A new article was published in Psychological Medicine in response to an ongoing debate around “precision psychiatry,” the attempt to personalize treatment based on the unique characteristics of each patient, from genes to environmental conditions.
Jim van Os and AnneMarie Kohne of Utrecht University criticize precision psychiatry and its assertion that we must view mental disorders as brain disorders that can be cured with “the right treatment at the right dose at the right time.”
“The very foundations of the concept of precision psychiatry are unsafe,” they write. “It is therefore not enough to merely sing its praises. Perhaps it would be more prudent to first focus on the scientific holes in the theory before building a practice that the world outside the culture of traditional academic psychiatry is increasingly unwilling to accept.”
The authors criticize the popular idea within academic psychiatric circles that as our ability to examine the human body improves and our data collection strategies evolve, we can better prescribe the correct medication to alleviate mental suffering. The authors attack the two basic assumptions made by the champions of precision psychiatry: that mental suffering is ultimately a brain disorder and that mental health outcomes are determined and predictable.
Many authors have pointed to similar problems of an overemphasis of the biomedical model (mental suffering = brain disorder) in psychiatry. Although evidence is sparse, the biomedical model of mental illness has pushed other psychosocial models into the background. The result has been far more treatment models based around medications at the expense of other psychosocial alternatives.
Recently, the biomedical model of mental health has come under criticism by mental health professionals worldwide, including a 2019 United Nations report. There is also growing evidence that mental health predictions are unreliable, for instance, when it comes to the success of antidepressants. The criticisms of “precision psychiatry” made in the current article by Os and Kohne echo those made across psychology and psychiatry.
The authors begin by addressing the idea that mental disorders are brain disorders. They argue that precision psychiatry proponents take this assertion as self-evident and label anything that disagrees as a hoax or “antipsychiatry.” This results in institutional unreadiness to treat mental disorders with anything but medications.
The authors point to a growing number of voices presenting contrary evidence, including those featured at Mad in America. For Os and Kohne, the existence of this body of evidence calls into question the “self-evident” assertion that a mental disorder is a brain disorder.
Os and Kohne point to how precision psychiatry is viewed outside academic psychiatric circles. They quote important figures from across the social scientific disciplines: For example, the well-known scientist John P. A. Ioannidis writes:
“There is an enormous investment in basic neuroscience research and intensive searches for informative biomarkers of treatment response and toxicity. The yield is close to nil.”
Recently, the psychiatrist Caleb Gardner and the Harvard medical anthropologist Arthur Kleinman added:
“…psychiatric diagnoses and medications proliferate under the banner of scientific medicine, although there is no comprehensive biologic understanding of either the causes or the treatments of psychiatric disorders.”
Researchers have also criticized the continued promotion of the brain disorders myth despite the lack of evidence. For example, Estelle Dumas-Mallet and Francois Gonon wrote in the Harvard Review of Psychiatry in November:
“We suggest that clinical psychiatry’s taken-for-granted, everyday beliefs and practices about psychiatric disease and treatment have narrowed clinical vision, leaving clinicians unable to apprehend fundamental aspects of patients’ experiences.”
These quotes suggest that the idea that mental suffering is a brain disorder waiting to be discovered is not supported by the existing evidence.
The current article then addresses what the authors call “AI Solutionism,” the idea that given enough data, we can determine any human outcome using machine learning algorithms. Os and Kohne draw a parallel between AI solutionism and the assertion by proponents of precision psychiatry that we can determine the right treatment at the right dose for each case of psychological suffering given enough data.
Ex-NIMH chair Thomas Insel has added to this trend in his efforts to find a “digital phenotype of mental illness” using online behavioral data. He moved in this direction after admitting that efforts to find quantifiable biomarkers during his time at the NIMH were mostly a failure:
“I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs—I think $20 billion—I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have a mental illness.”
The authors argue that mental health treatment outcomes are linked to innumerable factors in the psychosocial world and will not be determinable and predictable the way precision psychiatry envisions. For the authors, this immense complexity is a refutation of the “self-evident” assertion from precision psychiatry that mental health outcomes are determined and predictable.
Os and Kohne criticize the notion within psychiatry that given enough data, we can tailor a personalized biomedical treatment for psychological suffering. They undermine the basic psychiatric premise that mental disorders are brain disorders and that brain disorders are predictable. Without these foundational yet ill-proven assertions in place, there is little scientific basis for the idea of precision psychiatry.
Van Os, J., & Kohne, A. (2021). It is not enough to sing its praises: The very foundations of precision psychiatry may be scientifically unsound and require examination. Psychological Medicine, 1-3. doi:10.1017/S0033291721000167 (Link)
NON PRECISION PSYCHIATRY
“…For example, a study published in 1982 reported that when a group of patients with schizophrenia were each given 20 mg of fluphenazine, the difference between the highest and lowest blood level of the drug was 40-fold. Thus, a very low dose of an antipsychotic is sufficient to control the symptoms of many patients with schizophrenia, even if it does not produce full recovery, whereas other patients may require much higher doses to achieve the same effect….”
“…Without these foundational yet ill-proven assertions in place, there is little scientific basis for the idea of precision psychiatry…”
Theres little scientific basis for psychiatry if
– nobody recovers, as they don’t.
“Precision psychiatry” can start as soon as psychiatry is able to precisely distinguish between an “ill” person and a “well” person. And I won’t hold my breath that this ability will develop in my lifetime, or ever. Because there is no way anyone can establish with precision that someone’s emotional condition is specifically caused by a “mental illness” that is based on committee consensus and voting.
For me it was a Bad Dream, but a lot of people Lost their Sanity, and their Lives on Fluphenazine.
I remember discussing my situation with my Psychiatrist in 1986:- I mentioned the problems I had with involuntary movements and Suicidal Reaction on Fluphenazine. My Psychiatrist was Apologetic and then made a statement that had me thinking that he was under the Influence of Alcohol.
He Stated:- that he could have had someone on 10 times what I was on, and that they wouldn’t have had my side effects. He then stated that he could have had someone on 25 or 30 times what I had been on and they wouldn’t have my side effects.
At our next appointment he told me he was taking a years Sabbatical to conduct Reseach in Canada:-
Maybe read the book Psychiatry: The Science of Lies by psychiatrist Thomas Szasz.
Ignaz Semmelweis was a significant inspiration to Dr. Szasz.
If one clings to fundamental assumptions that are ultimately wrong, it can have far reaching unintended consequences. Interesting article. Thank you.
“…I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs—I think $20 billion—I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have a mental illness…”
MOVING THE NEEDLE
.. on Suicide, Hospitalizations and Genuine Recovery:-
Reduce “medication” Carefully Down to Nothing while Offering Inexpensive Adjustment Psychotherapy.
Can be proven to move the needle inexpensively!
I would see a term such as “precision” psychiatry (vs. whatever else they have) as akin to differentiating between a “smart bomb” and B-52 saturation bombing. (To the brain,)
Isn’t this all just a way to come up with more excuses for psychiatry’s existence?
I agree, psychiatry’s random “looking for the right drug cocktail,” is largely the opposite of “precision psychiatry.” But that’s who and what psychiatry seems to have chosen to become, those who “tell a lie big enough and keep repeating it ….”
“If you tell a lie big enough and keep repeating it, people will eventually come to believe it. The lie can be maintained only for such time as the State can shield the people from the political, economic and/or military consequences of the lie. It thus becomes vitally important for the State to use all of its powers to repress dissent, for the truth is the mortal enemy of the lie, and thus by extension, the truth is the greatest enemy of the State.”
Thus being, am I correct in understanding, that psychiatry’s goal, is in effect, destroying the leaders of the US? Just like they did during Nazi led Germany, and seemingly also in Bolshevik led Russia?
Psychiatry is just repeating the worst of history, by design?
We have leaders?
“Precision psychiatry” might have some merit, but not when it’s inextricably linked to pharmacological “treatments” and “cures”. There are many things outside the brain that can induce disordered emotions and moods, but not that many that will succumb to pharmacological agents alone.
Are you suggesting that “precision psychiatry” would have to actually be focused on finding out what ACTUALLY WORKS and WHY, and applying it on a case by case basis?
You are such a radical!
“Precision Psychiatry” is inherently useless because human beings are not robots of just wires, chemicals, and algorithms. They can not be patented like a new-found device that can be sold on late night tv or over the internet. Human Beings are living breathing unique individuals with minds, souls, spirits and yes, bodies. To reduce a human being to nothing but the lies as applied in precision psychiatry is to deny the sovereignty of each person. Thank you.
A psychosocial demand does not mean a brain disorder exists unless you have biological evidence of a causal alteration. But with psychiatry there is so much confusion and abuse, that the “precision” claim seems laughable. In psychiatry, when there is no demand, and nobody complains, there is no “disorder”. Where is your “disorder” then? Oh, as an evidence it has disappeared, like magic! That is embarrassing, so much so that most psychiatrists never consider nor certify their clients as actually “cured”. Satisfy basic human rights and the demand may cease. Have you “cured” a “disorder”? Of course not, there was none, and the brain was functioning normally under some stress, until someone correctly identified and met the demand. Change the OCD-inducing job and, abracadabra, the brain disorder disappears. Hire the unemployed back and his depression is cured like magic in a single day. Some psychiatric so-called brain disorders may not be cured so easily, though, because of social benefits or identity claims: You may not want to be “cured”. And psychiatric drugs or other addictions may have altered your brain for real, for some time, and you may not be able or allowed to stop them. If you want to change your life experiences, you may seek social, legal, psychological, dialogic, initiations or spiritual help. For example, it may help somebody to pray, but such a practice is neither medicine nor should be compulsory.
In computer engineering everybody knows the distinction between hardware and software. You may update, correct, change, enrich, adapt the software or learn how to use it better. The distinction is easy. No need to incriminate the computer unless you have indications and proof of hardware problems and you would not damage the computer either. Yet in medicine, apparently, physicians cannot distinguish the brain from the psyche and damage the brain instead of addressing the psyche. You may integrate your past traumas, know yourself, your body, your soul, your purpose, your guides, learn new skills, manage emotions, cope with difficulties, reprogram your psyche, communicate better, solve conflicts, forgive, adapt, change your behaviors, stop destroying yourself. Was your brain “disordered”? No, not exactly: the brain was functioning normally, but under some stress, with bad programming or bad habits. Was that medicine? Not exactly, it was counselling.
The tragedy of psychiatry, etc. is that almost all those things, etc. you list the psychiatrists, etc. see them as “symptoms” of something wrong (a DSM diagnosis) which of course needs treatment (drugs, therapy, which is nothing but a glorified, extended med review) and other malicious tools in their evil toolbox to make you feel less than human. This is done through constant reminders of your defects and faults. Oh yes, they may pretend to tell you your strengths, but only when these strengths are couched in their definition of your weaknesses. Of course, just like the patient is poly-drugged, the patient is more likely to be poly-diagnosed. Just those very malevolent attributes of psychiatry, etc. disallow it to ever be described as precise as in “precision psychiatry.” Thank you.