Psychiatry’s undeclared identity crisis in a changing world!

Marazziti and Stahl’s article in the February 2021 issue of CNS Spectrums titled “Novel challenges to psychiatry from a changing world” provides a sincere and refreshing view of modern psychiatry. The article addresses key points about the necessity of psychiatry to transform itself and adapt to new obstacles in a constantly moving and changing world.¹ Interestingly, the authors claimed that the future of psychiatry lie on the acknowledgment of these difficulties and on the attempts to “resolve them quickly.”¹ Additionally, the authors clearly proclaimed psychiatry as a “person-centered” branch of medicine that includes and utilizes other disciplines such as neuroscience, psychology, sociology, and anthropology.¹ They also listed few suggestions that can help the metamorphosis of modern psychiatry into a more agile field that effectively maneuvers new burgeoning problems. Per example, the authors suggested wider applications of genetic techniques that should be less expensive and more readily available.¹ In addition, they recommended the validation as well as the translation of diagnostic instruments into several other languages as a means to overcome linguistic barriers.¹ The authors also denoted the importance of using ethnically and culturally sensitive pharmacological approach, as well as the creation of individualized diagnostic instruments to assess the psychopathological impact of climate change.¹ Moreover, the authors emphasized the importance of considering each person as the result of interactions between brain and the environment, while admitting that a “pure” neuroscientific approach was not enough to attain comprehensive management of psychiatric conditions.¹

Unfortunately, Marazziti and Stahl overlooked some of the core issues that have afflicted psychiatry throughout the past several decades. Additionally, the calamities in the world, whether it is human-made or natural disasters, are not truly novel issues. Most of them are centuries-old struggles of the human condition and its strife with itself and nature. Adapting a discipline such as psychiatry to swiftly and effectively deal with these enormous challenges is daunting and far from being simple or quickly remediable as the authors suggest.

Historically, negative public notions, speculations, and uncertainties have besieged psychiatry, and rendered it into an obscure science desperate to achieve credibility.

The authors neglected to address the monkey wrench that hindered and choked the evolution of psychiatry, such as the negative perception of the public, as well as the denial of an existing “identity crisis” among practitioners combined with the plethora of equivocal psychiatric DSM diagnoses, which are burdensome to prove and validate. Therefore, adding diagnosis for climate change, “desertification,” or other catastrophes may prove to be counterproductive.

It appears that the inherent complexities of the brain-milieu intersection, compounded with the political miscalculation by the psychiatric leadership, in addition to disinformation propagated by the antipsychiatry movement have all converged as culprits in fomenting the psychiatric identity crisis.

Psychiatrists are medically trained doctors, who have chosen the noble field of psychiatry for personal reasons or for genuine interest in the understanding of human behavior and the intricacies of the brain. Regrettably, the pressure for approval and social status combined with the quest for glamor and wealth have diluted the psychiatric mission and compelled some practitioners to become pharmaceutical agents rather person-centered physicians, hence the few tainted the reputation of the majority. Meanwhile, the field remains befuddled with the true etiology of most of the psychiatric disorders as most of the neuroscientific hypotheses are at best speculative.

The suggestions by the authors to make psychiatry more malleable and reliable might be a good start. However, translating and validating or even creating new culturally sensitive individualized diagnostic tools might not be enough to deal with the massive issues the globe is currently facing. Furthermore, wider and cheaper genetic techniques may not be the answer either, due to its current lack of reliability. According to the NIMH, current genetic tests cannot accurately predict a person’s risk of developing a mental disorder. ² In addition, genotyping has also shown to be unreliable. ³ Therefore, genotyping every patient, and creating a cytochrome P450 metadata of high metabolizers and low metabolizers would not improve psychiatric outcomes at this point.

Grossman et al’s ⁴ review of genetic testing indicated that current evidence does not support the use of CYP450 genotyping to guide SSRI treatment of patients with depression. Similarly, a review of genetic testing in schizophrenia by Jürgens et al ⁵ yielded similar results as randomized clinical trial did not support routine CYP testing in patients with schizophrenia. These are some of many existing studies that marginalize genetic techniques as it remains a work in progress and may not be the answer for an immediate quick fix.

Realistically speaking, it is critical that psychiatry takes the initiative to construct certain foundational components to address some of the pressing global psychiatric issues discussed in this article. Psychiatry’s partnership with the pharmaceutical companies as its sole lifeline is no longer tenable. Similarly, the reliance on a new drug with unknown or presumed mechanism of action will not transform the field. Therefore, the psychiatric leadership should focus on new and creative global strategies that could expand its influence and improve its image.

The following general strategies might initiate an honest conversation about the future of psychiatry, and lay groundwork that will undergird the future success of the authors’ suggested clinical interventions.

1. 1. Creating a global mental health network that promotes availability of services that are affordable and reliable.

2. 2. Fostering a global marketing campaign to overcome the stigma that plagues the mental health field.

3. 3. Engaging in international collaborative effort with local officials to establish affordable psychiatric community clinics in various cities.

4. 4. Instituting international educational psychiatric seminars that target the political parties to engender funding for these services.

5. 5. Revitalizing interest in the psychiatric field in medical schools to help resolve the deficiency crisis as the number of psychiatrists continues to plummet.

Finally, psychiatry should become honest with itself and its limitations. It should also clearly redefine its boundary and its mission to reduce identity confusion, and create a clear path for treatment, thus maintaining the homeostasis of the bio-psycho-social-cultural-person-centered model it claims to be.