Staging sets trajectory

To the Editor

It was disheartening to read the May 2017 Special Issue of ANZJP, particularly Professor McGorry’s (2017) contribution, with the continuing complaint of lack of funds and his conclusion that the well-being of people with schizophrenia has barely improved, despite the huge efforts of people like himself, over many years.

Two contributing issues stand out: first, readily apparent in this Special Issue, is the preference for top-down studies rather than fundamental developmental biological studies at a molecular, atomic and systemic levels; the second and more immediate issue is psychiatry’s continuing support of the idea that mental illness is somehow entirely different from other medical illnesses.

The time has surely come when we must dispense with Cartesian duality (McFarlane, 2017) and insist that anxiety, depression, post-traumatic stress disorder (PTSD), mania, schizophrenia and other diagnostic categories of mental illness are medical disorders very like a range of other systemic disorders. Some presentations are, like some infections and other systemic disturbance, so mild as to warrant no medical interference and others can have deadly consequences. Depression and PTSD are already described as systemic disorders (McFarlane, 2017; Sotelo and Nemeroff, 2017). Acceptance of mental illnesses as unequivocal medical conditions would have to have ‘popular culture’ and political consequences.

While this requires a stand by all psychiatrists as medical doctors, it does not devalue the importance of psychology in the management of dis-eased persons. We are much better equipped than all other animals to understand our disabilities and take some responsibility for controlling/managing them ourselves. But, as the gatekeepers, psychiatrists have the responsibility of setting the level at which disturbance becomes disorder and recognised as illness.

A new classification encouraging neuroscience research is being called for, especially by biological researchers. Nevertheless, RDoC will continue to have a significant place even when the relevance of problems at different periods in gestation, as risk factors for nervous disorders, are determined.

With the growing awareness of the overlap between psychiatric disorders and other systemic disorders, including immune, inflammatory and cardiac disorders, the time is ripe, it would seem, for a paradigm shift or, at very least a much closer look at the molecular activities in all these conditions.