From the Editor
For psychiatry, progress isn’t what it used to be
There is a widespread notion that today’s medical practices and advances—including in psychiatry—are superior to the tools and therapies of the past, yet a second
look at the facts will temper that perception.
I might have a jaundiced view of progress but, across most medical specialties, diseases are still managed, not cured. Chronicity is almost ubiquitous among medical ailments, and no specialty can boast that it restores function completely and fully restores patients’ quality of life.
Psychiatry has had its share of missteps
Prefrontal lobotomy is perhaps the most infamous of many discredited treatments that were introduced as a great solution to severe brain disorders such as schizophrenia.1 Prefrontal lobotomy (leucotomy) was initially heralded as a major medical advance in 1935; its originator, neurosurgeon António Egas Moniz, shared the Nobel Prize in Medicine or Physiology in 1949 for what is now regarded as mayhem. Prefrontal lobotomy was widely used for many conditions—not just for psychosis—but it fell from favor rapidly after the discovery of anti-psychotic drugs.
A similar fate befell other treatments that were introduced to psychiatry:
• malaria therapy (1917) for general paresis of the insane (the condition was later recognized as tertiary syphilis)
• deep sleep therapy (1920) for schizophrenia
• insulin shock therapy (1933), also for schizophrenia.
Those discredited therapies were lauded as significant advances, only to be shunned later as harmful, even barbaric.
Treating addiction is another saga of false steps. Fifty-nine different treatments for addiction have been introduced over the past few decades, many later discredited as “psychoquackery.”2 In the breathless rush to cure desperate conditions, there often is the risk that pseudoscience will masquerade as science. Many patients suffer needlessly before the medical community examines the accumulated evidence and discredits useless or harmful treatments.
Psychiatry isn’t alone in lacking cures
A fitting slogan of many non-psychiatric medical specialties is “to treat, perchance to cure.” Consider some examples:
• In cardiology, congestive heart failure, a chronic illness, is managed but rarely cured, and leads to early mortality.
• Nephrologists struggle to maintain a semblance of kidney function in renal failure patients, before placing them on the long waiting list for a kidney transplant.
• Gastroenterologists can only hope to maintain liver function in severe hepatitis, or to alleviate the misery of ulcerative colitis.
• Rheumatologists do what they can to relieve the debilitating symptoms of rheumatoid arthritis, systemic lupus erythematosus, and Sjögren’s syndrome.
• Pulmonologists know they can never restore normal lung function for their patients with chronic obstructive pulmonary disease; they can only help them hang on with partial function.
• Oncologists valiantly fight aggressive cancers with the hope of prolonging life for a few months or years.
• Neurologists valiantly try to manage multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, epilepsy, stroke, myasthenia gravis, and amyotrophic lateral sclerosis—often with limited, if any, success at achieving remission.
Internal medicine has had its share of discredited therapies, too—ones that were withdrawn because they caused harm or were of dubious or inconclusive efficacy.3 Thanks to careful analysis of the efficacy and safety of medical procedures introduced during the past decade, we know that 40% of 146 procedures examined were eventually discredited and withdrawn. (That kind of analysis should be undertaken in psychotherapy, where evidence-based therapies can be counted on one hand but dozens more are promoted as legitimate.4 Psychotherapy can be harmful.5)
As with patients in psychiatry, patients of all these specialties are at risk of suffering disruptive iatrogenic side effects that, at times, approach torture—just to have progression of disease halted but not necessarily to deliver full remission. The quality of life for patients who have a chronic disease ranges from barely tolerable to poor, but is rarely good or optimal—and that is the case across all of medicine, including psychiatry.
Desperation often drives dubious innovation
There are numerous “desperate” diseases across all medical specialties, including psychiatry. Radical and harmful measures are sometimes proposed and marketed to treat many of those conditions; more often, useless, ineffective, futile “treatments” are introduced, and it might take years before they are discredited and withdrawn.6,7 Useless treatments can be harmful, too, because they delay the use of potentially effective procedures.
Move forward with caution!
What does this brief look at the missteps of medicine tell us? First, medical progress is like the mambo: We take steps forward but then step backward again; and, as Karl Popper noted, science learns more from its failures than from its successes.8 Second, all physicians must be judicious and guided by evidence when they select treatments.
For your patients’ sake, choose wisely!9
For psychiatry, progress isn’t what it used to be