From the Editor

The transient truths of medical ‘progress’

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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.


 

References

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

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