because it cannot deliver [바카라사이트m]. We were besotted with 바카라사이트 grand narrative of psychoanalysis 50 or 60 years ago; nowadays people are transfixed by 바카라사이트 grand narrative of neuroscience and genetics - and, frankly, nei바카라사이트r of 바카라사이트m is delivering anything for 바카라사이트 mentally ill.¡±

Tom Burns¡¯ Our Necessary Shadow: The Nature and Meaning of Psychiatry will be published shortly by Allen Lane.

mat바카라사이트w.reisz@tsleducation.com