The truth,the whole truth and nothing but the truth

This truth is incontrovertible. Panic may resent it, ignorance may deride it, malice may distort it, but there it is.

(Sir Winston Churchill, 1916)

A couple of years ago, the ANZJP made a strategic decision regarding its publishing policy, heralding that it would steadfastly pursue the truth (Malhi, 2016). The essence of this mission (which we chose to accept) was to challenge opinion wherever it was deemed necessary so as to test it to its full extent, to posit new ideas and proffer alternative perspectives, and to generate genuine discussion and debate – all with the overarching aim of gaining a clearer perspective on reality. Notably, many liked the article and admired the ambition of the Journal but, at the same time, expressed reservations, stating, for example, ‘This is likely to ruffle a few feathers … I’m not sure everyone would approve’. Others described the move as ‘bold and daring’ – meaning foolhardy and risky. To some extent, the ‘experiment’ is still underway, but indicators thus far suggest that this new strategic direction has only benefitted the Journal, with an increase in impact factor, submissions to the Journal and visibility online. It is therefore time to consolidate our position by being more assertive and at times provocative.

For some time, the ANZJP has been sounding the alarm, a booming foghorn audible across the cold Antarctic sea warning of imminent danger. Psychiatry, nay medicine, nay science, is ultimately about seeking the truth – observing reality for what it really is. It is an endeavour charged with the responsibility of understanding nature and comprehending the essence of being. It is precisely this that charges scientific enquiry with excitement. But as we charge forward armed with new tools and novel strategies, we seem to have lost our way and no longer have a deeper understanding of psychiatric illnesses as our target. In our wake, we have created a landscape that has been given structure through scientific taxonomy; we feel reassured that these are charted waters. However, a closer look at the map of psychiatry reveals that it is nothing but a chimera and that, in reality, we have failed to drop anchor and are very much still at sea. This is a grave problem.

The fact that we are directionless in the face of enormous challenges is not our main problem, however. The much greater and far more perilous danger is that we seem to be losing our passion and drive for genuine discovery. We seem no longer to want to know the truth. Instead, we are increasingly satisfied with acknowledging that the psychiatric conundrums we face are difficult, far too difficult indeed for us to comprehend or have any hope of solving. In fact, the search for truth is viewed as folly – and the belief that a truth exists as misguided. In other words, we are no longer hungry because we feel reassured (falsely) by what we already seemingly ‘know’, and yet, many of the ideas and concepts that form the bedrock of our wisdom are as ephemeral as the waves in the sea. It is this washing away of interest, this diminished appetite, that is most sinister, as it heralds the emergence of an insidious melancholia that is gradually seizing the science of psychiatry.

Is this true? Is this really ‘The Truth’? Where is the evidence? One example is our undertaking to understand and treat depression.

We have come a long way since the advent of electroconvulsive therapy (ECT) and the discoveries of tricyclics and lithium. Indeed, we now have an impressive armamentarium, both pharmacological and psychological, not to mention the burgeoning interest in physical treatments. And yet, tangible improvements in outcomes are modest at best (Malhi and Mann, 2018). Instead, more often than not, patients with depression fail to respond to successive therapies and drift inexorably towards treatment resistance (Malhi et al., in press). And, the same can be said for nearly all other psychiatric illnesses. The irony is that never before have we had such impressive tools, such wonderful means of examining the architecture of the mind – in short, such opportunity. So, why is it we are increasingly withdrawing from the real challenge before us – i.e., to have a complete and meaningful understanding of the brain that fully explains psychiatric phenomenology; knowledge that will allow us to develop new and far better treatments, prevent some illnesses altogether and perhaps even remove some from ever being a possibility. Instead, we have resigned ourselves to achieving otiose goals. Part of the reason is that this has not been a conscious decision – it has happened gradually, imperceptibly and perhaps without us knowing. Through a variety of channels, caution has become the favoured pathway in lieu of leaps of faith and true experimentation. This is evident, for example, when seeking grant funding for research. Despite the ambitious mission statements of our research bodies, in reality, genuine zeal for novelty and risk-taking is curbed. The idea of significant advancement has been displaced by incremental change – the concept of building gradually – moving slowly but with greater confidence and assurance towards a goal. It sounds like a sound approach, but it is one that rarely approaches fruition. Added to this stance of circumspection, increasing emphasis has been placed on repeating the same paradigm with only slight (often negligible) variations on the theme. There is no longer a need to demonstrate an advance per se, only the promise of a difference is required; a difference that, in practice, translates to simply more of the same.

Returning to the example furnished earlier, it has meant that the bar for treatment has remained static. A new drug only ever needs to improve upon placebo and show equivalence to those agents that are already in place, provided it is ‘acting’ in a ‘different’ manner. This mechanistic change in effect usually means that the new drug has a different side effect profile and its means of bringing about improvement remains as much of a puzzle as the agents it intends to supersede. In terms of real differences, i.e., clinical improvement, there is rarely significant change. Of course, not every new medication has to be a significant advance, and sometimes, several modest steps are needed before there is a genuine leap forward. But reviewing the pharmacological development of antidepressants over the past three decades, it appears that we have been treading water and that, despite our efforts, we are no closer to the shore than before. Indeed, our early clinical insights and our initial serendipitous findings (e.g. ECT, lithium and tricyclic antidepressants) remain at the top of our league tables. Efforts to displace them have arguably largely come from marketing rather than innovation per se.

This is why the ANZJP is reaffirming its commitment to seeking the truth, encouraging discovery, challenging the zeitgeist and questioning clinical and, in particular, classificatory dogma. Psychiatry is medicine of the mind – science of the psyche. Psychiatric disorders can be fathomed, and the truth can be found. We simply need to regain our belief that this is true and can be so.