Março de 2024 – Vol. 29 – Nº 3
Psychiatry online Brasil deseja homenagear um grande médico e professor e ao mesmo tempo propiciar aos nossos leitores suas reflexões sobre a psiquiatria.
Leon Eisenberg, M.D., D.Sc. (8 de agosto de 1922 – 15 de setembro de 2009)[1] foi um psiquiatra infantil americano, psiquiatra social,[2] e educador médico que ““transformou a psiquiatria infantil, defendendo a investigação sobre problemas de desenvolvimento” (para mais informações pesquisar no Wikipedia)
PAST, PRESENT, AND FUTURE OF PSYCHIATRY:
PERSONAL REFLECTIONS
Leon Eisenberg, MD1
(Can J Psychiatry 1997;42:705–713))
Objective: To review the past half century of North American psychiatry from personal experience and to gaugeits future prospects.
Method: An examination of the relevant literature, recollections from a long academic career, and analysis of trends.
Results: The pendulum of psychiatric theory continues its swing from its psychological to its biological pole;current economic forces are driving it toward reductionistic biology. The very considerable gains in the psychosocial and neurobiogical knowledge base of our field will ultimately have a potent yield in patient care once the restrictive controls on its application to service provision are lifted.
Conclusion: The future of research in the sciences basic to psychiatry has never been more promising. How rapidly progress will occur will be a function of the resources society is willing to commit to mental health research. The prognosis for the translation of the new findings to clinical practice will depend on whether professionals can mobilize public support for quality care for the mentally ill.
(Can J Psychiatry 1997;42:705–713)
Key Words: psychoanalysis, psychotherapy, psychopharmacology, outcome research, temperament, gene
knockout, cost caps
The grandiose title of this review was proposed by the Journal’s Editor-in-Chief. The hubris of the author is evident from his willingness to accept it. In so doing, I exercise a prerogative of age. One advantage of growing older (there aren’t many, I have discovered!) is that one has become
history, having lived through it. What follows are personal and idiosyncratic reflections on the past half century of psychiatry in North America (focused primarily on the United States). I conclude with forecasts (admittedly uncertain) for the next half century.
When Psychoanalysis Was in Bloom
When I entered my residency in 1950, academic psychiatry in the US was in thrall to psychoanalysis. Although no more than 10% of US psychiatrists were psychoanalysts, more than half the chairmen (there were no chairwomen) of departments of psychiatry held membership in psychoanalytical societies (1). The best and the brightest psychiatric residents entered analytic institutes. University hospital residencies
provided little or no experience in the state hospital sector, where poor patients received such care as they got.
Training focused on the intensive psychotherapy of neurotic patients under the close individual supervision of privately practising senior psychiatrists. This apprenticeship, considered to be the “plum” of the residency by trainees, was decisive for career choices.
In some centres, almost all the residents entered personal analysis. Whatever its usefulness for self-understanding, it had a profound effect on professional careers. geographic mobility for a long period; its cost necessitated after-hours private practice (officially frowned upon but tacitly
tolerated); and above all, the didactic analysis, together with evening courses in the institute, prepared the resident for a treatment technique inapplicable in the public sector. Was it at all reasonable to expect the young man or young woman to cast aside what he or she had so painfully and so expensively
acquired (2), particularly when its pursuit promised na honourable and comfortable career?
How Did Psychoanalysis Come into Power?
How did an untestable theory and a method without proof of effectiveness come to be so dominant 50 years ago?
Understood in the context of the times, its prevalence was not at all surprising. Three characteristics of pre-1950 medicine help to explain it. First, most treatments, psychiatric or medical, were based on “clinical experience” rather than on randomized trials; second, there were few therapeutic alternatives in psychiatry and no other equally comprehensive theory; third and most important of all, psychoanalysis
had the very considerable virtue of requiring doctors to listen to their patients in order to help them.
Clinical Experience as Evidence
First, as to the role of “clinical experience,” Richard Doll (3) reminds us that: until the end of the second World War, the introduction of new treatments had generally been based on the results reported by senior members of the medical profession, who had tried out a new treatment on a series of patients . . . and concluded that the
outcome was better than that reported by others or obtained by themselves in the past (3, p 365).
The very first double-blind randomized controlled Trial (RCT) in medicine, the United Kingdom Medical Research Council trial of streptomycin for the treatment of tuberculosis (4), did not take place until just after World War II. Although the RCT rapidly became the gold standard for clinical research, treatment recommendations continued to reflect tradition (and medical uncertainty). Indeed, pulmonologists (5)
continued to place the “rest cure” at the centre of tuberculosis treatment for 15 years after the value of chemotherapy had been demonstrated, whereas there never had been any data on the effectiveness of bed rest!
Alternatives Were Lacking
Second, as to alternative theories, no other psychological formulation provided as comprehensive an account of the origins of psychopathology. The brain sciences were largely irrelevant to clinical practice. Descriptive psychiatrists were held in little esteem; diagnosis was unreliable; in the event, diagnosis made little difference for treatment. The psychiatric pharmacopeia was limited to hypnotics and sedatives—drugs that brought little relief at much risk for addiction. Electroshock for depression was effective, but it had medical complications and made many patients fearful. Insulin shock treatment, in common use for schizophrenia, was of uncertain utility and considerable risk.
What Psychoanalysis Contributed to Psychiatry
Third, psychoanalysis seemed to “explain” the bizarre symptoms patients exhibited. Its very complexity and counterintuitiveness enhanced its allure. It connected the symptoms of mental illness to the psychopathology of everyday life. Whatever its value as a scientific doctrine, psychoanalysis
made a powerful and lasting contribution to psychiatry. It taught trainees to listen to patients and to try to understand their distress, not simply to classify them or sedate them or lock them away. It taught us the importance of memory, its vulnerability to distortion, and its centrality to patients’ life narratives, the stories they tell themselves and others. It made clear how those narratives can be self-defeating and defined the task of therapy as helping patients to reconstruct their autobiographies in ways that permit growth.
Then, as now, many patients improved with what was derided as “talk therapy.” Psychoanalysis helped psychiatry preserve an abiding interest in the individuality of the patient while othermedical specialists were losing sight of the patient in their preoccupation with the biology of disease. We helped our patients by paying attention to what troubled them in na era when we had no special procedures. Now that we do,
financial exigencies have made listening a luxury rather than the linchpin of care for chronic illness, whether the illness be diabetes or schizophrenia.
Attempts to measure the effects of psychotherapy and to contrast schools of treatment with one another, however, were beset by difficult methodologic problems. Jerome Frank (6) compared research in psychotherapy to: the nightmarish game of croquet in Alice in Wonderland in which the mallets were flamingos, the balls hedgehogs, and the wickets, soldiers. Since the flamingo would not keep its head down, the hedgehogs kept unrolling themselves and the soldiers were always wandering to other parts of the field . . . itwasavery difficult
game indeed (6, p 332).
At the American Psychological Association Conference on Graduate Education in Clinical Psychology, a wag commented: “therapy is an undefined technique which is applied to unspecified problems with a nonpredictable outcome. For this technique, we recommend rigorous training” (7, p 547).
Critique of Theory Was Unavailing
This was the situation when the American Psychiatric Association convened its Conference on Graduate Psychiatric Education in the early 1960s. The participants were charged to assess “the relative adequacy with which present training is preparing the psychiatrist to meet changing medical, social and public needs” (8, p vii). Treatment of acute psychiatric illness was shifting from the isolated mental hospital into the community; the duration of inpatient care was growing shorter; the need for continuum of treatment in the community had become evident; public services were understaffed.
There was general agreement among the participant in the conference that new knowledge in the social sciences,pharmacology, and the neurosciencesmust be reflected in the training curriculum. At the same time, a human resource shortage precluded longer training.
At the final plenary session, I made a modest proposal. Given the agreement that instruction in the social and neural sciences must be increased but the duration of training couldnot be, the current syllabus would necessarily have to be CUT back. No one having nominated candidates for trimming, I proposed a sharp reduction in the inordinate emphasis on psychoanalysis. Not only did it lack a scientific foundation,
not only was there no evidence of differential effectiveness, but it led to the abandonment of public service in favour of private practice. In a veritable stampede of senior figures to the floor microphones to defend psychoanalysis as “the basic science” of psychiatry and its practitioners as the stalwarts of
public service, I barely avoided the crush. No vote needed to be taken; my proposal went down in flames. The conference monograph cites my (unattributed) words as “a dissenting opinion”:
Psychoanalysis, while initially a liberating influence in freeing psychiatry from a purely phenomenologic orientation, has in turn had stultifying effects on the further evolution of psychiatric thinking. Its simulation of comprehensiveness has led to premature closure. Too many residents are satisfied with so-called explanations of behavior that are philosophic exercises rather than scientific theories subject to test. This satisfaction deadens
their curiosity for further critical study. It can be argued that major advances in psychiatric research and practice will have to be based on critical questioning and perhaps even rejection of psychoanalytic theory (8, p 8).
Fourteen years later, the editor of the next training conference (9) reported that the deemphasis of psychoanalysis had been the most notable trend during the previous decade and a half. The change, I must acknowledge, had nothing to do with my critique of theory and everything to do both with reports on treatment outcomes, on clinical course, and on temperamental characteristics and with the advent of powerful psychopharmacologic agents.
New Clinical Data Raise Questions
Data challenged dogma. The Cambridge-Somerville Delinquency Prevention Project (10) reported the results of counselling and casework therapy for several hundred underprivileged delinquent boys whose outcome was compared with a group receiving conventional services. The caseworkers were confident that their intervention had brought substantial benefit to two-thirds of their clients; more than half
of the “clients” themselves claimed they had been helped.
Nevertheless, there were no significant differences in outcome between subjects and controls (11).
Lee Robins published the results of a 30-year follow-up of patients seen at the St Louis Child Guidance Clinic; her findings demonstrated just how out of touch with clinical reality theory and practice were (12–14). The child guidance movement had been founded in the 1920s specifically to serve delinquent and neglected youngsters, but by the 1950s, clinics were serving predominantly neurotic children. The St Louis data made it clear, however, that neurotic children, though at somewhat greater risk for psychiatric “caseness” as adults than the classroom controls, proved to be far better off as adults than adjudicated delinquents and aggressive, runaway, and paranoid children. Many of the former became sociopaths;
many of the latter went on to suffer from schizophrenia.
In our annual review of progress in child psychiatry, Professor Kanner and I noted: “These findings should spur a re-examination of our preoccupation with treating the neurotic child to the exclusion, often, of the antisocial child, since it appears to be the latter who constitutes the greatest risk for later personal and social decompensation” (15, p 609).
The 1950s saw another signal contribution. Stella Chess and Alex Thomas (16,17) reintroduced to child psychiatry the concept of nonmotivational factors in behaviour, an aspect that had been “obscured in our contemporary pre-occupation with psychodynamic factors” (15, p 609). Michael Rutter, in assessing the importance of their work, has written: At a time when American psychiatry was dominated by psychoanalytic
concepts of intrapsychic conflict, they emphasized that children’s behavior was shaped by crucial stylistic components (the “how” of behavior), as well as by motivational concerns (the “why” component), content (the “what” element), and maturational level (18, p 23).
The fit, or the lack of fit, between the temperament of the child and the characteristics of its family environment proved decisive for the probability of a behaviour disorder (19).
Drug Discovery by Serendipity
These data from treatment trials, from long-term outcome, and from observational studies of early differences in infant behaviour began unravelling faith in received wisdom.
The most telling impact on practice and theory, however, resulted from a series of chance discoveries in the 1950s and 1960s of reserpine’s psychotropic effects when it was used to treat high blood pressure; of chlorpromazine as a tranquillizer during research on anesthesia; of iproniazid as a euphoriant
during the treatment of tuberculosis; of the antidepressant properties of imipramine when it was employed as a presumptive antipsychotic; and of the antimanic effects of lithium when its urate salt sedated experimental animals. Each was discovered by serendipity; there was no coherent biological
theory of psychosis. Theory emerged in the effort to account for the unexpected findings: the new drugs revolutionized treatment practices and the way that psychiatrists thought about their field and themselves.
Drugs and Deinstitutionalization
The new drugs were credited with emptying out the mental hospitals. Is that true? Only in part, for the story is considerably more complex. State and county mental hospital beds in the US, which had peaked at 560 000 in 1955, fell to just over 400 000 by 1970 (20). They dropped to 93 000 by 1992 (21),
but the beginnings of deinstitutionalization preceded the introduction of drugs. In geographic areas where the open hospital movement and community-based programs of the late 1940s had been implemented, drugs had relatively little additional effect on length of hospital stay (22), but the effects of their introduction were decisive in hospitals that still warehoused patients (23). The process in the US was driven by economic forces (cost-shifting from state to federal budgets) rather than by data on outcome; indeed, there were no such data (20). Some patients went to nursing homes (they were “transinstitutionalized”); others were discharged to neighbourhood addresses that had been bulldozed. These unfortunate individuals usually found their way to the streets. Calls for evaluation of the new community mental health movement were unavailing (24).
Psychopharmacology and Psychiatric Practice
Because drugs made it possible to abort acute psychotic episodes and minimize recurrences and because the new agents were relatively syndrome-specific, diagnosis and classification suddenly became important for clinical management (25). Psychiatrists rediscovered their medical roots. It became convenient to emphasize the importance of being licenced to write prescriptions; that ability provided an edge in marketplace competition with the rapidly multiplying numbers of psychologists and social workers.
Psychiatry has begun to trade the one-sidedness of the “brainless” psychiatry of the past for that of a “mindless” psychiatry of the present (26). Some residency training programs have become exercises in diagnosis and classification and instruction in the subtleties of drug prescribing. Psychotherapy
is relegated to social workers and counsellors because costs are lower (so far!). At the same time as these changes have taken place (is it because of them?), psychiatry hás become less attractive as a specialty to graduatingUS medical students.
The Validation of Psychotherapy
Paradoxically, the teaching of psychotherapy is withering on the vine just as evidence of its effectiveness is emerging from systematic research. In 1980, Smith, Glass, and Miller (27) reported that a metaanalysis of aggregated studies of psychotherapy demonstrated highly significant treatment effects; what was puzzling was that the effects did not vary with the school of psychotherapy or the experience of the therapist.
A closer examination of a subset of the best studies by Andrews and Harvey (28) revealed that behavioural psychotherapies are reliably better than verbal psychotherapies and that both are more effective than simple advice giving or the administration of a placebo. Meta analysis of the treatment of
neurotic patients (29) established the value of cognitive behaviour therapy.
We now have good evidence that specific psychological treatments are effective for particular conditions: family intervention to reduce relapse in schizophrenia (30,31); cognitive therapy, interpersonal psychotherapy, and problem solving therapy for the treatment of depression (32–38); and
cognitive behaviour therapy for eating disorders (39). Structured behavioural and cognitive therapies seem to have stronger effects than “dynamic” and “humanistic” approaches (40,41).
Psychobiological Interfaces
Not only does appropriate psychotherapy help, but evidence is accumulating that the improvement it brings about is paralleled by changes in the brain (42). One example must suffice: the relationship between brain and behaviour in obsessive–compulsive disorder (OCD). The symptoms of OCD
are associated with changes in cerebral metabolism in the basal ganglia, the limbic system, and cortical projections from both (43). Yet symptoms are reduced by behaviour therapy about as effectively as they are by serotonin reuptake inhibitors.
When the patient improves, what happens to brain metabolism?
When treatment, whether by drug or psychotherapy, produces improvement, that improvement is associated with a relative “normalization” of brain metabolism (44). In a replication, Schwartz and others (45) have obtained similar changes in brain metabolism in OCD patients after successful behaviour therapy. Starting from the opposite direction (symptom provocation), Rauch and others (46) have demonstrated that psychological stimuli capable of provoking obsessions in individual patients lead to an increase in regional blood flow. Thus the new methods in neuroscience make it possible to explore linkages between mind and brain that were not yet imagined a decade ago.
Advances in Neurobiology
The pace of progress in the scientific knowledge base of psychiatry (42) continues to be extraordinary. At the molecular level, the ability to “knock out” specific genes has made it possible to identify their biologic roles in the otherwise intact animal; new imaging techniques, such as echoplanar functional magnetic resonance imaging (fMRI), make it possible to capture the sequence and time course of brain events associated with higher cognitive functions. Samples of the stunning array of data produced by the new investigative methods include the following highlights.
Tsien, Huerta, and Tonegawa (47) have demonstrated that spatial memory in the mouse, shown by others to be dependent on long-term potentiation in the hippocampus, is impaired when the N-methyl-D-aspartate receptor gene is selectively deleted from hippocampal neurons. Although cell firing accompanies change of place in these animals, it is much less place-specific; further, coordinated firing in cell pairs is lost (48). Chae and others (49) have created a knockout mouse lacking the gene for p35. In the normal mouse, p35 generates a neuron-specific protein that activates cyclin-dependent kinase 5, an important actor in cell division cycles. In mice (and men), the genesis of the cerebral cortex ordinarily proceeds in a highly organized fashion from progenitor cells lining the lateral ventricle; late-arising neurons migrate to occupy the most superficial positions in the cortical plate (“inside-out”
generation of layers). In mice lacking p35, packing order is reversed; earlier-born neurons are superficial and later-born neurons remain deep. The mutant mice exhibit seizures; about 15% die prematurely in adulthood. The pathology of the knockout mouse resembles human lissencephaly of the Miller-Dieker type with cortical malformation and epilepsy.
As a final example in this research area, Brown and colleagues (50) have generated mice with an inactivated fosB gene, one of the “immediate early genes” that are induced rapidly in response to environmental stimuli. The most striking abnormality in fos B mutants is a profound behavioural
deficiency in their ability to nurture their young, despite apparent preservation of other cognitive and sensory functions.
The fos B-deficient dam fails to crouch over her pups or to retrieve them; the abandoned pups die unless they are cross-fostered to a normal dam. Both male and female fos B mutant mice exhibit defects in mouse-specific nurturant behaviour.
To turn to functional imaging studies, fMRI scans detect changes in blood flow and volume that serve as proxies for local increases in brain activity; activity can be localized to distinct anatomical structures in the brain because of the high spatial resolution of the technique. For example, when subjects
are presented with pictures of human faces and asked to recall whether the picture shown is the same as or different from one presented 8 seconds earlier, visual areas in the cortex respond maximally during sensory stimulation, whereas prefrontal activation is greatest during the delay periods (51). In a parallel experiment, subjects are presented with written consonants at 10-second intervals and asked to recall whether the letter presented is the same as the letter presented one, 2, or 3 trials back in the sequence. Activation in the primary visual, somatosensory, and motor córtices recedes during the “memory” interval, whereas activation in the prefrontal cortex is sustained throughout the trial (52).
Because anatomical studies had suggested an anomaly in the magnocellular visual subsystem in dyslexia, Eden and coworkers (53) used fMRI to study visual motion processing in normal and dyslexic men. In all the dyslexic subjects studied, the presentation of moving stimuli failed to produce the same task-related functional activation in area V5/M-T as it did in controls, whereas presentation of stationary patterns
resulted in equivalent activations in V1/V2 and extrastriate cortex in both groups. Other investigators (54), using pósitron emission tomography to measure cerebral blood flow and glucose metabolism and employing MRIs for anatomical localization, identified an area of abnormally decreased activity
in the prefrontal cortex ventral to the genu of the corpus callosum in both familial bipolar depressed and familial unipolar depressed patients. MRIs in those patients demonstrated reductions in gray matter volume in the corresponding area. Significantly, this region is implicated in the mediation of emotional and autonomic responses to provocative stimuli; patients with subgenual lesions demonstrate abnormal autonomic responses to emotional experiences, inability to experience the appropriate emotion, and impaired understanding of anticipated consequences (55).
These few examples from a large literature can only hint at what is at hand and what is yet to come.
The Intellectual Renaissance of Psychiatry
Psychiatry has recaptured the excitement it had a century ago when in the span of a few short years, the discovery of the spirochete as the cause of general paresis and the extraordinary psychodynamic speculations of Sigmund Freud promised to bare the secrets of brain and mind. By midcentury,
when my career began, the gold of neuropathology had turned to dross; psychoanalysis continued to provide a raison d’etre for clinical practice. On the eve of the millennium, neurobiology is illuminating brain function in a way few would have dared to predict; psychosocial research has begun to come
into its own. Lee Robins, in her 1997 Cutter Lecture, has reviewed the evidence from the 4 major epidemiologic studies she designed and carried out. She concludes that there has been during this century a secular increase in the lifetime prevalence and a lowering in the age of onset of psychiatric
disorders as varied as conduct disorder, substance abuse, depression, mania, and schizophrenia. This phenomenon cannot be ascribed to genetic change because the interval is far too short; clearly, it speaks for the profound influence of social risk factors; the task of teasing out which are the salient
psychosocial variables is a challenge for future research. The Project on Human Development in Chicago Neighborhoods has demonstrated that “collective efficacy” (defined as social cohesion among neighbours willing to intervene on behalf of the common good) serves to reduce the incidence of violent acts, a powerful effect that persisted after statistical correction for the sociodemographic composition of inner city neighbourhoods (56). George Brown and his colleagues at the University of London have over a number of years produced an impressive and self-consistent body of work on the psychosocial
precipitants of depression (57). Experiences of humiliation and entrapment following a severely threatening event are important risk factors for depression (58), whereas positive events involving hope are instrumental in recovery (59) from depression. Lisa Berkman’s elegant research in clinical epidemiology (60) has demonstrated the powerful impact of social isolation on mortality (after controlling for initial health status and other identifiable risk factors). Social isolation lowers survival after myocardial infarction (61) and predicts depressive symptoms in elderly patients (62,63).
Arthur Kleinman’s work has led to the recognition 1) of health care activities as socially organized responses to disease, responses that constitute a special cultural system (64); 2) of somatization as an idiom of interpersonal distress (65); and 3) of suffering as a socially constructed personal experience
(66). The magnitude of world-wide mental health problems and their relationship to recurrent cycles of violence, poverty, internecine warfare, and forced displacement are beginning to be tallied as a first step in designing United Nations prevention and control programs (67).
Thus the science underlying psychiatry has an extraordinarily promising future. Progress in human genetics is proceeding so rapidly that we are virtually assured a revolution in prescribing practices. No longer will doctors have to treat patients from data based on the average response of a heterogenous
population of patients with a given symptom complex to a range of drug dosages. Instead, data from the Human Genome Project will inform doctors about the kinetics of drug metabolism in the very patients seated before them, thus permitting more rational decisions about choice of drug, dose, and frequency of administration. Psychiatrists will be treating schizophrenia type a, b, . . . n, or depression 1, 2 . . . X, for
which prognoses will be clearer and for which therapeutics can be more precisely targeted. Further, the ability to identify subsyndromes will enable clinical epidemiologists to pinpoint more specific psychosocial precipitating and protective factors for clinical disease in individuals at a particular level
of genetic risk (identified by genomic analysis). At present, the “noise” in the system (the heterogeneity of gene distribution)makes it more difficult to discern the psychosocial “signal.”
Remember, it was only after vitaminD enrichment of Milk had largely eliminated environmentally caused rickets that clinical investigators were able to detect what they termed “rickets resistant to vitamin D,” an inherited disorder of D metabolism (68). In parallel fashion, but proceeding in the opposite direction, knowing which members of a population have the greatest genetic risk for a particular schizophrenic
(or a particular depressive) subtype will enable psychosocial investigators to detect more reliably the environmental factors that interact with a particular combination of genes to yield or postpone the clinical phenotype. In turn, the specification of precipitating and protective psychosocial factors
will provide rational grounds for designing preventive and therapeutic interventions. Progress in genetics will not wash out the environmental impact but, contrarily, make it more evident; conversely, progress in psychosocial research Will enhance the identification of additive genes, each of which makes a small but distinct contribution to risk. In a word, I am an optimist about psychiatry as an academic specialty.
What about the future of psychiatric practice?
The Imposition of Caps on Costs
At the very moment when the evidence for the value of comprehensive psychobiological care has become compelling, the focus in national health policy the world over hás shifted from health outcomes to costs. Third-party payers, whether public or private, refuse to reimburse for more than brief psychotherapy. The practice of psychiatry—indeed, the clinical practice of medicine—is being constrained and confined
by the centrality of cost control. The competitive market treats medical visits as commodities on a production line (69).
Efficiency is gauged by the number of patients processed per unit of time, without regard for the destructive effects of foreshortened consultations on patient care. Patients need time with their doctors; they seek doctors who place Paramount emphasis on patient health rather than on the profits of
the corporation.
Time is the Currency of Medical Care
Time has become the currency of medical care; population health is the only valid measure of its effectiveness. The technical virtuosity of modern medicine has reemphasized fundamental human issues. Now that we can preserve life by cardiopulmonary assist, it becomes necessary to ask: Should
we? As a current Institute of Medicine Report states: “Humane care for those approaching death is a social obligation as well as a personal offering from those directly involved”(70). Now thatwe have means to treat acute illnesses, medical practice is increasingly devoted to ameliorating chronic infirmities,
a task in which psychosocial issues are prominent.
Changing the biobehavioural risk factors for morbidity and mortality (smoking, eating, drug taking, drinking and driving) challenges the competence of all physicians. Perhaps one-half of physician visits are for complaints without an ascertainable biological basis. The sick role provides a socially sanctioned
way of responding to intolerable situations. Without curiosity about life circumstances and an attempt to alter them, the physician’s activities become futile, medical costs mount, and patient dissatisfaction increases. Comprehensive evaluation and effective treatment planning require the physician to be as knowledgeable about the psychosocial determinants of health as about its molecular base (71).
This is as true for the primary care physician as it is for the psychiatrist, as true for the surgeon as it is for the endocrinologist. Kaplan and colleagues (72) have summarized the results of 4 randomized trials focused on improving communication between patients and physicians. The medical conditions
studied were peptic ulcer, hypertension, diabetes, and breast cancer. In each case, greater participation in and control of treatment by the patient, more expressed affect from the patient, and the exchange of more medical information between patient and physician led to diminished morbidity.
The power of patient participation in managing chronic disease is impressively illustrated by a recent randomized controlled treatment trial for patients with insulin-dependent diabetes. The Diabetes Control and Complications Trial (73) enrolled 1400 patients in a multicentre study comparing standard with intensive care. Patients in the intensive therapy arm were placed on multiple daily insulin injections or continuous subcutaneous insulin infusion by pump. The treatment program began with 4 days of patient education in hospital followed by frequent outpatient visits, group meetings, and phone calls to reviewprogress, monitor hemoglobin A1c, adjust insulin dose, maintain diet and weight control, and
regulate exercise patterns. The results were remarkable: the intensive management program significantly delayed the onset and slowed the progression of the microvascular and neurologic complications of diabetes. On average, each patient gained an additional 7 years of sight, 6 years free of end-stage renal disease, and a 5-year postponement of the need for limb amputations (74). The treatment regimen was
extraordinarily demanding of the patients and required close cooperation between patients and clinicians. It is, therefore, all the more remarkable that 99% of the patients completed the trial, a tribute to joint participation by research team and patients.
Canadian Health Care at Risk
Canada’s health scheme, the envy of many of us in the US because of its universality and comprehensiveness, is under siege because costs have increased far more rapidly than the
overall economy. Even though the percentage of the Canadian gross domestic product spent on health care is considerably less than the 14% (or higher) in the US, federal and provincial governments in Canada are limiting funding despite increasing needs for a growing and graying population
(75). At the same time, however, the commitment of the Canadian public to the principles of universal access is evident from the rhetoric of all the parties in the 1997 election; each portrayed itself as the defender of universal health care (76).
The Future of Patient Care: Economics and Ethics
The very greed of the for-profits in the US compels them to shortcut care in ways that are becoming visible to patients (drive-through deliveries, outpatient mastectomies, refusal of specialist care, and costly treatments). The patient revolt is influencing politicians. A bill under consideration in the US
House of Representatives as of June 1997 proposes safeguards for patient care by outlawing “gag rules,” requiring specialist care when it is recommended by generalists, mandating reimbursement for out-of-plan emergency care, and providing an appeals mechanism when coverage is denied (77). Legislative micromanagement is hardly the way to run medicine, but what is noteworthy is the recognition by the
public that short-changingmedical care is bad for health. That recognition will ultimately bring US and Canadian patients and physicians together to support a patient-centred health care system.
Is my optimism warranted? What credentials do I have as a Nostradamus? Full disclosure to the reader requires acknowledgement of a prediction I made 25 years ago. At a symposium entitled “Medicine in the Twenty-First Century” during the Centenary of the University of Manchester Medical School, I predicted that: Psychiatry is a paradigm for the general medical practice of the future . . . psychiatric practice deals with human distress in a context that must include the psycho-social as well as the biological.
There are no imperialistic aims behind this claim . . . in so far as psychiatry is successful in clarifying the psychobiological bases of health and illness, that knowledge will pass into the domain of the generalist and the psychiatrist will join other specialists in the secondary and tertiary cadres of the health system (78, p 12).
I was right and I was wrong—right in contending that psychobiological understanding will become as central to general medicine as it is to psychiatry, wrong in failing to recognize that the mounting cost of health care would endanger the kind of medical practice I envisioned. Nothing, however,
has shaken my conviction that the superiority of patient-centred, psychologically sensitive, integrative medicine will become evermore evident to patients, who will serve as its advocates and assure its ascendancy.
I claim no novelty for this idea. It was recognized in classical antiquity. Let me conclude with a passage from Plato’s The Laws, written about 350 BC. An Athenian “Stranger” addresses Cleinias, a Cretan, and Megillus, a Spartan. The Athenan Stranger (in effect, Plato himself) hás this to say about “slave” and “free” physicians: Slaves . . . are almost always treated by other slaves who either rush about on flying visits or wait to be consulted in their surgeries. This kind of doctor never gives any account of the particular illness of the individual slave, or is prepared to listen to one; he simply prescribes what he thinks best in the light of
experience, as if he had precise knowledge, and with the selfconfidence of a dictator. Then he dashes off on his way to the next slave-patient, and so takes off his master’s shoulders some of the work of attending the sick. The visits of the free doctor, by contrast, are mostly concerned with treating the illnesses of free men; his method is to construct an empirical case history by consulting the invalid and his frieds; in this way he himself learns something from the sick and at the same time he gives the individual patient all the instruction he can. He gives no prescription until he has somehow gained the invalid’s consent; then, coaxing him into continued cooperation, he tries to complete his
restoration to health. Which of the two methods do you think makes a doctor a better healer . . .? (79, p 181–2).
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Résumé
Objectif : Examiner l’histoire de la psychiatrie en Amérique du Nord depuis un demi-siècle d’après l’expériencepersonnelle de l’auteur et évaluer les perspectives d’avenir de cette science.
Méthode : Un examen de la littérature pertinente, un rappel de souvenirs accumulés au fil d’une longue carrière en enseignement et une analyse des tendances.
Résultats : Le pendule de la théorie psychiatrique continue d’osciller entre ses pôles psychologique et biologique :les forces économiques actuelles le poussant vers une biologie réductionniste. En bout de ligne, les progrès três considérables de la base des connaissances psychosociales et neurobiologiques dans notre domaine se traduirontpar un rendement important sur le plan des soins aux patients lorsque seront levés les contrôles restrictifs sur l’application de cette base à la prestation des services.
Conclusion : L’avenir de la recherche en sciences fondamentales de la psychiatrie est plus prometteur que jamais.
La rapidité des progrès sera fonction des ressources que la société accepte de consacrer à la recherche en santémentale. Le pronostic de la traduction des nouveaux résultats en pratique clinique dépendra de la capacité desprofessionnels de mobiliser le soutien de la population en faveur des malades mentaux.