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The Royal College of Psychiatrists Improving the lives of people with mental illness

Making an impact: the science of psychiatry

There are numerous myths and misconceptions about psychiatry. One of my first junior doctor posts in psychiatry was at the justly renowned National Hospital for Neurology, known as “Queen’s Square”. I was the only psychiatry trainee in the place, vastly outnumbered by neurology trainees and consultants. I lost count of the number of times people would approach me and say words to the effect of “I don’t know why a decent chap like you is going into psychiatry - none of your patients get better”. It was ironic since, with the best will in the world, that statement seemed to apply more to those occupying the beds at Queen's Square with diagnoses such as motor neuron disease, multiple sclerosis, Parkinson’s and so on. But it was also untrue.

The Science of Psychiatry: Making an Impact

Many of those seeing psychiatrists do get better - not overnight as in the scenarios beloved of Dr Kildare in my youth, or House in my children’s time - but if you have the patience to stick with them over weeks and sometimes months, get better they do. But there was also a second misperception - that “psychiatry just isn’t science”.

That annoyed me then, and still does. What people usually mean by this is that psychiatry is not very technological - routine clinical practice does not rely as much on what the Armed Forces call “kit” - expensive machines with flashing lights, dials and expensive maintenance contracts. There is some truth in this, at least at the moment. I think the fact that psychiatry does require considerable interpersonal skills is a plus, not a minus, but what is at issue is the false equation between technology and science.

Science is a way of thinking, a way of tackling questions and a good randomised controlled trial, prognostic or clinical study is just as scientific as one involving blood gas measurement or measuring cardiac volume. And there we have nothing to be ashamed of - psychiatrists were pioneers of the earliest clinical trials, and there are probably more epidemiologists working in clinical psychiatry than any other clinical discipline. I should know, I am one. Just because I don’t use the latest scanning or genetic technologies doesn’t mean I am not a scientist.

But hang on a minute. As an academic psychiatrist I am surrounded by people who do use the latest technology to study the mechanisms behind many mental disorders. Indeed, judging by the main journals, it is probably people in my corners of academic psychiatry who are in the minority. So it is me who is in danger of perpetuating a false distinction - that old chestnut mind versus brain. Just as geneticists, including psychiatric ones (especially psychiatric ones) study nature AND nurture, and look with condescension on dinner party guests who try to get a conversation going by saying “so where do you stand on the nature/nurture debate?”, for which the only answer is “there isn’t one, you clot, it’s both”, so do all psychiatrists, whether interested in research or not, agree it is body AND mind.

But the well-meaning but misguided interlocutor who has now been persuaded that psychiatry is as scientific as any other part of medicine, sometimes still has one trick up his or her sleeve. “OK, you are trying hard, I give you that, but you haven’t really achieved very much have you? It’s all terribly clever, and I grant you very interesting - but where’s the meat? What have you achieved? Where is the impact?” Well, Ladies and Gentlemen, it’s here. Because we can show you the impact. In the United Kingdom every academic is subjected once every six years to a particular form of torment which used to be called the Research Assessment Exercise (RAE), but more recently was renamed the Research Excellence Framework (REF).

“Excellence”, along with “passionate” and “inspirational” is the new black. No doubt it will be called something else next time. And for this every person who does any research in a university is assessed on the quality of their output. One of the most important parts of this assessment is to demonstrate what is called “impact”. How did your research make a difference?

We have gathered examples of what are known as the “impact statements” submitted to the last assessment exercise, known as the REF, from around our universities which are concerned with psychiatry, and produced by psychiatrists, usually working closely with psychologists as we do. These are not just advertisements for what we do (although there is no problem with that either) but rigorously checked and peer reviewed documents, which have been used as part of the overall assessment of the quality of the work we do. I will wager that anyone who takes time to have a look at these will realise just how misguided it is to claim that “psychiatry isn’t scientific” or that research in psychiatry “doesn’t make any difference”. Try it and make up your mind.

I am confident that you will enjoy the range and breadth of what we have achieved in the last few years, and will be as excited as I am as to what is still to come. Perhaps you might want even to join in. You will have the chance to make a real difference to some of the most important health problems not just in this country, but around the world.

Trust me, it won’t be dull.

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Comments

Re: Making an impact: the scie
I must confess that I haven't been invited for a dinner party for some time now, maybe something to do with working in Sunderland. If I was an academic in London I would have more social success! However, I do look forward to a take away lamb saag Balti on a Friday evening to celebrate Shabbat, after a very unscientific and morally ambiguous 5 days, typical of my clinical life.

Anyway, the main problem we face as psychiatrists, in my opinion, is bias; both in individual and team settings. Despite me providing the college with 2 eCPD modules on the topic (including one on team leadership with Mike Hobkirk – shameless plug), I am still prone to this ‘original sin’. At least as clinical psychiatrists we are willing to admit to this, I suspect unlike some of our academic colleagues both within and out with psychiatry.

The practical implication of this unscientific mind set is polypharmacy, typically in ‘treating’ children and adults with neurodevelopmental and neurodegenerative disorders. The process of adding another drug is often lacking in target symptom definition, and deciding on duration of a trial of 1. Withdrawing other psychotropic before or after a trial is also sometimes lacking. It is rare for our pharmacy colleagues to be actively involved in the decision making process; often having to comment after the act, making MDT decision making a farce. Questioning polypharmacy can also be met with questions about one’s ‘clinical acumen’.

Academic psychiatrists have had difficulty with bias in terms of study design, cropping or expanding the study cohort (CDC with vaccines and autism in African American boys). Also, the genie of financial benefit for PIs is a problem in our specialty.

In terms of scientific understanding, I recently attended a teaching session on the so called ‘legal highs’ correctly called New Psychoactive Substances (NPS), which is very much embedded in the science of pharmacology. As you would expect psychiatric drugs are included by street experimenters, and efforts are underway in (non-university) labs to modify atypicals and benzodiazepines. We need to gen up on this topic quickly as it has major implications on all our sub specialities including old age (we are getting increasing number of 40-50 year olds at out memory clinic). It also has implications for our rapid tranquilisation protocols, and 136 suite use. I wonder if all mental health staff should receive an annual mandatory training session in NPS (along with one on sleep disorders). Maybe the government should regulate all our psychotropics alongside NPS in a single group, as I fail to discern much difference.
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Professor Sir Simon Wessely

   

Professor Wendy Burn FRCPsych

President


Professor Wendy Burn became a consultant old age psychiatrist in Leeds in 1990 and now works fulltime in a community post. Her main clinical interest is dementia.

She has held a regional leadership role in this area from 2011 and was co-clinical Lead for dementia for Yorkshire and the Humber Strategic Clinical Network between 2013 and 2016.

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