PSYCHIATRISTS and other mental health practitioners are nothing if not pragmatic, using the best available evidence to guide diagnoses and treatments. But not since Freud’s pseudoscientific theories early last century has psychiatry claimed any broad theoretical basis for making sense of our normal and abnormal feelings, thinking and social behaviours – the complexities at the heart of being human.
In fact, the international classifications used to diagnose mental disorders are descriptive and explicitly “atheoretical” – to acknowledge our limited understanding and the need for empirical evidence rather than fanciful theory.
While this is a necessary stage in the development of a complex field and intellectually attractive to some, there is a need to create a coherent scientific narrative and a more theoretical foundation for psychiatry. This may seem like a challenge too far for many, and it has undoubtedly been an impediment to recruiting enough of the best minds.
That matters for everyone. Mental ill health accounts for some 15 per cent of the disease burden in developed countries – and people who are seriously mentally ill typically die 20 years earlier than would otherwise be expected. Globally, by 2020, the WHO expects depression to come second only to heart disease as a cause of lost years of health. For that to improve, psychiatry must be able to recruit the very best.
Recently, some colleagues and I launched a report, Strengthening Academic Psychiatry in the UK, and found ourselves justifying how psychiatry had acquired – and was still struggling to shrug off – the label of a “vulnerable academic discipline”. There were particular concerns about a fall in academic recruitment and unfilled academic posts.
Compare this with a field like physics. At just one frontier, it has a standard model that describes particles, Higgs field theory, the search for the Higgs boson and the Large Hadron Collider. These constitute a clear narrative: there is a global collaborative search for a “missing” particle based on fundamental theory, using a large and expensive piece of equipment that allows experimental testing of this and other predictions. This heady mix understandably makes physics a popular career choice.
Psychiatry, on the other hand, started the new millennium a few hundred years behind physics. But the decade that followed saw radical change, and set the stage for an intense period of catch-up. It is not fanciful to describe what will happen as the equivalent of some 200 to 300 years of progress being compressed into 20 to 30 years. This corresponds to the period of greatest productivity in a scientist or clinician’s career, so someone starting research now stands to make great headway.
Psychiatry was centuries behind physics, but the stage is now set for an intense period of catch-up
If such a speedy catch-up seems like an extravagant claim, consider that the scientific kit and culture of “big science” are now sufficiently developed to deliver unprecedented insights into the neuroscience of mental illness. Key tools include molecular genetics, neuro-imaging and artificial intelligence.
We are already seeing research into the neuroscience of decision-making and social behaviours such as neuro-economics, which models choice behaviour mathematically. And enormous advances are being made in understanding the molecular genetics of major disorders such as schizophrenia, bipolar disorder and depression.
For centuries, we have known that susceptibility to psychiatric illness can be inherited. In the past five years, studies of tens of thousands of people are beginning to pin down some of the genes and biochemical pathways involved.
Take voltage-gated calcium channels. They were initially implicated in bipolar disorder in 2008, but have subsequently been linked to other psychiatric disorders. This was not a pathway that researchers had considered. It is, however, well understood when it comes to heart disorders.
That fact immediately opens up new ways of using existing knowledge and drugs. Crucially, too, this kind of exciting research may help us understand why we quite often see people who are both mentally and physically ill. In the calcium channel example, it may help explain why we often see patients with both heart disease and mood disorders.
Another tantalising finding is the involvement of the major histocompatibility complex – a key part of the immune system – in influencing how susceptible people are to mental illness. Together with research into other immune-related genes in diseases such as Alzheimer’s, the idea that immune processes are involved in some psychiatric phenotypes is looking ever more solid.
Powerful advances are also being made in using computer networks to model neuron biology and to build complex neuronal networks, which should produce interesting emergent properties. The European Union’s €1.1 billion Human Brain Project, for example, aims to understand the brain as a single system, integrating multiple levels of organisation – surely a key step towards preventing or curing psychiatric diseases.
One of the biggest challenges will be to unite these disparate methodologies to tease apart the normal and abnormal working of the brain in schizophrenia, bipolar disorder, depression, and the like, diseases that devastate the lives of so many and are so often associated with early death.
So, in 2013, psychiatry has powerful scientific tools and a developing narrative that already points to strong theoretical bases. Yet, in the UK research into mental illness has stalled at around 5 per cent of the annual medical research budget, and the picture is similar in other rich countries. That will have to change – and governments and funders are starting to see this. The door is open: all that is needed is for more of the best to come in and find out just how hot psychiatry really is.
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