THE FUTURE OF PSYCHIATRY IS THE BIOPSYCHOSOCIAL MODEL

1. THE FUTURE OF PSYCHIATRY IS THE BIOPSYCHOSOCIAL MODEL D B Double

2. My argument • Psychiatry has always had a biomedical emphasis

3. My argument • Psychiatry has always had a biomedical emphasis • There has always been a biopsychosocial minority view

4. My argument • Psychiatry has always had a biomedical emphasis • There has always been a biopsychosocial minority view • The future needs to be shifted away from biomedical to biopsychosocial

5. John Haslam (1764-1844) • Insanity is "a corporeal disease".

6. John Haslam (1764-1844) • Insanity is "a corporeal disease". • Mental illness is "the peculiar and exclusive province of the medical practitioner" (his emphasis)

7. John Haslam (1764-1844) • Insanity is "a corporeal disease". • Mental illness is "the peculiar and exclusive province of the medical practitioner" (his emphasis) • “[M]adness has always been connected with diseases of the brain and of its membranes”

8. John Haslam (1764-1844) • "[T]he various and discordant opinions, which have prevailed in this department of knowledge, have led me to disentangle myself as quickly as possible from the perplexity of metaphysical mazes."

9. John Haslam (1764-1844) • "[T]he various and discordant opinions, which have prevailed in this department of knowledge, have led me to disentangle myself as quickly as possible from the perplexity of metaphysical mazes." • "[F]rom the limited nature of my powers, I have never been able to conceive . . . a disease of the mind." (his emphasis)

10. Henry Maudsley (1835–1918) • Donated money to found Maudsley hospital - centre of treatment and research rather than confinement and "asylum".

11. Henry Maudsley (1835–1918) • Donated money to found Maudsley hospital - centre of treatment and research rather than confinement and "asylum". • Expanded scope of Journal of Mental Science to include psychology and philosophy

12. Henry Maudsley (1835–1918) • Donated money to found Maudsley hospital - centre of treatment and research rather than confinement and "asylum". • Expanded scope of Journal of Mental Science to include psychology and philosophy • "The explanation, when it comes, will not come from the mental, but from the physical side”

13. Aubrey Lewis (1900-1975) • Inaugural chair from 1948 of Institute of Psychiatry which was “Maudsley Hospital Medical School”

14. Aubrey Lewis (1900-1975) • Inaugural chair from 1948 of Institute of Psychiatry which was “Maudsley Hospital Medical School” • Postgraduate psychiatry for “ardent, critical, lively, disputatious and reflective, eager minds.”

15. Aubrey Lewis (1900-1975) • Inaugural chair from 1948 of Institute of Psychiatry which was “Maudsley Hospital Medical School” • Postgraduate psychiatry for “ardent, critical, lively, disputatious and reflective, eager minds.” • Lewis’s sceptical approach to psychiatry may not be enough

16. Wilhelm Griesinger (1817-1868) • Mental pathology and therapeutics (original German edition 1845)

17. Wilhelm Griesinger (1817-1868) • Mental pathology and therapeutics (original German edition 1845) • “Mental diseases are brain diseases”

18. Wilhelm Griesinger (1817-1868) • Mental pathology and therapeutics (original German edition 1845) • “Mental diseases are brain diseases” • "It is only from the neuropathological standpoint that one can try to make sense of the symptomatology of the insane”

19. Ernest von Feuchtersleben (1806-1849) • The principles of medical psychology (originally German edition 1845)

20. Ernest von Feuchtersleben (1806-1849) • The principles of medical psychology (originally German edition 1845) • "The notion, mental disease, must be deduced neither from the mind nor from the body, but from the relation of each to the other."

21. Ernest von Feuchtersleben (1806-1849) • The principles of medical psychology (originally German edition 1845) • "The notion, mental disease, must be deduced neither from the mind nor from the body, but from the relation of each to the other." • "Psychopathies have no seat; they are combined constitutions which appear in the disturbance of these functions by which the mind is manifested, that is, in the collective personality."

22. Pluralism in psychiatry (1900-1970) • Psychoanalysis – Freud first spoke publicly in USA at Clark University in 1909

23. Pluralism in psychiatry (1900-1970) • Psychoanalysis – Freud first spoke publicly in USA at Clark University in 1909 • Pragmatic approach of Adolf Meyer - Psychobiology

24. Pluralism in psychiatry (1900-1970) • Psychoanalysis – Freud first spoke publicly in USA at Clark University in 1909 • Pragmatic approach of Adolf Meyer - Psychobiology • Focus on the person

25. The current scene • Underwhelming evidence of efficacy of medication

26. The current scene • Underwhelming evidence of efficacy of medication • Lack of appreciation of environmental factors in psychiatric disorders

27. The current scene • Underwhelming evidence of efficacy of medication • Lack of appreciation of environmental factors in psychiatric disorders • Non-standardised use of operational diagnostic criteria

28. The current scene • Underwhelming evidence of efficacy of medication • Lack of appreciation of environmental factors in psychiatric disorders • Non-standardised use of operational diagnostic criteria • Lack of ability to examine the structure and function of the mind directly

29. 1) Underwhelming evidence of efficacy of medication • About a third of published studies show no difference between antidepressants and placebo

30. 1) Underwhelming evidence of efficacy of medication • About a third of published studies show no difference between antidepressants and placebo • Mean drug–placebo difference in improvement scores is only 1.8 points on the Hamilton Rating Scale for Depression

31. 1) Underwhelming evidence of efficacy of medication • About a third of published studies show no difference between antidepressants and placebo • Mean drug–placebo difference in improvement scores is only 1.8 points on the Hamilton Rating Scale for Depression • Raters' expectations and patients' suggestibility could entirely explain the small effect size

32. 2) Lack of appreciation of environmental factors • Work of the geneticists has been replete with uncritical dogmatic statements and lack of scientific rigour

33. 2) Lack of appreciation of environmental factors • Work of the geneticists has been replete with uncritical dogmatic statements and lack of scientific rigour • Despite the hype, genetics of psychiatric disorders so complex that accurate prediction may not be possible

34. 2) Lack of appreciation of environmental factors • Work of the geneticists has been replete with uncritical dogmatic statements and lack of scientific rigour • Despite the hype, genetics of psychiatric disorders so complex that accurate prediction may not be possible • Genes only set the boundaries of the possible; environments define the actual

35. 3) Non-standardised use of operational diagnostic criteria • Diagnostic criteria do not solve the dilemma surrounding psychiatric classification

36. 3) Non-standardised use of operational diagnostic criteria • Diagnostic criteria do not solve the dilemma surrounding psychiatric classification • The basic issue is about the meaning of psychiatric diagnosis

37. 3) Non-standardised use of operational diagnostic criteria • Diagnostic criteria do not solve the dilemma surrounding psychiatric classification • The basic issue is about the meaning of psychiatric diagnosis • Too easily assume a diagnosis is an entity of some kind

38. 4) Lack of ability to examine structure and function of the mind directly • Structural and functional cerebral abnormalities are at best subtle rather than gross.

39. 4) Lack of ability to examine structure and function of the mind directly • Structural and functional cerebral abnormalities are at best subtle rather than gross. • Brain cytoarchitecture itself is fashioned by input from the social environment

40. 4) Lack of ability to examine structure and function of the mind directly • Structural and functional cerebral abnormalities are at best subtle rather than gross. • Brain cytoarchitecture itself is fashioned by input from the social environment • Even psychosis should be understood in psychosocial terms, rather than reduced to brain abnormalities

41. Conclusion - Biomedical psychiatry as the Emperor’s new clothes • “Biomedical psychiatry is naked," the child said.

42. Conclusion - Biomedical psychiatry as the Emperor’s new clothes • “Biomedical psychiatry is naked," the child said. • Biomedical psychiatry could not admit to that. It thought it better to continue the procession under the illusion that anyone who couldn't see its clothes was either stupid or incompetent

43. Birth pang of a new age? • Questioning the biological basis of mental disorder does not necessarily amount to denial of the reality of mental illness or invalidation of the practice of psychiatry

44. Birth pang of a new age? • Questioning the biological basis of mental disorder does not necessarily amount to denial of the reality of mental illness or invalidation of the practice of psychiatry • Avoid the need to objectify those identified as mentally ill

45. Birth pang of a new age? • Questioning the biological basis of mental disorder does not necessarily amount to denial of the reality of mental illness or invalidation of the practice of psychiatry • Avoid the need to objectify those identified as mentally ill • Recognise the inherent uncertainty in psychiatry and medicine