Thursday, 18 June 2015

Conference on Psychiatry and Society (2)

On 12th May 2015 in London I attended the "Psychiatry and Society" conference organised by the Psychiatry Section of the Royal Society of Medicine. Here I will summarise the talks I heard in sessions 2 and 3, emphasising those themes that have already been discussed in the blog. (If interested in session 1 of the conference, I reported on it last week).

Session 2: Genetics, Neuroscience and Mental Disorder

Neuroscientist Pamela Sklar (pictured above) asked "How may genetics change our understanding of mental illness?" and she focused on schizophrenia as a "mystery", that is a disorder that is both inherited and very common. Thousands of DNA alleles are involved in the risk of developing schizophrenia and bipolar disorder. The difficulty in identifying the genetic bases of such disorders made some people think that research in this area was doomed to failure. But both for bipolar disorder and for schizophrenia some regions that increase risk have been discovered so there is reason for optimism. One very controversial issue is whether genetic risk factors are shared or split among diseases. There is significant more overlap than one would think by following the DSM or the ICD (examples: bipolar and schizophrenia, schizophrenia and autism). Progress in this area will help distinguish between successful and unsuccessful pharmacological treatment, and implies a rejection of current diagnostic categories.

Psychiatrist and psychiatry researcher Robin Murray (pictured above) discussed Pamela's paper and commented on the large study showing which regions are involved in the genetic risks for schizophrenia, welcoming the day we will stop talking about schizophrenia and start using terms that better reflect the advances in genetics and neuroscience. Latest results in neuroscience suggests that there is no one gene responsible for schizophrenia and that schizophrenia is not a categorical concept. Rather, we need to adopt a dimensional view of schizophrenia because this is supported by current research (in other words, we all have some risk of developing schizophrenia).

Risk of psychosis seems to be increased by: (1) childhood adversities; (2) adverse life events; (3) abuse of cannabis and drug abuse; (4) migration and ethnicity.

Neuroscientist and psychiatrist Steven Hyman (pictured above) asked: "How may neuroscience change our understanding of mental disorder?" and focused on the challenges we face because of the inaccessibility of the brain in life and because of the inadequacy of animal modelling. We need to better understand the brain as "this magnificent machine produced by evolution" and recognise the collision between biological science and the subjective, lived experience of people.

Cognition, emotion, decision-making, and behavioural control are "emergent properties of neural circuits" and at the moment we can only rely on indirect observation to link activity in the brain with cognitive and emotional behaviours. That partially explains why it is difficult to predict whether adolescents with behavioural difficulties will develop schizophrenia and why understanding the reward system is not sufficient to solve the problem of addiction. Ultimately, people with mental disorders need to be seen both as objects and subjects: the loss of agency and the loss of control characterise their predicament and cause significant distress that cannot be dismissed.

Psychiatrist George Szmukler (in the picture above) discussed Hyman's talk and started with a question: "What does it mean to ask a patient to wait a long time before neuroscience can provide some answers to their questions?" Szmukler argues that people with mental illness need to participate in research and become advocates for it. They need to be involved and to understand, with some training, what success in neuroscientific research requires.

Patients need to collaborate actively and be asked what they think the risks are from an ethical perspective in these studies. The best outcome, he said, is to reduce stigma and at the same time offer hope for treatment. This helps people come on board. But it is not easy, due to the hypothesis that psychotic medication decreases the chances of recovery long term even if it is effective in the short term. This hypothesis seems to be supported by some data suggesting that disability in people with mental illness has increased in the last 50 years. At the moment, there is no other data that can be used to assess this hypothesis, and that is why patient participation is so fundamental to future research.

Session 3: Implications for Diagnosis in Psychiatry

Social scientist Nikolas Rose (pictured above) asked: "What should count as a psychiatric diagnosis?"and expressed some scepticism about the the capacity that neuroscience might have to affect clinical practice. The starting point is to establish what the object of diagnosis is. The crisis of psychiatric diagnosis highlighted by criticism of the DSM comes from the attempt to categorically divide conditions, specify for each a set of criteria, and propose unique aetiology, prognosis and treatment. The problem is that no biomarkers can be associated with DSM categories and the list of criteria identified are behavioural.

A break from the DSM was made by Insel who launched the RDoC as an alternative, but one thing that did not change is that the approach is to look at the causes of mental illness within the person's body, and in particular the brain. Even if RDoC is primarily an aspiration for research, the goal is to achieve "precision medicine for mental disorders". One worry is that this approach does not take into account the circumstances of the individuals who experience mental health issues, and these can differ widely across diagnostic categories, independent of whether these categories are based merely on symptoms or on biomarkers. Instead, we need to start with the patient's complaint.

Psychiatrist and researcher in psychiatry Simon Wessely (in the picture above) responded to Nikolas by observing that it has always been claimed that psychiatry is in a crisis, but that the "perpetual crisis of diagnosis" is overestimated and exaggerated. We are not losing the essence of psychiatry or the social dimension of psychiatry which are still at the core of the clinical encounter.

Actually, Simon argued that the social dimension is something that attracts people to clinical practice and won't be made irrelevant by neuroscience or the RDoC. Diagnosis presents challenges but is an important part of education for psychiatrists and it captures overlaps among mental health issues that are important and useful.

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