NICE (UK), RANZCP (Australia, New Zealand) etcetera, and apply this to the patient. For all of the many pages and for all the appeal to expert judgment, these guidelines are just glorified flowcharts. Actually it is simpler still for the psychiatrist, as most will have their favourite few drugs or drug combinations for each of the disorders, be it the so-called antidepressants/anxiolytics, mood stabilizers or antipsychotics. For example, take the depressed patient. If the depression is mild start with CBT. If it is moderate add CBT to the SSRI. If unsuccessful move to a tricyclic, if unsuccessful still augment with lithium or antipsychotic. The end of the line if all else fails is ECT or an MAOI, or both
Granted the doctor need be aware of dosing considerations, if and when to test serum drug levels, exclusion of organic causes of depression (i.e. medical causes of depression such as underactive thyroid), when and how to switch medications and so on. Yet this is not too daunting, also just a memorization or reference to flowcharts. The psychiatrist might be able appear more erudite by justifying specific medication choice on the basis of what receptor systems they act upon and which they do not. These are by and large convenient stories, mirages of oasis that vanish when one looks closer at the literature. The psychotherapy is more often than not outsourced to psychologists as psychiatrists take upon themselves a managerial mantle, this being convenient for psychiatrist is by and large as neither competent at, or interested in, the “talking cure”. If they are, they will have their pet little approach that is also easy to learn in practice. Surely this fact is not controversial.
My example is a deliberate one, for it is worth digressing at this juncture to hurl grenade at the myth of the power of so called antidepressants, these also often marketed as first line for anxiety. Once again my little spiel will be unreferenced. Suffice it to say for now that these agents correct no chemical imbalance in the brain, for no chemical imbalance has ever reliably been found, nor any other biological pathogenesis accounting for any but a tiny subset of depressed (or anxious) patients. It is the same also for schizophrenia. What these medications do is run the risk of creating a chemical imbalance, for the brain reacts to an excess of neurotransmitter with altering its neurochemistry such that it then becomes imbalanced, as the brain “fights” what the drug is ‘attempting” to do. Oft times the consequences of imbalance is not recognised until one attempts withdraw from the SSRI or SNRI (or any psychotropic really), and whatever attendant symptoms emerge is reinterpreted by the psychiatrist as a relapse of the imaginary biological illness, not a withdrawal phenomenon pure and simple, i.e. a side effect of the drug. And so they wind up on the medication yet again, and the circus continues. But you might say that you, or your patients, have an undeniable salutatory effect. Irving Kirsch, the Harvard psychologist and doyen of the placebo effect, has provided us the best evidence yet that the vast majority of what might be considered the drug effect is actually placebo, what beneficial effect there might be being below what a psychiatrist will subjectively judge as the minimum possible discernible improvement. This is the best evidence that evidence based medicine has given us, and Kirsch’s deflationary findings have ben replicated at every turn to date over now more than two decades. As it happens I am disposed to the view that SSRI’s and SNRI’s have a function that extends beyond the placebo, though this hardly offers any consolation. I have lost count of the number of patients whose anxiety is substantially reduced in correlation with the takings of these drugs, and who claim to not be as depressed as they were. Indeed the anxiety may be so reduced as to be negated altogether. Where once they were crushed by anxiety over public speaking or an exam, now when the train is late and they walk into the exam an hour late they take it in their stride. They can sometimes tell me, when one is so bold to explore, that they wonder if they would react with even a tint of worry if a bomb were to explode in the quad. And the patient who might have been labelled depressive no longer feels as depressed, their mood has moved from 2/10 to 6/10. Bravo. Yet they are not moved by anything. No longer depressed, they no longer feel the suspense of a thriller and the tears no longer well at the reading of melodrama or the attendance at the opera. And if they were anxious about their job, their battering husband or whatever the mood is now is more “Hmm cest la vie”, untouched they are from the passions that are a signal to change, and the driving force behind change itself. The battering husband no longer feels the pangs of conscience on mind altering drugs, and so on goes the circus. Were I to be a dictator of a docile minimally functioning people, the first thing I would do is commence the populace on an SSRI, plus minus some cannabis. The children I would give low dose stimulants. Some adults, or children also, I would administer so called antipsychotics. And no revolution would ever disturb my sleep.
Having returned from digression, let us return to what defines the psychiatrist, as an adjunct to the police with powers to deprive persons of their liberty. To the reader who is a non-patient, there but by the grace of God (or good fortune) go you.
Epistemology. Cogito, Ergo Cogito.
“Human beings are complex biological systems, with mind as an emergent property. For this reason there are inherent uncertainties regarding diagnostic formulation and optimal care. It is anticipated that this guideline will assist clinicians to better navigate complex and challenging clinical scenarios. Tailoring care to the individual in the context of an effective working relationship is the foundation upon which the proper application of this guideline relies.”
The above quote was taken from the elsewhere mentioned Guidelines into the management of mood disorders published by the Australian and New Zealand guild of psychiatrists. The amphibology is almost impenetrable, as the text gives us no clue to the relation of the parts. Are the “inherent uncertainties” in the process of minds alleged emergence from matter (matter as material and efficient cause?) or in there being the mind per se after having emerged? Or is the challenge in the human being a complex biological system, where being can otherwise imply an experience of being as noun or as verb, as much as denoting this or that member of the species homo sapiens? Or is the complexity in the irreconcilable combination of the two elements of mind and matter as I will claim, or the human qua a human person and not a scientistically formulated “biological system”? And what on Earth has this ontology have to do with profane issues of psychiatric diagnoses? I will argue it matters greatly, this being the subject of the present chapter. Such is the matter of mind.
There is no inherent uncertainty in diagnosing a heart attack when this diagnosis is properly made, this despite the heart attack being in the minutia of its pathophysiology a complex biological event in a complex biological system, with the attack certainly emergent in the sense that it had not occurred a day before, yet not emergent as anything outside its own physicality and temporality. And so we have to ask, as later we will, what is meant by the word “emergence”? In any case this guild, as do others, nail their colours to the wall in acknowledging that to know the maladies of mind requires a knowledge of the mind itself, this being the solid ground upon which they need stand when diagnosing and treating. This is not a controversial expectation. How can pathological anatomy be possibly understood without a knowledge of the normal? What is mental illness without a knowledge of mind in general, either as noun or verb? This being so, the mind nonetheless renders psychiatry “inherently” different to other specialties which might make a claim to be medical. And so with that acknowledgement made, let us not dishonour what they have seen to be the case and state the matter simply; psychiatry cannot know itself or the patient either, unless it first knows the mind. I would argue its predicament is direr still, as the psychiatrist cannot know either itself or the patient without looking itself square in the eye as a participant in a social and political transaction, this also in part defining the patient to whom they might relate and who in turn relates to others. What was missing in the bio (complex biological), psycho (mind) formulation was the greater collective (socio) component of this greater complexity, which has also been called, in toto, a biopsychosocial model. And yet whether bipartite or tripartite, the latter so called biopsychosocial model is nothing more than a collection of considerations that can be placed under three differentially listed columns and so is not any model of the person at all, where model implies an explanation of where and why the boundaries between the categories and what are the interactions between these and their elements so as to produce the final product. A model is an explanation of precisely
