Civil War psychiatry

The tensions continue to be felt between the two camps in psychiatry. Some may jib at a Civil War comparison, but it seems as though we have the Cavaliers of Neuropsychiatry on one side, boldly and flamboyantly going in their search for truth where no psychiatrist has gone before, and the Roundheads of Community Psychiatry, with its Model Multidisciplinary Army, keeping its head down and concentrating only on problems on the ground that are clearly real, alive and needing solutions. Bullmore et al (pp. ) have raised the King's Standard yet again in this issue, taking forward the initial charge of Craddock et al ^{Reference Craddock, Antebi, Attenburrow, Bailey, Carson and Cowen1} and making the case for ‘a brain-based medicine of the mind’ on the grounds that this is the only intellectual way forward if we are to advance knowledge. They would have the support of Velakoulis et al (pp. ), whose studies of psychosis in frontotemporal dementia suggest a direction for elucidating the neurobiology of psychosis; Juruena et al (pp. ), who seek explanation for treatment resistance in depression through the hypothalamic–pituitary–adrenal axis; Lencz et al (pp. ), who suggest a role for brain-derived neurotrophic factor in schizoaffective disorder; and Selvaraj et al (pp. ), who show, almost unequivocally, that damage to serotonergic neurons does not take place in those who use ecstasy as a recreational drug. The Roundheads would be reinforced in their daily toil by suggestions that we may be able to prevent the onset of depression in those with physical illness (Robinson & Jorge, pp. ); evidence that the mental health of detained immigrants depends greatly on the duration of detention (Robjant et al, pp. ); and the fascinating study by Steele et al (pp. ), demonstrating that cultural factors have a marked effect on symptoms of mental distress and may alter prevalence rates in different societies.

There are several reasons why this debate is necessary but should still remain largely uncontentious. As Bullmore et al admit (p. ) in current clinical practice there is ‘no clear role for neuroimaging, biomarkers or genetic testing’, but in 20 years time it may be very different. The Roundheads, largely foot-soldiers, have to get on with their daily tasks on the basis of empirical evidence without any fancy tests to help them provide better care, and if they sometimes think that the Cavaliers with their flashing steeds are indulging themselves a little, this is perhaps not surprising, ^{Reference Kingdon and Young2} even though it may be unfair. The most common problems facing coal-face psychiatrists are ones in which all evidence-based psychiatric interventions have failed or become stuck in some way. New tests are of virtually no use here, and in the new discipline of the psychiatry of recovery we have to adopt different approaches. In a review of David Whitwell's book, ^{Reference Whitwell3} Roberts refers to what almost may be the antithesis of the Bullmore approach in attempting to help patients with intractable problems: ‘his [Whitwell's] experience was that in learning how to be less knowledgeable he became better connected to the reality of peoples’ lives and struggles,' and therefore more successful. ^{Reference Roberts4} I have gone a similar way in giving up on direct treatment approaches for those with personality disorder who only want their environments improved ^{Reference Tyrer5} and have been surprised by the results.

We should encourage research along the new frontiers of psychiatry but monitor its implications carefully, because the precursors have not always been propitious. ^{Reference Pilgrim6} Above all we need good independent assessments of the value and applications of the burgeoning data derived from these new methodologies to ensure they connect to psychiatric practice. I referred recently to the ‘new phrenology’ ^{Reference Tyrer7} by which a correspondent had disparagingly referred to neuroimaging. The independent evaluation (by agencies of society) that a former scion of the Royal Medico-Psychological Association, Dr Daniel Hack Tuke, recommended over 150 years ago to investigate the claims of the old phrenology is equally apposite here:

Does the British Journal of Psychiatry no longer publish papers on psychoanalysis?

This question was asked of me recently. Is it true? No. If a paper on psychodynamic principles, treatment or outcome satisfies the MINI criteria mentioned in the February issue of this column ^{Reference Tyrer9} (methodology, innovation, novelty and implications), then it will have a good chance of publication. One or two will be published in the next few months; I hope to see more. Examination of our book reviews and commentaries reveals that although the terrain for research in psychoanalysis is a little rocky at present, the subject is far from sleeping, and with correspondents such as Jeremy Holmes on our shoulders at all times ^{Reference Holmes10} we are not going to be allowed to forget.