1950 onwards academic Psychiatry was dominated by psychodynamic theories, psychotherapy and psychosocial interventions. During that period Psychiatry suffered from the lack of knowledge about the brain. The Harvard Psychiatrist Leon Eisenberg rightly named it - Brainlessness in Psychiatry.
1990 onwards the period was announced as the Decade of Brain. We saw phenomenal advances in brain imaging, electrophysiological and multimodal studies of neurosciences. Empowered by that knowledge there was a revolution in psychopharmacology. Today psychiatrists are busy prescribing drugs only. The pendulum has swung from one direction to the other. Leon Eisenberg pointed out that Psychiatry was suffering from mindlessness. In January 2013, two bombshells were dropped that could alter the medical and scientific landscape forever. First, in his State of the Union address, president Barack Obama stunned the scientific community by announcing that federal research funds, perhaps to the tune of $3 billon might be allocated to the Brain Research through Advancing Innovative neuro technologies (or Brain) Initiative. Like the Human Genome Project, Which opened the floodgates of Genetic research, Brain will pry open the secrets of the brain at the neural level by mapping its electrical pathways. Once the brain is mapped, a host of intractable diseases like Alzheimer's, Schizophrenia, bipolar disorder, Autism might be understood.
Almost simultaneously, the European Commission announced that the Human Brain Project would be awarded 1.19 billion euros (about $ 1.6 billion) to create a computer simulation of the human brain. Using the power of the biggest super computers on the planet, the human Brain Project will create a copy of the human brain made of transistors and steel.
Three Approaches to the Brain :
Brain is so complex, there are at least three distinct ways in which it can be taken apart, neuron by neuron. The first is to simulate the brain electrically with super computers, which is the approach being taken by the Europeans. The second is to map out neural pathways of living brains, as in BRAIN (either anatomically, neuron by neuron or by function and activity). And third, one can decipher the genes that control the development of the brain, which is an approach pioneered by Paul Allen of Microsoft. There is a caveat in the concept. Instead of modelling the entire brain, Scientists try to duplicate just the connections between the cortex and thalamus where much of brain activity is concentrated. This means that the sensory connections to the outside world are missing in this simulation. Today, using the full power of the Blue Gene Computer Scientists have simulated 4.5 percent of the human brain's neurons and synapses.
In the decade of brain, many prefers to talk about brain disorder in place of mental disorders.
There is not a single mental of neurological diseases in which anybody knows what is malfunctioning in this circuit which pathway, which synapse, which neuron, which receptor. Brain can be thought of as hard disc of the computer simulation. The software comes from the environmental and outside connections with the world at large- culture & social factors are important in software and make it holistic one. In this conundrum of paradigm shift the burning question is the role of psychiatrists. Psychiatry has now become very much biologically focused. Psychotherapy and psychosocial orientation are equally important in patient care to promote functional recovery in the continuum of Patienthood to Personhood. Biological reductionism has created a blind spot in the mindscape of psychiatrists by three false assumptions :
1) Genes = Disease.
2) Patients present with single disorder that responds to single evidence based treatment.
3) The best treatment is pills.
Hundreds of studies suggest that behavioural, psychodynamic and other forms of psychotherapy are effective treatments. The combination of medications and psychotherapy is often better than either used alone. Brain changes associated with psychotherapy, as seen by imaging techniques, allow therapy responders to be differentiated from non responders. Psychotherapy is as much a medical treatment as pharmacotherapy as scientists have pointed out. Inspite of this, psychotherapy and psychosocial interventions have taken a backseat in the present scenario. Psychiatrists today focus on single diagnosis as per ICD or DSM and the only modality of treatment is pharmacotherapy. Several factors contribute to this shift of focus:
1) The discovery of neurobiological correlates.
2) A shift towards the medical model as the dominant paradigm away from biopsychosocial model.
3) The efficacy assessment of psychotropic drugs by RCT and rise of quasi-scientific evidence based psychiatry.
4) Equating genes with mental diseases and over expectation from the Human Genome Project.
5) The considerable influence and financial power of the psychopharmacological industry.
There has been a visible decline in provision of psychotherapy in postgraduate training program and in clinical practice. The place of psychotherapy in psychiatry is endangered. In the present scenario should psychiatrists continue to focus on this reductionistic "bio-bio-bio" model or broaden its medical model for integration of brain and mind - Brain- Mindfulness Paradigm?
Psychiatry is more than applied neuroscience. It is Humanistic Medicine. Integration of Psychopharmacological therapy (bottomup approach) and psychotherapy (topdown approach) will make psychiatry unique and very special in the medical arena .
False assumptions in psychiatry : We need to correct our biologically reductionistic stance as well as three critical false assumptions connected with patient care.
False Assumpsion # 1 : GENE = DISEASE :Mental Disorders are clearly heritable. It was hoped that sequencing of human genome would reveal the genetic underpinnings of mental disorders. In schizophrenia, over a hundred relevant genetic loci have been identified, indicating a very complex and polygenic inheritance. Genome Wide Association Studies (GWAS) in large samples of depression did not reveal meaningful SNPs that illuminate the genetic basis. No biomarkers for any mental disorders have been found to date and some have likened the search to that of the Holy Grail. Tully et al report that the presence of maternal depressive disorder during child rearing increase the risk of depression in both adopted and nonadopted adolescents. Other studies provide support to the theory that early adversity is an important "Enviromarker" associated with the risk of mental disorders. Hence it is logical to deduce that psychotherapy and psychosocial treatment will have a great impact in patient care. The biomedical approach focuses on a "vulnerability model" of disease rather than a "plasticity model". This is a genuine blind spot in psychiatry.
A plasticity model, with its concept of RESILIENCE lays great importance on past and present beneficial environment and relationships, highlighting the value of psychosocial intervention. Environmental factors interact with genes to shape individuals by turning genes on and off. It is more Gene-by-Environment (G×E) than genes alone. Epigenetic model is the recent way of expression of bio-psycho-social model. British psychotherapy researcher, Holmes opines that "Phenotype does not come just from genes but rather, Phe = GE2". Here Holmes mirrors Einstein's transformative E = mc2 equation that taught us energy and matter are different manifestations of the same entity and even a small amount of matter can produce a huge amount of energy. In this transformation Phe = GE2 equation, Holmes suggests that phenotype is a function not only of genes but also of Environment squared (a function of both the early and recent environments). Recently there has been an effort to include environmental factors in the search for biomarkers.
According to Holmes :
l. Phe = GE2
2. Phenotype is a function of genes and of the environment squared (i.e both the early and recent environments).
False Assumption #2 : Patients present with single disorders that respond to specific evidence based treatment.
Practice guidelines and RCTs generally assume that most patients have single disorders that respond to evidence based medicine, which are tested in carefully selected, non- comorbid samples. How far this assumption fits real world patients is anybody's guess.
Results from authentic STAR*D sample suggests almost 78% had comorbid conditions that exclude them from RCTs. The response and remission of depressive symptoms are 39% and 25% respectively. Other evidence from the Collaborative Longitudinal Personality Disorder Study (CLPS) suggests personality disorders specially BPDs robustly predicted persistence of MDD. The mainstay of treatment of personality disorders is psychotherapy. Hence there is substantial evidence that most patients present with multiple disorders and comorbidity. The future of psychotherapy and integration of psychosocial intervention in patient care will depend on the psychiatrists ability to make a mid course correction of the false assumption about patients and the treatment they need.
FALSE ASSUMPTION # 3 : The best treatments are pills.
Current psychotropic medications are undoubtedly effective and powerful agents with their limitations as well. Antidepressant efficacy studies are confounded by high placebo response rates. Effect sizes of psychotherapy are greater than the effect sizes of medications. There is evidence that patients with chronic and complex comorbid depression, specially those with history of early adversity respond well to CBT and other forms of psychotherapy. Similarly cluster B personality disorders respond well with DBT and CBT more than medications.
Nemeroff et al conclude "Our findings suggest that psychotherapy may be an essential element in the treatment of patients with chronic forms of major depression and with a history of childhood trauma". Jerome Frank says "Psychotherapy is not a technical procedure but a healing relationship - in which patients arrive demoralized and hopeless but improve by regaining morale and hope. Therapist is an expert companion who understands patients distress and help him out of morass. Empathy and feel good factor in therapeutic alliance is the lynch pin of functional recovery. Eric Kendel in his essay "Psychotherapy and single synapse" emphasised that psychotherapy works at the same level in neural circuits and synapses as drugs. Psychotherapy changes gene expression. Learning changes neural connections. This point of view integrates brain and mind in the frontiers of neuroscience. This echoes the opinion of Leon Eisenberg "Neither mindlessness nor brainlessness, brain-mindfulness "is the paradigm of patient care for today and tomorrow.
The mission of psychiatry : We look forward to a psychiatry that is neither brainless nor mindless but focuses on brain-mindfulness. This will help in patient care. The most important responsibility is to care for the large number of people with mental illness who are victims of stigma, myth and misconceptions. Research will continue to influence the future of psychiatry. As science develops, and as the mind and the brain are better understood, new methods of treatment will emerge. The commitment of psychiatry should be to science and science tells us both biological and psychological interventions are each in their own way, prescriptions that can heal the mind.