Psychiatry Headed into the Future or Off a Cliff?

Two Chinese investigators, Ying Wu and Zhiguang Duan at Shanxi Medical University, have recently tried to assess highlights in psychiatry since the 1960s. They analyzed references in 85,612 papers published in 10 leading psychiatry journals, using a variant of who-cites-whom analysis, to identify central issues. This is not a method of establishing truth but rather of telling where the lemmings are headed.

The research is interesting because it highlights what forgotten trends in science need to be remembered, and what research that is still at the forefront of scientific chatter may ultimately be seen as unproductive and left at the wayside that is already cluttered with such abandoned concepts as “hysteria” and “ovarian insanity.”

A number of the clusters of scholarly activity they identify have been important and do hold promises for the future, such as Bernard Carroll’s work on melancholia and the dexamethasone suppression test (the DST). Good to see this returned to prominence after years of languishing in the graveyard of forgotten scholarship. (Ears have started to perk up again at the expression “endocrine psychiatry.”)

But more to the point, a lot of the research they see as central will doubtlessly end up shortly in that very same graveyard. Being cited does not mean being right. If you had done this kind of analysis for the psychiatric literature in the 1930s and '40s, you would have concluded that psychiatry’s future lay in the study of hysteria.

Their own knowledge of the history of psychiatry is inadequate. They cite the key date for Eugen Bleuler’s description of schizophrenia as “1950.” (1908 would be more on the mark.) And they put Emil Kraepelin’s “key document” at 1921 (rather than decades previously). In their view, “the field began to develop gradually” from here.

Not really. But let’s not get hung up on details. Of interest is their analysis of the last 40 years, not the last hundred.

Their analysis of the 1960s and '70s makes the key event the development of scales. Sure, but a lot else was going on as well, like the blossoming of psychopharmacology. This was real science.

In the 1980s they associate with abnormal brain findings in schizophrenia. Yes, such key figures as Daniel Weinberger at NIMH undertook pioneering science.

But here again, one is uneasy. “Schizophrenia” as the most promising research focus in the 1980s? That would be like claiming, as many did, that “hysteria” was once the most promising focus. There is now deep uneasiness in the field that there exists such a single entity as “schizophrenia,” and celebrating research on it merely reinforces what is almost certainly going to turn out as a colossal scientific error: There seem to be several main forms of chronic psychosis, not just what we’ve been calling for the last hundred years “schizophrenia.” ( Just imagine cardiology today using diagnoses that were popular in 1908.)

In the 1990s, they associate with the discovery that distinct neurotransmitters are linked to specific diseases. No. This view had been demolished by the 1990s and the blossoming of interest in the neurotransmitters dated from the 1960s. At the time, this was tremendous, fast-lane science, before

• the “neurotransmitters” became captured in pharmaceutical advertising
• it became apparent that the neurochemistry of psychiatric illness is so complex that, in seizing upon serotonin and dopamine, we had only cut into a tiny slice of a pie of unknown size

As for therapeutic advances based on the neurotransmitters, the most ballyhooed was the drug class called Selective Serotonin Reuptake Inhibitors (SSRIs), including such agents as Prozac and Zoloft. Many patients even today are told that their problems are associated with “low serotonin.” This so does not correspond to the present status of science: Someone did an analysis of all the “posters” on psychopharmacologic agents at the recent meeting in Toronto of the American Psychiatric Association. The posters are a good indication of where science in the field is heading because they generally represent the research of keen young scientists who tomorrow will be at the field’s cutting edge. There were, for example, five posters on amphetamines, an important drug class. There was not a single poster on the SSRIs. Which turn out to have been a commercial category rather than a scientific concept.

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Back to Wu and Duan: They see the bright spots in the twenty-first century as the molecular genetics of emotions, and it is difficult to disagree with this. The field now seems ready to break new ground, plunging away from drug companies, which used the “neurotransmitters” as a promotional device and heading in the direction of real science.

But this positive shift towards plumbing nature’s important secrets has taken place only after years of wandering in the desert of the DSM, the SSRIs, and such heterogeneous categories as “major depression.” Is it finally time for science to take the lead in psychiatry? We’ll see.