There’s a truly delightful little piece in February’s Current Psychiatry. It’s written by Henry Nasrallah, MD, and is titled Psychiatry’s future shock. Dr. Nasrallah is Editor-in-Chief of Current Psychiatry.
The gist of the article is that “transformative” changes are occurring in the psychiatric field, and psychiatrists had better get on board, or they will be left behind.
Here are some quotes:
“The ‘neuroscientification’ of psychiatry, ongoing for more than 3 decades, is now approaching a tipping point: The specialty is on the verge of an unprecedented denouement of the old tenets and assumptions.”
A tipping point! The great breakthrough is just around the corner. Where have we heard that before?
“Psychiatry of the future will be drastically different once new models of objective diagnostic tests and physiologically specific interventions emerge from fast-moving discoveries of the molecular biology of the mind and its pathologies.”
“There are many reasons to be optimistic that transcendent scientific transformations will sweep away the fuzzy biologic, diagnostic, and therapeutic ambiguities that have plagued psychiatry for so long—plagued us because of the herculean challenges of investigating the divinely complex brain and its gloriously enigmatic mind.”
So psychiatry has been plagued with ambiguities. This admission stands in marked contrast to the arrogant confidence with which psychiatry routinely promoted its concepts and marginalized those of us who dared to criticize its “fuzzy,” biological, diagnostic, and therapeutic ambiguities. And this “divinely complex brain” is the same organ that they formerly pathologized, with complete confidence, as chemically imbalanced! Apparently for psychiatry, the complexity of the brain is a recent discovery.
“New methods and tools for exploration and paradigmatic shifts in conceptualizing the etiopathogenesis of psychiatric brain disorders are rapidly leading to a discarding of many simplistic, even primitive, notions that have guided psychiatry over the past century. Psychopharmacological breakthroughs of the past 50 years, which, admittedly, have yet to cure or eliminate disabilities associated with major psychiatric disorders, are only a prologue to the coming revolution in neuropsychiatry, in which prevention, not just intervention, will change everything. Curing deteriorative brain disorders will be a reality once that revolution in neuroscience enters its propitious translational phase.”
Prevention will change everything! Neuroleptic drugs for bad-tempered four-year-olds, and for socially awkward teenagers. It certainly will change everything. In particular, we can expect to see an epidemic of tardive dyskinesia.
“Instead of remaining fondly attached to ancient constructs such as id, ego, superego, and defense mechanisms, we should be thinking about the default mode network, seeking to understand the connectome, the envirome, the metabolome, and the proteome; microglial activation, inflammatory markers, IL-6, TNF alpha, oxidative and nitrosative stress, and physiologic vs pathologic apoptosis; BDNF, FGF, VEGF, MIF, GFAP, and S100B; neuroplasticity and dendritic spines; and genes such as CLOCK, NOTCH3, and Met-to-Val mutations—and so on.”
I can’t remember the last time I heard a psychiatrists even mention id, ego, or superego, let alone be “fondly attached” to these notions.
“Those of us who do not adapt to swift transition of knowledge might suffer the fate of clinical dinosaurs, as the massive asteroid of neuroscientific advances smashes into the placid landscape of psychiatry.”
So basically it’s a cheerleading piece. Lots of fluff and imagery, including dinosaurs and asteroids, but no substance. The old concepts and treatments are out, and we must welcome the genetically caused neural circuitry notions and the high-tech super-duper treatments that will be available very soon. We won’t even need the 15-minute med check – just a quick saliva swab, and a computer-generated prescription, and you’re on your way! Oh Happy Day!
What Dr. Nasrallah fails to communicate, however, is that not too long ago, he himself was a big proponent of the tired old concepts. Here are some quotes from his not-too-distant past.
“Long-acting [anti-psychotic] agents represent a valuable tool for the management of schizophrenia and merit wider use, especially in light of emerging literature regarding the neuroprotective advantages of atypical antipsychotics over conventional agents in terms of regenerating brain tissue during maintenance therapy.” [The case for long-acting antipsychotic agents in the post-CATIE era, 2007]
This article is essentially an infomercial for risperidone (Risperdal), which in 2007 was the only long-acting atypical antipsychotic on the market. Risperdal is manufactured by Janssen, a subsidiary of Johnson and Johnson. The disclosure statement in the article indicates that Dr. Nasrallah had received “research grants” from Janssen, and according to Dollars for Docs, he received $172,840 from Johnson and Johnson in the period 2010-2012 (the only years for which this data is available). The present cost of a month’s supply of long-acting risperidone is about $900 in the US.
“As a chronic disease, schizophrenia is associated with lifelong morbidity, increased mortality and a short lifespan. It is a costly mental illness to treat, with an estimated annual cost of $70 billion in the US. The chemical imbalance in schizophrenia is correctable by medications and choice of medication formulation is critical for a full long-term remission.” [A More Rational Paradigm for Treating Schizophrenia, 2010]
The fact of the matter is that there was no valid evidence for Dr. Nasrallah’s 2007 assertion concerning the neuroprotective advantages of atypical antipsychotics, nor for the notion that these products regenerated brain tissue during maintenance therapy. Nor was there any evidence for his 2010 assertion that the condition known as schizophrenia is caused by a chemical imbalance “correctable by medications.“
Dr. Nasrallah made these statements because they were an integral part of the standard psychiatric orthodoxy at the time. They were the spurious philosophical underpinning to psychiatry’s routinely destructive and disempowering practices. Dr. Nasrallah was a “key opinion leader,” and according to Dollars for Docs, until 2013 was among the top 22 earners (number 7) of pharma dollars in the US. He had a huge vested interest in promoting and sustaining the status quo. And he discharged his duties with vigor and distinction.
Now that the standard psychiatric orthodoxy has been discredited as the spurious drivel that it is, he’s busy distancing himself from the errors of his past (notably without acknowledgement or apology), and is frantically climbing aboard the next gravy train – genes and neural circuits, “…objective diagnostic tests,” and “physiologically specific interventions.”
But there’s no more evidence to support the new orthodoxy than there was to support the old. It’s just more spin and hype. Will it never end?