Recently, the Observer in the U.K. (29/1/12) carried at least three articles concerning mental health issues. One refers to the growth of brain cells from stem cells, themselves derived from skin samples of people with schizophrenia and bipolar depression with an eye to testing new drug treatments for these conditions. Another discusses political debate over definitions of happiness as ideological differences play out around these distinctions. Emphasising how compelling the media find the study of happiness, the Observer also treated me to a free copy of Tal ben-Shar’s 192 page book on the subject. The third was an outline of statistics and expressions of concern about suicide amongst children in penal custody.
Years experience of teaching psychiatry to medical students have made its Marmite-like properties clear … they either love it or they hate it, and year on year more fall into the latter category. Despite figures which present mental illness as an impending tsunami of disability; one in four of the population will suffer, single most common reason for sickness-related benefits, predicted greatest cause of disability world-wide by 2030, huge numbers of American adolescents taking psychiatric medication, more than forty two million NHS prescriptions for antidepressants in 2010/11, and rising, few want to do it. Despite initiative after initiative, psychiatry remains close to the bottom amongst medical students’ and newly qualified doctors’ career choices.
Those that don’t like it find it messy. One recent survey from New South Wales reported that students find psychiatry “low prestige”, that its treatments are ineffective and that it lacks scientific foundation1. Those that do like it also find it messy, but revel in the mess. A parallel Canadian survey reported that students interested in psychiatry had an educational background in the arts and a strong social orientation2. The uncertainties of diagnosis, the absence of confirmatory laboratory findings and conflicting theoretical frameworks which range from the neurobiological through cognitive behavioural to psychoanalytic and the socially constructed make psychiatry feel like a messy swamp. Not a comfortable place for the aspiring doctor wanting to practice the appliance of science.
Swamps are only a problem if you want to farm, to build a house or to drive a road across them. If you are a botanist, a bird watcher or an entomologist they are a delight, which brings us back to the Observer. It reminds us that for the wider world, mental health and illness are not just the narrow concern of specialists. Happiness, despair and confusion are everyone’s business and most people’s experience at one time or another. Attempting to shoe-horn the vagaries of human experience into the conceptually narrow confines of “illness” isn’t working and won’t prove sufficient. Of course there may yet be therapeutic gains to win from neuroscience but the same is also true for other disciplines that contribute to the study of human difficulties and how we respond to them; law, nursing, philosophy, politics, psychology, social sciences and more. If those in the field are to match wider expectations of their teaching, their practice and their research, then we have to rise to the challenge, and acknowledge that what are about is indeed a truly pluralistic enterprise.
Unfortunately one person’s pluralism can be another person’s tribal conflict. Mental health services and mental health research remain firmly hierarchic, with the medically qualified psychiatrist at the top of the tree, and with that comes a whole herd of “elephants in the room”. Certainly the most able should lead, but is that synonymous with a medical qualification? Even if it is, is the pluralism necessary to do the task justice achieved by the training currently undertaken by the medical psychiatrist? Perhaps what is most striking amongst medical students encountering psychiatry for the first time is their struggle with the credibility of “these are just illnesses like any other”. However else they might be described, on the whole medical students are bright young people. Is the honest insight of the young trying to say something we find difficult to hear?
1.Mahli, G.S., Coulston, C.M., Parker, G.B., Cashman, E., Walter, G., Lampe, L.A. and Vollmer-Conna, U. (2011). Who picks psychiatry? Perceptions, preferences and personality of medical students. Australian and New Zealand Journal of Psychiatry. 45 861 – 870.
2. Gowans, M.C., Glazier, L., Wright, B.J., Brenneis, F.R. and Scott, I.M. (2009). Choosing a career in psychiatry: Factors associated with a career interest in psychiatry amongst Canadian medical students on entry to medical school. Canadian Journal of Psychiatry 54 557 – 564.
“one in four of the population will suffer, single most common reason for sickness-related benefits, predicted greatest cause of disability world-wide by 2030, huge numbers of American adolescents taking psychiatric medication, more than forty two million NHS prescriptions for antidepressants in 2010/11, and rising, few want to do it. Despite initiative after initiative, psychiatry remains close to the bottom amongst medical students’ and newly qualified doctors’ career choices.”
Perhaps in the U.K., but in the U.S. that spells CHING CHING CHING CHING! MONEY! Psychiatry in the U.S. is primarily the cause of everything you just mentioned. Expanded diagnostic criteria, increasing number of people – especially children – being prescribed debilitating drugs, ect. They’re doing it simply for the economic prosperity that comes from having an ever growing number of consumers. As Whitaker has noted recently, it has spilled over to other countries since much of the world revolves around the U.S. but I can see the obvious problem in that not all psychiatrists in all countries may not be able to profit from it the same as the psychiatrists from the U.S. who made it this way.
I think Dr Middleton is writing, not about money, but about the need for change in psychiatric medicine. The situation is pretty bad over in the UK (as in the USA) and it is interesting to learn that the ‘honest insight’ of the young medical students tells them something has gone badly wrong. What we need, in my opinion, is a new generation of medics to tackle the problem – along with those who have been through the system and survived it, who can guide them to understand the patient’s experience of mental distress. I have recently heard of some projects underway in this country for peer specialists to work alongside psychiatrists in this manner.
On a lighter note, I am keen for at least one of my four children to become a doctor, hopefully a psychiatrist. I had high hopes for my youngest (aged four) who used to agree with me that it would be a good choice of career. However, he has now decided to be a rock star, a scientist and a brave knight instead. Thinking about it, perhaps he would be the perfect practioner of the pluralistic approach that Dr Middleton advocates…
I meant practitioner! Sorry, I hate typos…
May be psychiatry needs reforming to make it a revarding profession. May be psychiatrists should be taught how to treat brocken people- like people not things or rabid animals. May be they should learn to listen, work with carers, see their patients more often then 10min during “ward rounds” to adjust medication, laugh at them if they report side effects from medication. May be carers should be allowed to have an input. May be there should be a “therapeutic allience” between patient and his consultant psychiatrist. May be NICE guide lines should be reworked. Medication is not everything. Psychiatry could be a very rewarding profession if the myth of brain-desease was revised. Psychiatrists should be allowed to apologize when they make mistakes and put things right instead of stubbornly continuing to ruin their patients’ lives…
Mental illnesses are not illnesses like any other. Diagnosis is subjective as is effectiveness of treatment.
Perhaps those attracted to the messiness — the medical students with the more “artistic” temperaments — find the opportunity to unrestrainedly “paint” on another human’s nervous system with chemicals appealing.
It certainly seems a lot of doctors are thrilled by mixing and matching psychiatric drugs just to see what happens.
On the other hand, I’m sure there are some truly compassionate, ethical, and responsible people among the medical students attracted to psychiatry. If only every patient could fall into their hands instead of the others.