In Search of an Evidence-Based Role for Psychiatry

While psychiatrists everywhere are doing their best to help people, their profession is in crisis. Psychiatry is struggling to defend itself from multiple sources of critique, and to reassert its future role. One possibility that is taboo for any profession to consider, however, is that it has little or no useful role. That possibility must be contemplated by others. An evidence based approach to evaluating what good psychiatry contributes to mental health services in the 21st century leads to some challenging conclusions. Psychiatry’s crisis is evidenced in many ways. Most blatant is the international outpouring of criticism at the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [1], its latest attempt to categorize human distress into discrete psychiatric ‘disorders’. The fact that the attack on the poor science involved was led by the editor of the fourth edition [2], and the Director of the USA’s National Institute of Mental Health [3], was embarrassing. It seems psychiatry is now held in low regard by other medical disciplines. Medical students in numerous countries are uninterested in psychiatry as a career, seeing it as unscientific and ineffective [4]. In one study only 4–7% of UK medical students identified psychiatry as a ‘probable/definite’ career choice, partly because of its poor empirical basis [4]. In a recent survey over 1000 nonpsychiatric medical faculty members, at universities in 15 countries, “did not view psychiatry as an exciting, rapidly expanding, intellectually challenging or evidence-based branch of medicine” ([5], page 24). A total of 90% believed that ‘Most psychiatrists are not good role models for medical students’. The most negative opinions were expressed by neurologists, pediatricians, radiologists and surgeons. Even more revealing than the survey findings was psychiatry’s response to it. The researchers themselves, including a former President of the World Psychiatric Association, wondered whether their colleagues’ opinions are ‘well founded in facts’ or ‘may reflect stigmatizing views toward psychiatry and psychiatrists’. Their own answer to that question becomes abundantly clear when, instead of proposing efforts to address the problems identified by the medical community, such as having little scientific basis, they recommend only ‘enhancing the perception of psychiatrists’ so as to ‘improve the perception of psychiatry as a career’ [5]. Similarly, all six responses to the survey, in the same edition of the journal, written by 13 psychiatrists (including current and past Presidents of the European Psychiatric Association and the current President of the World Psychiatric Association) dismissed all the concerns raised by the 1057 medical experts and blamed everyone but their own profession, including their supposedly ignorant, prejudiced medical colleagues and the biased media. The titles of these responses included In search of an evidence-based role for psychiatry