Is the Field of Psychiatry Doing More Harm than Good?

Is the Field of Psychiatry Doing More Harm than Good?
Anil Rickhi Emergency Physician

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While it has been documented that approximately 25% of the population is afflicted by one or more psychiatric disorders according to recent studies and the DSM 5, as a clinician who has also had experience in psychiatry and Emergency Medicine, I tend to fall on the side and the beliefs that our population is being way too over-diagnosed with mental health issues.

The consortium that comes up with these diagnoses and sits and the board of the DSM does not provide evidence. One may ask themselves why so many more people are being diagnosed with mental health conditions than ever before. For example, in the DSM 3 if you were homosexual in any way, you “had a mental disorder.” And you need to be treated for that. In fact, it has been shown any “normal” person can be diagnosed with up to 5 mental health conditions which is currently now 33%.

In fact, some researchers and physicians have speculated it is about 40% of people. This is due to not seeking help from a physician due to the stigma in society with respect to mental health. An interesting study was published in Neuropsychopharmacology (2013) 38, 2327–2334, which elaborates on the importance of diagnostic imaging and mental illness.

In fact, as mentioned, mental disorders are diagnosed by the Statistical Manual of the American Psychiatric Association. In order to meet a specific diagnosis, one has to fulfill certain criteria. For example, If you have five symptoms for a specific mental disorder, you meet the standards for having a mental illness, but if you only have four of the symptoms you do not have this disorder. Studies also show the reliability which is defined by those in agreement between mental health care professionals is approximately 18%. This means that if one person saw 100 healthcare professionals for a diagnosis of a mental illness based on the DSM alone, 18 of the mental health professionals would be in agreement about the diagnosis while 82 would give the patient an entirely different diagnosis. 

Twin studies reveal a substantial heritability for psychiatric disorders, including schizophrenia and bipolar disorder (BD), major depression, and substance use disorders including nicotine dependence. Although pharmacotherapy represents the foundation of psychiatric treatment, most patients do not achieve a sufficient therapeutic response. To improve treatment outcomes, genetic variants that code for drug-metabolizing enzymes and pharmacodynamic targets are being examined to identify individuals most likely to benefit from alternate therapies and those at risk for adverse drug reactions. Despite some progress, there are a limited number of actionable findings, due in part to the low penetrance of implicated genes and a failure to capture the complexity in pathophysiological phenotypes that give rise to variable treatment outcomes.

In search of evidence based medicine and to increase reliability amongst mental health professionals, the field of psychiatry is still not stepping up to this challenge. But many health care professionals suggest that functional imaging of the brain is needed to substantiate a diagnosis. For example, on FMRI (Functional Magnetic Resonance Imaging).

Moving beyond simple classifications of treatment responders and nonresponders, genetic variability can be studied in the context of intermediate phenotypes related to treatment effects on brain structure, neural circuitry, and neurochemical processes. There are a variety of neuroimaging approaches that have substantial potential utility in this regard, including: blood-oxygen-level-dependent (BOLD) functional magnetic resonance imaging (fMRI) to examine neural activity associated with treatment targets such as attention, working memory, reward-related responding, emotional processing, and in the case of addiction, reactivity to drug-related cues; BOLD signal at rest to characterize spontaneous fluctuations of connectivity within and between neural circuits; and positron emission tomography (PET) to estimate receptor availability and neurotransmitter levels in the brain. Although the imaging genetics approach has been used to study underlying pathophysiological processes in psychiatric conditions, few studies have combined both genetic and imaging approaches to study effects of psychiatric treatment.

The goal of this paper is to outline promising avenues for, and the challenges of, incorporating neuroimaging phenotypes into psychiatric pharmacogenetics research.

The emerging integration of neuroimaging along with pharmacogenetics research has the potential to accelerate psychiatric treatment development and delivery. For example, neuroimaging studies are contributing to a more refined understanding of treatment targets by elucidating the neural circuits and neurochemical processes underlying a broader range of neurobehavioral phenotypes. These include: alterations in reward seeking, learning and response to reward, executive cognitive function, decision-making and behavioral control, emotional reactivity which also have an evidence-base in neuroimaging. Further, neuroimaging of treatment effects on these targets can generate profiles of the effects of efficacious treatments on aberrant neural circuitry or neurochemistry, providing a biomarker of treatment response against which novel compounds can be compared and selected for future research by Incorporating genetics into these studies can provide an assay of individual differences in treatment response, enabling the development of medications that are targeted to particular genotypic groups. The identification of treatment responders and non-responders using a combination of genetic and neuroimaging approach may thus provide a more powerful strategy for targeted therapy and an increase in the reliability.