Almost two weeks ago I went to the National Student Psychiatry Conference, which took place at the Institute of Psychiatry in London. I heard about it through a friend of mine and decided that since I live very close to the IoP and should probably be keeping up with the latest research and developments in mental health, it would be both useful and informative to attend the event. I was unaware at this point that it was actually primarily aimed at medical students who were considering specialising in psychiatry later on, which meant that I must have been one of the very few non-students attending the conference. However, I am still very glad I went – and even though I actually studied psychology rather than psychiatry (the main difference, as far as I’m aware, is that psychiatrists, being medically trained, are able to prescribe drugs, whereas psychologists can’t), it was still very interesting.
Seeing as I know several people, both online and IRL, who are interested in mental health issues for various reasons, I thought perhaps I would write a description of the conference to give the general public an idea of what it’s like to be a psychiatrist, some of the current issues in psychiatry and some ideas about the future of the profession and some of the challenges it faces. Rather than giving an overview of each of the talks in turn, as I had originally planned to do, I have decided instead to focus on what I perceived to be the main themes of the conference (and indeed, of psychiatry in general). In most cases, these themes reflect the chief points that nearly all the speakers referred to in their attempt to inspire medical students to choose psychiatry rather than any other branch of medicine, such as neurology or general practice.
The first point, which may seem rather obvious, is that psychiatry is a branch of medicine. As much as mental illness is seen to be something separate from physical illness, the fact remains that if you want to treat a mental illness with medication, you must understand how the body works, not just the brain. Interestingly, one of the speakers (I believe it was Dr Mark Salter) said that in fact psychiatry was involved in all branches of medicine, because a large proportion of a doctor’s time with patients (no matter what their specialism) is spent on “hand-holding and lifestyle advice”. In other words, as he quoted from someone else, “60% of medicine is showbusiness”. This might at first seem rather silly, after all, what do doctors spend all those years training and acquiring detailed knowledge of the human body for, if all they’re really doing is offering reassurance and telling us to smoke/drink less, eat well and exercise more?
Of course, the point that Dr Salter was making is that one of the most important qualities that a doctor should possess is the ability to connect with their patients, to empathise and understand the nature of their suffering. He mentioned House as being an excellent example of this, because over and above all his more dubious personal qualities, House cares deeply about his patients. Another speaker, Dr Avie Luthra, also said that psychiatrists are like film directors (he himself was both!) because it is about guiding your patients (or actors) towards producing the desired behaviour, e.g. taking medication or admitting they have an addiction. A third speaker – who was in fact a service user – echoed this sentiment by saying that psychiatrists need to be good salesmen. I think you probably get the idea – the key to being a good psychiatrist or doctor is to understand the psychology of the individual (as Jeeves would say!).
Leading on from that last point, I was rather pleased to discover, over the course of the conference, that I was not the only one who had been drawn to study psychology mainly because I was interested in people’s stories. I’d always thought this was a rather lame reason and had been slightly ashamed of it, but several of the speakers said psychiatry was all about listening to people’s stories, so an interest in them was vital. One speaker, Dr Florian Ruths, admitted that his main reason for choosing psychiatry was probably because he was naturally nosy! Connected with this is the idea of the life of each person being an individual world in and of itself. I can’t remember which speaker it was, but one of them said that many people become doctors because they think they can be heroes and “save the world”. The speaker said that in psychiatry, you may not be able to save the world, but you might be able to save an individual’s world, which would of course make a world of difference to that person. This might sound trite, particularly when written down, but, like most clichés, it is a cliché primarily because it is true. The idea of individual worlds was stretched further by another speaker who emphasised that in order to be a good psychiatrist, it was necessary to immerse yourself in the particular “world”, or social community, in which you happened to be working. This was essential, he said, in order to develop a deeper understanding of the social and environmental issues that may be affecting someone’s illness, as well as allowing you to connect on a more meaningful level with the patient.
I was both astonished and delighted to find that, during the two days of the conference, not just one but several of the speakers mentioned poetry – and there was even a poetry competition for the students to enter – the winning entry was brilliant and I really wish I had a copy of it so I could share it with you. I had not even considered that psychiatrists might have an interest in poetry. I suppose I considered them to be so coldly medical and efficient that they would be unable to appreciate the beauty of something as messy and emotional as poetry. But of course I was forgetting that psychiatrists deal with the messy and emotional every day – they come face-to-face with despair, joy, hope, anger, fear and all the other extremes of the human condition perhaps more often than any other profession. And it is therefore entirely natural and right that people who are so immersed in understanding and observing what it truly means to be human should also have a love and appreciation for a type of art that can express this better than any other.
Although science has come a very long way in providing us with explanations for why we do the things we do and even to a certain extent how we came to be here, it still cannot answer (and perhaps never will) the deepest, most personal and yet most universal questions, such as the one which Albert Camus suggested was really the most important of all – “Should I kill myself?” For most people the answer is an obvious “no”, but for others the answer is much less clear and requires careful consideration. This is of course the origin of Hamlet’s musings in that immortal line “To be or not to be, that is the question”. And if a patient is sat in front of you asking that question, you can’t just fob them off with some bullshit about life-being-a-gift, or these-things-are-sent-to-try-us. You need to think about what might have caused them to ask it and then listen to their story.
This is where poetry starts merging into philosophy, another subject which has close links to psychiatry. For example, when working as a forensic psychiatrist, questions such as “what is the nature of evil?” and “what is the difference between right and wrong?” are issues which regularly crop up, perhaps not on a daily basis, but certainly with enough frequency to give one pause for thought. That is not to say that forensic psychiatrists spend most of their working lives lurching from one internal moral crisis to the next (although of course it’s possible that some of them do!), but simply to illustrate the point that being a member of that profession is more likely to provoke thought on such matters than if you were a cardiologist, for example.
A second – and much more controversial – issue which is relevant to the whole of psychiatry is that of power and control. The Mental Health Act of 1983 (in the UK) gives a psychiatrist the power to keep a patient in a hospital against their will so they can be given treatment which they may not actually want. The implications of this are obviously huge and there is a depressing history of this power being abused e.g. Soviet dissidents being deemed to have a mental illness because no ‘sane’ person would object to the authority of the state. Having said this, the ability to enforce treatment is extremely useful in cases where the patient has little or no insight into their illness – that is, they do not recognise that the symptoms they are experiencing are part of an illness. The service-user who did one of the talks had suffered from schizophrenia and he told us that he would probably not have taken his medication had he not been ‘sectioned’ – the term used to describe keeping someone in hospital under the Mental Health Act.
There has been further controversy over the introduction of Community Treatment Orders (or CTOs) in the amended version of the Mental Health Act (2007). A patient who has a CTO is allowed out of hospital and back into the community, on the condition that they take their medication. If they are found to be non-compliant with the treatment, they can be brought back into hospital again. Opponents of this have claimed (not without reason) that this is little short of blackmail. But others have argued that it gives patients the option of going home whilst also making sure that they continue to take the medication that will (hopefully) reduce their symptoms. It will be interesting to see whether CTOs will remain as part of the Mental Health Act or be removed at a later date.
Speaking of the future brings me on to the last main point that came up several times during the conference – the future of psychiatry as a profession. There were a couple of talks specifically addressing this and a few others mentioned it in passing. The main crisis currently facing psychiatry is the almost total lack of new medications coming on to the market and the severe funding deficit which has partly caused and partly exacerbated this. One speaker (Professor Ed Bullmore) said that GlaxoSmithKline (a top pharmaceutical company) had actually axed its research department for psychiatric medication because so little progress had been made in recent years. How they think this will improve the situation is anyone’s guess, but clearly GSK no longer think it profitable to invest in the development of medication for mental illnesses. Part of the reason for this is that no new antipsychotic or antidepressant drugs have come on the market for years, even the atypical antipsychotics only alleviated some of the side effects caused by the first generation of antipsychotics, rather than providing any noticeable improvement in symptom reduction.
But it is not all doom and gloom. Professor Bullmore outlined two possibilities for the future direction of pharmacological research, the first being what he termed “re-purposing”. This involves finding new uses for drugs that have been developed (or are in the process of being developed) to treat another illness. The classic example of this is Viagra, which was originally developed as a drug for angina, until the participants in the initial trial starting reporting some unusual side effects and the researchers decided to market it to treat something quite different! Another discovery which is more relevant to psychiatry is the use of an antibiotic called minocycline – commonly used to treat acne and rheumatoid arthritis – to treat the negative symptoms of schizophrenia. It is still not entirely clear why this treatment is effective, but in any case the re-purposing idea looks like it could be a lucrative one, not least because such “recycled” drugs do not take as long to go through health and safety checks and can therefore be put on the market a lot faster.
The other direction for future research is immunology. Professor Bullmore was a little sketchy about what this actually involved – I suspect this was because the time allotted for his talk didn’t allow him to go into more detail – but the idea behind it seems to be that immunological processes are implicated in almost all medical disorders and that the immune system is closely linked to the nervous system. (Biological psychiatry already focuses on the role of the nervous system in the development of mental illness, although some have criticised this approach as being too simplistic). Professor Bullmore argued that re-medicalising psychiatry would enable it to tap into the vast research resources that are currently available for biopharmacology and immunology. But how is the re-medicalisation of psychiatry possible when the diagnostic criteria for many psychiatric illnesses is so arbitrary? Psychiatrists currently diagnose a particular mental illness by observing the symptoms of a patient and checking them off on a list of symptoms associated with that illness. Unlike most physical illnesses, there is no definitive test that can be done to verify the diagnosis, such as a blood test or biopsy and patients may be diagnosed with several different mental illnesses over many years before the “correct” diagnosis is eventually reached. Almost everyone working in psychology or psychiatry is aware of the deep flaws in the diagnostic criteria for mental illnesses, but no real alternative is currently available.
However, this may be about to change. Professor Steve Williams gave a fascinating talk on the use of brain imaging in psychiatry. His research has focused on the use of MRI scans not only to diagnose mental illnesses such as depression and schizophrenia (with surprisingly high levels of accuracy in some cases) but also to predict treatment response. This means that it might be possible for psychiatrists to use the information gathered from brain imaging to determine whether a patient would respond better to, for example, antidepressants or psychological therapy, thus saving a considerable amount of time (and more importantly the patient’s own morale!) by not needing to try out several different treatments before finding one that is actually effective.
This seems to be an almost inconceivably huge step forward in the treatment of mental illness – if it can be shown to be consistently accurate and feasible. The main issue would be the cost of installing the scanners, as brain-imaging equipment is extremely expensive, both to buy and maintain. However the amount of time and money that would be saved by early and accurate diagnosis, not to mention accurate predictions of treatment efficacy, would be enormous. Professor Williams also suggested it might be possible in the future to perform intra-uterine diagnoses, before a person was even born. This would undoubtedly cause much controversy if it were ever introduced…apart from the fact that, unlike most physical illnesses, there are often strong social and environmental factors involved in the development of mental illnesses, making it difficult to predict not only whether a person is likely to suffer from mental illness later on, but also which particular illness it is likely to be, it would also raise the issue of whether parents would want to have a child that has, for example, a strong likelihood of developing schizophrenia. For all that mental illness is perceived by some as a “permanent disability” (a quote from the speaker who was a service user), those who suffer from such illnesses often have much to offer in terms of, for example, the creative drive that can stem from understanding and experiencing extreme mental states and conditions.
Finally I feel it is worth mentioning that the most important factor concerning the future of psychiatry is whether there will in fact be any future psychiatrists. This was the first time that this conference had taken place, the main aim of it being to encourage medical students to choose psychiatry as their specialism. I’m not sure what the UK statistics are, but an American psychiatrist called Dr Matt Goldenberg informed us that of the 1,000 psychiatry places on offer in the US every year to medical students, only 600 are taken by Americans, the rest are filled by international students. In India the situation is even worse, they have 3,000 psychiatrists to serve a population of 1.2 billion. If it had the same number of psychiatrists – relative to population size – as the UK, there would be 150,000 of them. Clearly more work needs to be done to highlight the rewards and benefits of a career in psychiatry and I think this conference went quite some way to achieving that.