Who wants to be a psychiatrist?

Three apparently unrelated items of information. First, our good friends at Psychiatric Times have an article this week on the latest fad... excuse me, scientific development, in psychiatry, Deep Brain Stimulation. This consists of shoving needles in the brain, connecting them to an electric jigger and waiting to see what happens. It is based on the idea that specific mental disorders, renamed "functional domains," can be "tracked to specific brain areas ..." There is no mention of a theory of mind to guide the needles, how much is being spent on this research or, assuming it works, how it could be translated into the larger world. This is important because this sort of blind probing was exactly how "psychosurgery" (leucotomy/lobotomy) started: it seemed like a great idea.

Also this week, yet another edition of Depression Research Review, subtitled Making Education Easy. If only. This glossy production, courtesy of the drug companies, provides potted summaries of eleven papers published over the past two months. For example, the first is on esketamine nasal spray for depression, followed by antidepressants, incidence of depression in Europe and South America, genes, transcranial magnetic stimulation, drugs, drugs and more drugs.

Finally, the average age of psychiatrists in Australia is somewhere in the late fifties and there is now a rush to the exits as the baby boomers reach retirement. This week saw an urgent plea from the local branch of the college of psychiatrists telling of a "chronic and severe psychiatry workforce shortage in Australia." Members were asked to fill in a questionnaire on something called "burnout" and sign a letter to the Minister for Health to "invest" more money in attracting graduates to psychiatry, training and retaining the workforce by "preventing burnout."

In fact, these little gems are closely related. First thing to remember is that Australia has never, ever, graduated enough medical practitioners. There have always been quotas on medical schools, although that may be changing with the schools that don't provide clinical experience. Why this is the case, I don't know as I've never had anything to do with medical schools.

When I graduated in Perth, the WA Medical School managed at most fifty graduates a year, quite often less. Because there were quotas, the medical schools were choosy. Students' marks had to be right up there before they could see the inside of the medical school, meaning medicine was a prestige course. However, with the mining boom, the population of WA was rising by about fifty thousand a year, so there was a shortfall of at least a hundred graduates each year. They needed to graduate an extra hundred per year just to keep up. Of course, this was cumulative, meaning the state was 100 short one year, 200 short the next, then 300 short, and so on.

To make up the loss, the policy was to import doctors, initially from the UK and Ireland, later from anywhere. Increasingly, these were countries that didn't have enough medical graduates of their own. They paid to educate them - it costs a lot to train a medico - then we whipped them away. Essentially, we were (and still are) mining their (human) resources and not paying royalties. And as far as I can see, nothing's changed, except there doesn't seem to be the interest in studying medicine that there once was. If there's not much interest in medicine, there's going to be much less interest in psychiatry.

The response of psychiatry's KOLs (key opinion leaders) is an urgent letter to the minister of health that which they want everybody to sign:

Australia has a psychiatry workforce crisis. We need targeted and sustained government action to attract, train, and retain psychiatrists to meet the mental healthcare needs of our patients.

That is, it's all the minister's fault. It has nothing to do with what psychiatrists are doing, so he needs to pull his finger out and solve the problem. But back to the "psychosurgery." The urge to "do something to the brain" to relieve mental symptoms goes back forever. It may be just dulling it with drugs, or shocking it in various forms, but cutting the brain seems to exert an irresistible attraction for a certain breed of psychiatrist. I can't explain this peculiar fascination but, more to the point, nor can they. It's just there, the wish to assail the brain comes first while the "theoretical" justification, in terms of "functional domains ... tracked to specific brain areas ...," comes later. The reality is they have no idea what they're doing, just some vague intuition that there must be something that can be done to the brain that will "cure" mental disorder. It's the politician's syllogism again: "Something must be done. This is something. Therefore this will be done." Intellectually, it's at about that level.

Meantime, back on the drug circuit, we can check the titles of some of the papers reviewed:

• Esketamine nasal spray versus quetiapine for treatment-resistant depression.

• Duration of adjunctive antidepressant maintenance in bipolar I depression.

• Genetic contribution to the heterogeneity of major depressive disorder: evidence from a sibling-based design using Swedish national registers.

• Effects of vitamin D3 and marine omega-3 fatty acids supplementation on indicated and selective prevention of depression in older adults: results from the clinical center sub-cohort of the VITamin D and OmegA-3 TriaL (VITAL) (no effect, in case you wondered, so why did they quote it? To show that "fringe" therapies don't work and everybody should stick to psychiatric drugs)

Compare those snappy gems with the first few titles in the latest edition of the Australian and NZ Journal of Psychiatry:

• Preliminary results from the Australian Genetics of Bipolar Disorder Study: A nation-wide cohort.

• Predictors of the 6-year outcome of obsessive-compulsive disorder: Findings from the Netherlands Obsessive-Compulsive Disorder Association study.

• A randomised controlled trial of a psychoeducational group intervention for family and friends of young people with borderline personality disorder features.

What does all this add up to? It says that the view of psychiatry on offer, not just in this country but around the world, is dominated by drugs, statistics and neurology. In fact, not just dominated, that's all there is. There is nothing in any of those papers, or any of the others in those publications, or in the stuff on psychosurgery, about people who suffer, about people as people. So straight away, we see that their vision of psychiatry is likely to appeal only to people who like statistics, who like going to meetings and conferences, who like the idea that misery is "a disease just like diabetes" which can be relieved entirely without the pain (for the psychiatrist) of listening to the patient's moaning and bellyaching ... In short, modern psychiatry appeals to technicians, or what Thomas Insel, former and long-time director of the US NIMH, liked to call "clinical neuroscientists." This tells us why medical graduates have no interest in psychiatry: if all they can look forward to is a lifetime of “drugs, statistics and neurology,” then the students are voting with their feet.

None of this is new. Psychiatry's self-appointed "key opinion leaders" have been aware of it for many years. In 2002, the former editor of the main journal, Prof. Sydney Bloch, commented:

...there appears to be a disconcerting dearth of new recruits to psychiatric research ... it is salutory to note in the article on the level of interest in psychiatry among medical students … that an unattractive feature of our profession is its ‘perceived lack of a scientific foundation’. This is clearly not an accurate portrayal ... [1]

Nearly ten years later, what had changed? Nothing. A survey of medical students published in 2010 looked at their attitudes to psychiatry as a profession [1]. Students replied that they saw psychiatry as “lacking a scientific foundation, unscientific … boring … no skill base … does not treat the whole person”. This opinion shocked the establishment who genuinely couldn't understand why students weren't eagerly swallowing their narrative.

But to me, the answer is crystal clear. The students were absolutely right. By imposing their palsied vision of mental life on the world, the powers-that-be in mainstream psychiatry, the academics, administrators and the politically-minded, have achieved something that I would never have thought possible: they have made psychiatry boring. And that, to my limited way of thinking, is a grave moral crime.

References are available in my letter to the journal:

McLaren N (2010) Psychiatry's Lack of Scientific Foundation. Australasian Psychiatry 18:590. doi.org/10.3109/10398562.2010.499436

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