Response to “The State of Psychiatry Today”

An insider's defense

Posted Oct 29, 2013

While I tend to stay away from writing critical feedback about other blogs, the recent post by Dr. Liah Greenfeld entitled “The State of Psychiatry Today” requires some comment to correct what I believe are fairly monumental inaccuracies about psychiatry. As someone who performs research and trains young physicians to be child psychiatrists, I think I am in a good position to provide an inside view of the state of my field.

From the outset, it is worth noting that psychiatry is certainly not above criticism, and I have myself been quite critical on a number of issues. In addition, Dr. Greenfeld does make some valid points about the need to consider environmental factors such as culture in our understanding of what causes psychiatric disorders. If we asked most of us what things steer us to feel great joy or ultimate despair, we would probably hear references to family, love, and belonging much more frequently than the density of our dopamine receptors. However, in trying to make a point, Dr. Greenfield distorts psychiatry to a degree that is almost unrecognizable and grossly outdated. A few specific quotes deserve mention.

1) "No empirical proof of the biological causes of these major diseases exists at this point.” Let me table the logic behind whether mental functioning can be “nonbiological” for the moment and address the question directly. Dr. Greenfeld is certainly correct that a “smoking gun” that causes conditions such as schizophrenia and bipolar disorder has not been found, but going from there to a conclusion of a lack of biological evidence is an enormous leap. Just because there is not a single gene, pathogen, or brain circuit to blame does not mean in any way that biology is irrelevant. Perhaps psychiatry’s biggest mistake in this domain was to think (decades ago) that we ever were going to find such a cause in the first place. Because mental disorders tend to be characterized not by elements that don’t belong in the human body but rather by normally occurring behaviors (fear, sensation, sadness) being expressed too much, too little, or at the wrong time, it is quite likely that the biological “insults” are going to be more subtle. Despite this complexity, however, there are literally thousands of studies of all types (genetic, brain scan, animal, laboratory) that support a strong biological role in the cause of all psychiatric disorders. Furthermore, the best way to identify and defend the role of environmental factors like culture is not to ignore biological variables but to measure and control for them. It is also worth noting that a readily identifiable biological cause that is detectable through current technology is also not known for some of the most common nonpsychiatric problems from high blood pressure to headaches, yet nobody seems to be throwing in the towel for those searches. 

Dr. Greenfeld states that “even those committed to this position" admit to a lack of proof for biological causes and to that I would reply that I would love to introduce her to a few thousand of my psychiatric colleagues who would say otherwise. The parent of non-verbal autistic child who has struggled mightily since birth might also like to respond to the allegation that biology is not playing a large role here.

2) “Biological causes necessarily leads to biological treatment.” René Descartes in the 1600s promoted the idea of mind-body dualism and it remains a monkey on our back ever since I can say with complete confidence, however, that modern psychiatry has thankfully left that idea behind a long long time ago. Pick up a psychiatry journal today and it is full of how both genetic and environment causes are not only important but how they affect each other. Environmental events can cause changes in gene expression, psychotherapy results in changes on brain scans, and genetically influenced behavior causes certain environments to become more likely to occur. In this context, the whole question about biological versus nonbiological actually ceases to make sense. Psychiatry recognizes the importance of non-medication treatment because of the overwhelming research that things like psychotherapy are just as “biological” as a drug. Think about it a minute. How could it be otherwise?

3) “Family history was included as one of the symptoms in the psychiatric diagnosis.” It is misleading to report something a century ago as though it is still happening. The current DSM has thousands of criteria for hundreds of disorders and nowhere is family history one of them. Nobody makes a diagnosis simply based on family history. Do psychiatrists use family history? Sure—and so do internists when they ask about family history of breast cancer while trying to make a good recommendation for a patient. 

4) We study biology based on “career-enhancing considerations of social prestige.” Now it gets a little personal. Like all professions, psychiatrists include people with a wide variety of personalities, motivations, and attitudes. The vast majority, including those involved in biological research, are deeply committed to the welfare of people and improving mental health. Blanket statements that disparage a large group of dedicated professional are irresponsible, offensive, and just wrong.

Finally, what solution is being suggested in this post to this “biology ran wild” situation? As I mentioned in the beginning, a point about the importance of culture is fine, but making it at the expense of turning an entire field into a caricature is an easy and cheap way to go about it.  

David Rettew is author of Child Temperament: New Thinking About the Boundary Between Traits and Illness and a child psychiatrist in the psychiatry and pediatrics departments at the University of Vermont College of Medicine.

 Follow him at @PediPsych and like PediPsych on Facebook.