Is psychiatry directionless?

Malhi (2019) sees psychiatry as having lost its target, as being directionless and content with uninspired goals. Such an assertion by our Editor needs to be thought through. Could it be true? In 2016, he set out his vision for this Journal, saying it should ‘question, challenge the zeitgeist and put forward alternative models ...’. Under his Editorship, this has largely been achieved, fuelled by the increasingly impressive quality of material submitted to the Journal from across the world. All submitted papers are selected collaboratively by the Editor and Associate Editors, who then have them reviewed by experts internationally. This work is at no cost to the publishers. What finally appears in these pages is far from directionless or dull. It is important to recognise that Malhi thinks that it is psychiatry itself, not the Journal, that has lost its appetite, that it is now content with otiose goals and seems to accept slow, incremental progress rather than aspiring to major advances.

Such assertions should stop us in our tracks to consider if it is indeed the case; and if so, what might be done to bring about change. In psychiatry, as in the rest of medicine, progress has in fact been made, admittedly incremental and admittedly without the rapid advances made in other fields, such as the control of infectious diseases, cancer treatment, transplant surgery or medical imaging. But in psychiatry over the last 100 years, progress has undisputedly been made about aetiology, in at last having psychotropic drugs, in refining the psychotherapies, in the neuroscience of mental disorders, in the development of services, in mental health literacy of the public and perhaps above all, in the breadth of training required of tomorrow’s consultants. All this time, across medicine, no other specialty has been dealing with entities as complex as the human mind and brain.

But it seems Malhi is asking for more. Some major deficiencies have to be conceded. For example, the massive expansion in services and prescription of psychotropic drugs has not reduced morbidity of the common mental disorders at the population level, at least in Australia. Treatment of the psychoses is hampered by imperfect medications and under-use of psychosocial interventions. Mental hospitals have been emptied, but large numbers of very disabled people are now languishing in the general community or prisons under very adverse conditions. Fewer than 20% of incident cases of schizophrenia achieve sufficient recovery (Haro et al., 2015). For depression and other disorders, treatment resistance is all too often encountered. No new psychotropic medications are emerging that are significantly better. Classification is unsatisfactory – Malhi says it is just a chimera.

For such reasons, he is not content that we should just keep seeing patients day after day while passively hoping that progress will emerge from somewhere. This leads to the question of how major advances might be brought about, other than spontaneously or serendipitously, as history says is by far the most likely. Could there be strategies that might increase the chances of exceptional scientific leaps forward? At a time when mental health is at last being accorded some attention, here is an agenda that calls for assertive action by bodies such as NHMRC and the New Zealand HRC, the Australian Academy of Health and Medical Sciences and most of all, by our own College.

Meanwhile, some leads for progress can be proposed. In talking specifically about psychiatric research, Sir Geoffrey Vickers (1968) famously said,

Research workers are commonly regarded as geese who occasionally lay golden eggs. The three main ways of encouraging them to do so reflect different views of the extent to which this odd process can be either stimulated or directed.

One way is to cosset any goose that actually has laid a golden egg, in the hope that it will lay some more. A second way is to specify the golden eggs required and offer rewards for them, hoping thus to move still unidentified geese to egg-laying. The third way is to go on increasing the goose farm in the hope that some statistical law will ensure that the number of golden eggs laid rises in proportion to the number of birds capable of laying eggs at all.

Our two countries could consider all three of these strategies which are in no way mutually exclusive. An immediate matter to tackle is the availability in Australia and New Zealand of geese that can lay eggs. Both countries provide meagre opportunities for our young psychiatrists to have a career in research. Snatching a few hours a week for research, usually in isolation, is unlikely ever to lead to a major finding. Little can be expected to come from clinicians in private practice. Only a tiny number of psychiatrists are in true research appointments, and they of necessity are already established researchers, invariably. Such posts are never available for young psychiatrists who have yet to acquire the track record demanded for research fellowships. Financial disincentives are a final barrier to recruitment. In short, if a core of gifted young people were to be generated, carrying some promise for major progress, a fundamental change has to come about in the career structure available. The likelihood of this is remote. This writer predicts that any advances of clinical significance are likely to come instead from other professions, particularly behavioural and biological scientists, not psychiatrists. It is unclear whether the RANZCP should be acceptant of this or try to improve the balance while addressing its other priorities.

Fortunately, there is something constructive we could do ourselves in the course of routine clinical work. It has been said that the purpose of academic medicine is to keep asking the question, ‘Is there a better way of doing this?’ Suppose this precept were applied by every one of us in their daily clinical encounters? It is quite possible that the spread of such a mindset could, over the next few decades, occasionally lead to an abrupt advance. Notice the time frame here. Politicians expect immediate returns on their initiatives, but the reality for clinical progress is different. Significant advances are likely always to be infrequent, usually spread over decades. What is needed to meet Malhi’s challenge is a 50-year plan.

But could there be exceptions to the present slow progress? Recent advances in evolutionary biology raise the possibility, albeit highly speculative, of bringing about abrupt advances. The masterly review by Quammen (2018) sets out some of these. Darwin always emphasised that evolution through natural selection moved ‘with extreme slowness’. He wrote in On the Origin of Species that ‘Natura non fecit saltum’. Nature does not make leaps. But this is no longer true. In the 1990s, a ‘jumping gene’ or transposon was identified that brings about a sudden change in the wing colour of peppered moths. The analogy for psychiatry is that an element within one of our own fields could be deliberately applied in another. A further recent finding has been horizontal gene transfer, with the movement of genes sideways between unrelated species, hitherto thought never to occur. It means that fresh genetic variation emerges abruptly in the recipient species. Psychiatry has already had such a gift from outside, with the application of medical imaging to the brains of people with a mental disorder. Such an event is akin to what Wilson (1998) meant by consilience, the merging of two disparate fields. For psychiatry, a big advance may yet come from an unexpected direction. A third observation is that evolution seems to be faster in cities than rural areas, presumably because of greater selection pressure. It is plausible that innovative thinking is more likely in scientific environments where there is intense activity. Watson and Crick were in the right spot.

Meanwhile, this Journal eagerly awaits the occasional submission that promises something more than a slow forward creep.