A leading psychiatrist has criticised “ultra-scientific” approaches to mental illness and the harm wrought by the hugely influential American Diagnostic and Statistical Manual of Mental Disorders, the fifth edition of which is released this week.
Long before he became professor of social psychiatry at the University of Oxford, Tom Burns had first-hand experience of what was at stake. His mother had a nervous breakdown when he was 15, and he and his brother spent the next 20 years coping with the recurrences. Looking back, he believes he learned three central lessons.
“It taught me that psychiatric treatments do work,” he says. “They make a fantastic difference. They are not trivial, they are as good as anything you see in surgery or anywhere else in medicine…I also saw that there are limits to what we can understand, limits to what can be done - you have to live with that and not keep demanding that everybody can be cured.”
Yet Burns also could not help noticing that “some psychiatric teams were markedly better than others. The things that distinguished the better teams were not the treatments they had available in terms of drugs - they were the same for everyone - but the fact that they were able to maintain a more durable, sensitive focus on the individual.
“The thing I took from that and that has never left me is that psychiatry is utterly based in and dependent on a relationship. It is not a secondary, luxury add-on. It is the core of the activity. What I feel anxious about in modern psychiatry is that we have become quite preoccupied with the technology and, certainly in our writings, downplay the importance of continuity of care and relationships.”
Such are the central themes of Burns’ forthcoming book, Our Necessary Shadow: The Nature and Meaning of Psychiatry, which sets out to separate the many achievements of psychiatry from its equally striking history of incompetence, coercion and even abuse.
Most of the greatest advances, as in the rest of medicine, have come about by chance. The discovery of antipsychotic and antidepressant drugs, for example, was serendipitous, Burns says - “We just stumbled over them, we didn’t go looking for them” - but they have had an enormous impact.
“There’s a lot of romantic bullshit talked about how wonderful it was” before such drugs were available, he says. “Yet without these drugs, people lead miserable, diminished and often ghastly lives. It would be outrageous to deny the importance of those drugs.”
Burns worked as a clinician in the NHS for a decade before taking on an academic post at St George’s, University of London, where half his time was devoted to research and teaching. His position at Oxford is in essence a research role, and he is clear that academic analysis can and should transform clinical practice.
“Because our patients are often demoralised and depressed,” he explains, “we have to put a lot of emotional energy into the treatment; so perhaps it is not surprising if we are over-optimistic about the effects. The true test of decent research is that it should have the power to confound your expectations.”
Burns has recently completed a randomised controlled study of community treatment orders - which allow the compulsory medical supervision of mental health patients - a measure for which he has been “a strong advocate for 20 years”, as he reports in the book. And yet the research demonstrated that they produce “absolutely no effect. The CTOs neither reduce relapse and readmission to hospital nor appear to confer any real benefits in terms of symptoms or general wellbeing.”
Another study indicated that what Burns calls the “ultra-scientific, biomedical…public face of psychiatry” was something of an illusion. Videotaped consultations with long-term schizophrenia patients show that psychiatrists spent only two out of 20 minutes discussing “symptoms and tablets” and devoted the rest of their time to issues of how “patients were managing their daily lives”.
This leads Burns to consider one of the landmarks in the field, the new edition of the Diagnostic and Statistical Manual of Mental Disorders, known as DSM-5.
Its history is revealing. DSM-III, in 1980, was produced in response to an embarrassing report showing that US psychiatrists (along with their Cold War rivals, the Russians) were the worst mental health diagnosticians in the world. Robert Spitzer, the influential psychiatrist who was chair of the editorial committee for DSM-III, “had the express aim of tightening up diagnoses so that fewer people would be diagnosed”.
In practice, precisely the opposite happened. Where doctors had previously looked for the overall pattern of an illness, they began to fall back on checklists that tended to lower the threshold and increase the number of diagnoses.
The DSM, in Burns’ view, has now become a bloated “committee-driven tool, where everybody lobbies for their particular diagnosis, so it includes ludicrous things such as ‘oppositional defiant disorder’. It’s not used by psychiatrists. Most rely on the same dozen diagnoses we were trained with 20 years ago.”
The manual, he continues, serves the interests of pharmaceutical companies when people come to their doctors demanding drugs as soon as they “clock up four or five symptoms that most of us experience at some time or another”.
Although he has wider concerns that the DSM has led to “the medicalisation of every human activity”, Burns believes that researchers have particular reasons to be wary. Looser diagnoses “make it much harder to find a drug that works if a third of the patients in a study don’t really have a depressive illness”. Yet British academics, unfortunately, have no choice but to cite the DSM, he says, “because if you don’t use it to define the population you’ve studied, the Americans will not publish your articles in their journals, which have a higher impact factor”.
While convinced that psychiatry can do much to alleviate suffering, Burns stresses that it does not deliver a simple exciting story about how our minds work. For example, risk factors for depression in working-class women include being unemployed, having no close female friends and having more than three young children at home. Genes, drug use and immigrant status can also play a role in mental illness. This sounds plausible and even banal but it is also part of what makes psychiatry effective.
“We seek grand narratives, and that’s where psychiatry perhaps disappoints people, because it cannot deliver [them]. We were besotted with the grand narrative of psychoanalysis 50 or 60 years ago; nowadays people are transfixed by the grand narrative of neuroscience and genetics - and, frankly, neither of them is delivering anything for the mentally ill.”
Tom Burns’ Our Necessary Shadow: The Nature and Meaning of Psychiatry will be published shortly by Allen Lane.