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Rebalancing academic psychiatry: why it needs to happen - and soon

  • Arthur Kleinman (a1)

Summary

Academic psychiatry is in trouble, becoming the narrowest of biological research approaches of decreasing relevance to clinical practice and global health. What is required is a rebalancing of the psychiatric academy to include greater support for researchers conducting social, clinical and community studies within a broad, more humanistic biosocial framework.

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References

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1 Becker, A, Kleinman, A. Global mental health. N Eng J Med; in press.
2 Balaji, M, Chatterjee, S, Koschorke, M, Rangaswamy, T, Chavan, A, Dabholkar, H, et al. The development of a lay health worker delivered collaborative community based intervention for people with schizophrenia in India. BMC Health Serv Res 2012; 12: 42.
3 Patel, V, Weiss, HA, Chowdhary, N, Naik, S, Pednekar, S, Chatterjee, S, et al. Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster randomised controlled trial. Lancet 2010; 376: 2086–95.
4 Dias, A, Dewey, ME, D'Souza, J, Dhume, R, Motghare, DD, Shaji, KS, et al. The effectiveness of a home care program for supporting caregivers of persons with dementia in developing countries: a randomised controlled trial Goa, India. PLoS ONE 2008; 3: e2333.
5 Kleinman, A. Rethinking Psychiatry. Free Press, 1988.
6 Kleinman, A. Culture, bereavement, and psychiatry. Lancet 2012; 379: 608–9.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Rebalancing academic psychiatry: why it needs to happen - and soon

  • Arthur Kleinman (a1)
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eLetters

Keeping Academic Psychiatry Relevant.

Bonnie J. Kaplan
09 January 2013

We welcome Dr. Kleinman's perspective and want to elaborate on the manner in which academic psychiatry is making itself irrelevant. In addition to its relative neglect of psychosocial and cultural issues, academic psychiatry is failing to attend to the potential for recovery formost people with mental health problems. The recovery movement started with a broad civil rights perspective involving people who had experiencedhospitalization, forced treatment and highly stigmatizing labels of mentalillness. At the core of the advocacy efforts was the recognition that people could get better, i.e. recover. As the movement evolved, it was empirically supported by researchers like William Anthony (1), often referred to as the "father of the recovery movement," as well as by data from long-term outcome studies by people like Courtenay Harding (2) and Martin Harrow (3). The old adage that a mental disorder is analogous to insulin-dependent diabetes, requiring lifelong pharmacologic treatment, needs to be reconsidered.

Dr. Kleinman's hopes for more social justice, as well as increased attention to the effects of poverty and global health are welcome and complementary notions to the recovery movement. We also want to mention resilience, a key dynamic that is generally neglected by academic psychiatry. Resilience can refer to many of the psychosocial and economic factors mentioned in the editorial, and it can also be significantly shaped by the nutritional status of individuals. Dr Kleinman writes of putting global health on the agenda for upcoming researchers; global health in general is very sensitive to the field of nutrient status, and many international studies have shown the importance of diet and early nutrition for long-term physical and mental health outcomes. Worldwide, nutritional psychiatry is a rapidly expanding area of great relevance to mental health but virtually ignored by academic psychiatry. Recently, research from several countries has strongly suggested that Western dietary patterns may be contributing to our current epidemics of mental disorders (Jacka et al., 2011). Perhaps even more important for the field is research demonstrating that manipulation of diet by providing additional essential nutrients can prevent as well as reverse psychiatric symptoms (Rucklidge & Kaplan, 2013).

The Foundation for Excellence in Mental Health Care (www.femhc.org) was created by professionals and people with lived experience, for the purpose of tapping private philanthropy to fund projects that recognize the general failure of drugs to treat psychiatric disorders, as recently highlighted by the provocative work of Robert Whitaker in "Anatomy of an Epidemic." By moving away from the driving forces of the last few decades that have perpetuated the idea that one disease can be treated with one drug, we open up new avenues of treatment possibilities, including social,community, lifestyle and nutritional changes, areas of research that the new academics of psychiatry could and should embrace.

References:

1.Ellison ML, Rogers ES, Lyass A, Massaro J, Wewiorski NJ, Hsu ST, Anthony WA. Statewide initiative of intensive psychiatric rehabilitation: Outcomes and relationship to other mental health service use. Psychiatr Rehabil J 2011;35:9-19. 2.DeSisto MJ, Harding CM, McCormick RV, Ashikaga T, Brooks GW. The Maine and Vermont three-decade studies of serious mental illness. I. Matched comparison of cross-sectional outcome. Br J Psychiatry 1995;167:331-8.3.Harrow M, Jobe TH. Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: A 15-year multifollow-up study. J Nerv Ment Dis 2007;195:406-414.4.Jacka FN, Kremer PJ, Berk M, de Silva-Sanigorski AM, Moodie M, Leslie ER, Pasco JA, Swinburn BA. A prospective study of diet quality and mental health in adolescents. PLoS One. 2011;6(9):e24805. 5.Rucklidge JJ, Kaplan BJ. Broad-spectrum micronutrient formulas for the treatment psychiatric symptoms: A systematic review. Expert Rev Neurother 2013;13:49-73.

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Conflict of interest: None declared

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Academic psychiatry: don't engrave its epitaph just yet.

Wojtek Wojcik, Honorary researcher and locum consultant psychiatrist
02 January 2013

Professor Kleinman's recent editorial (1) depicts academic psychiatryas fossilised and Sisyphus-esque, obsessed with the recurrent yet apparently futile toil of researching biomedical paradigms for mental illness. He challenges it to broaden its scope, suggesting health servicesresearch, global mental health, and psychological medicine (liaison psychiatry) as examples. Whilst we agree with his argument for breadth anddiversity in research, we find it difficult to recognise the academic psychiatry he describes.

First, the author describes important and exciting areas of research as fringe activities which by implication lack mainstream support. Our experience locally is the opposite and we are not aware of this being at all at odds with the national, or even international, picture. In 2012 Kings College London appointed a new chair in Psychological Medicine and saw a global mental health collaborative study (EMERALD) win a 5.8 millionEuro grant. What's not mainstream about that?

Second, it is difficult to reconcile academic psychiatry as it was then - in a presumed golden age of progress - and its alleged rigor mortisnow, without dismissing out of hand advances in our understanding of the rich complexity of people's lives and mental illness. Advances in the bridging of nature and nurture through gene-environment (2), epigenetic, and life-course epidemiology approaches at last settles old disputes aboutthe primacy of either. Evidence for neuroplasticity and neurogenesis overturns old notions of an immutable brain which can degenerate but not repair or grow, and allows new dialogue about how life can impact on brainand mind for those who needed convincing. An evidence-led transformation in attitudes to the treatability of borderline personality disorder (3), as well as new psychological treatments for psychosis, OCD, anxiety and depression must similarly be ignored.

Finally, it is worth noting the recent history of treatment of mentalillness, particularly the rise of psychoanalysis in the early twentieth century and the anti-psychiatry movement of the 1960's. Whilst both contributed new ideas and hypotheses, neither translated directly into evidence-based treatments. Today, psychological therapies are being testedand accumulating an evidence base and critical psychiatry (the anti-psychiatry of old) continues to have a voice.

Diversity is ecologically important for maintaining a balance of explorative hypotheses and established paradigms, or the 'shock of the new' and the 'love of the true'. Our experience of UK academic psychiatry is that it is being and will continue to be invigorated by new ideas and research avenues as any field must be. Professor Kleinman's concerns do not ring true and ignore the main issue we currently observe which is of funding. Perhaps his concerns are more relevant across the Atlantic?

1.Kleinman A. Rebalancing academic psychiatry: why it needs to happen - and soon. Br J Psychiatry 2012; 201: 421-422.

2.Caspi A, Sugden K, Moffitt TE, Taylor A, Craig IW, Harrington H, McClay J, Mill J, Martin J, Braithwaite A, et al. Influence of life stresson depression: moderation by a polymorphism in the 5-HTT gene. Science 2003; 301(5631):386-9.

3.Stoffers JM, Vollm BA, Rucker G, Timmer A, Huband N, Lieb K. Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews 2012, Issue 8.

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Conflict of interest: None declared

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Balancing Act?

Philip J Cowen, Professor of Psychopharmacology
02 January 2013

It was a relief that Arthur Kleinman's bleak vision of the hegemony of biological psychiatry was redeemed to some extent by the original research papers which appeared in the same edition of the Journal ("Disease burden and mental health system capacity: WHO Atlas study of 117low- and middle-income countries", "Caregivers' appraisals of patients' involuntary hospital treatment: European multicentre study", "Effective treatment of perinatal depression for women in debt and lacking financial empowerment in a low-income country", etc).

Of course, this arrangement might well reflect innovative Editorial planning of a particular issue; however when I reviewed publications in the British Journal of Psychiatry over the last year I found over 90 original research papers of which only about 20 could easily be classifiedas "biological psychiatry". The great majority therefore were excellent psychosocial and clinical studies, suggesting that the condition of academic clinical and psychosocial research (at least in the UK and Europe) may be less desperate than Kleinman supposes.

Balancing biological, clinical and psychosocial approaches to psychiatry requires dialogue between all those involved in clinical mentalhealth work and Kleinman's arguments are important and compelling. I did, however, wish to query his apparent implication that senior academics pursuing biological psychiatry research were even more complacent and self-interested than their colleagues. Surely those working in psychosocial fields will not let this slight go unchallenged?

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Conflict of interest: I have advised companies involved in psychotropic drug development

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Questioning core assumptions re: Mind

Andrew JR Parker, Consultant Psychiatrist
02 January 2013

I agree whole-heartedly with Professor Kleinman's call for a rebalancing of academic psychiatry. It is important to understand what assumptions stand behind the failed promises of the biological programme. Professor Kleinman does not address these in his editorial, but one such issue is surely our implicit understanding of the relationship between mind (experience) and brain (physical structure)?

Unfortunately the philosophy of scientific materialism - that all is ultimately explainable in physical terms - is often assumed to be a truth amongst neuroscientists as well as the public. Dozens of popular books reinforce this view, purporting to explain away, reductively: consciousness, free will, and value1. These aspects of our being are at the very centre of every mental disorder. And yet, scientific materialism is increasingly being seen to be on very shaky philosophical grounds by those who have examined the issues carefully2,3,4,5. Might scientific materialism have skewed our efforts in dealing with mental distress? I believe we are very far from having solved the mind-brain problem, and philosophical positions other than scientific materialism must be considered.

One such position that is supported by our best physical theory (quantum mechanics) 2 is that the mental and the physical co-emerge from alarger (veiled) reality, rather than the physical causing the mental 2, 3.If such a view were taken seriously by academic psychiatrists then it would flow naturally from this that equal attention should be paid to existential and spiritual aspects of experience, at the level of personal meaning. Only then would it be possible to build a rich understanding of how mind, society and mental disorder relate, that gives due prominence toprimary features of mind - the creative, relational and holistic - rather than pretending that physical explanations are the ultimate and valid aim.

A psychiatry that is not sensitive to underlying philosophical assumptions quickly becomes a narrow and impoverished one, to the detriment of society. The mind is still mysterious and we must look again at our assumptions.

Refs1.Dennett D. Consciousness Explained. Allen Lane. 19912.D'Espagnat B. On Physics and Philosophy. Princeton University Press. 20063.Malin S. Nature loves to hide - quantum physics and the nature of reality, a western perspective. Oxford University Press. 20014.Nagel T. Mind & Cosmos. 20125.Koons RC & Bealer G. The Waning of Materialism. Oxford University Press. 2010

Andrew J R ParkerConsultant Psychiatrist (independent)Capio Nightingale Hospital, London.Email: ajrp35@gmail.com

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Conflict of interest: None declared

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Dear Editor,

Michael Fitzgerald, Psychiatrist
19 December 2012

In relation to Kleinman1 Re-balancing Academic Psychiatry: Why it needs to happen-and soon.

He is very critical of academic basically biological psychiatry. Unfortunately in the psychosocial front research there this discipline is simply repeating information that has been shown umpteen times in the pastand unfortunately that line of research is exhausted for all practical purposes.

Yours sincerely

Professor Michael Fitzgerald

1. Kleinman A., Re-Balancing Academic Psychiatry: Why it needs to happen-and soon. British Journal of Psychiatry 2012, 201, 421/422.

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Conflict of interest: None declared

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By tuning into the music we might be better placed to understand the dance

Ross G. White, MSc Global Mental Health - Programme Coordinator
19 December 2012

Prof Kleinman's reflections are largely consistent with recent articles by Kirmayer (2012) and Thomas et al. (2012) that examine the influence of evidence-based practice (EBP) on mental health research. Whereas the hierarchy of evidence that EBP espouses prioritizes data from meta-analyses and randomised controlled trials (RCTs), little or no priority is given to service users' preferences (i.e. values) or narratives (i.e. meaning) (Thomas et al. 2012).

There is now growing recognition that understanding about mental health difficulties requires knowledge about the demands and opportunitiesinherent to the social world in which individuals live (Kirmayer, 2012). Factors such as culture, language, ethnicity and religion play important roles in how mental health difficulties present, how these difficulties are understood, and how individuals respond to these difficulties (Gone & Kirmayer, 2010). However, the EBP epistemological frame marginalisesthese factors and inhibits the use of a broader range of methodologies (e.g. qualitative methods or ethnographic research) in mental health research.

The future of mental health research may lie in placing more emphasison the meaning of symptoms rather than the eradication of these symptoms. Abstract concepts such as 'meaning' have hitherto been largely neglected in mental health research. But progress might be gleaned by allowing spacefor alternative methodologies that more fully explore the meaning of symptoms. As Kirmayer (2012) remarks, this will require the development of"new measures of process and outcome, some of which may well lie beyond the individual, in family interactions, communities, or relationships to larger social systems" (Kirmayer, 2012, P. 254)

It was Nietzsche who remarked "those who were seen dancing were thought to be insane by those who could not hear the music". Perhaps in being too focused on stopping the dance, mental health researchers have not been sufficiently prepared to tune into the music to which people livetheir lives.

By bringing together researchers from mental health, anthropology, and sociology, the field of Global Mental Health provides an important opportunity to embark on research that firmly situates people in their socio-cultural context. Importantly, Global Mental Health will facilitate opportunities to critically reflect on how mental health difficulties are understood and treated not just in low and middle income countries, but inhigh income countries also.

References

Gone, J. P., & Kirmayer, L. J. (2010). On the wisdom of considering culture and context in psychopathology. In T. Millon, R. F. Krueger, & E. Simonsen (Eds.), Contemporary directions in psychopathology: Scientific foundations of the DSM-V and ICD-11 (pp. 72-96). New York: Guilford

Kirmayer, L.J. (2012). Cultural competence and evidence-based practice in mental health: epistemic communities and the politics of pluralism. Social Science and Medicine, 75, 249-56.

Thomas, P., Bracken, P., Timimi, S. (2012). The anomalies of evidence-based medicine in psychiatry: time to rethink the basis of mental health practice. Mental Health Review Journal, 17, 152 - 162.

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Conflict of interest: None declared

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Refreshing and important

Michael J. Smith, Consultant Psychiatrist
19 December 2012

Arthur Kleinman's article is a tremendous breath of fresh air.

Candidates for Consultant Psychiatrist appointments are often asked "what can be done to make psychiatry more attractive as a career option for medical students?"

The response is invariably to remind undergraduates that "psychiatry is a part of medicine like any other specialty". The interviewers then nodsagely, and lament the inability of medical students to grasp this fact without special assistance.

I think a better answer would be to show students that "psychiatry isa part of medicine *unlike* any other specialty". Every doctor should be aware of the psychosocial context of their patients' problems. But psychiatrists can't be effective unless they can also understand and explain how that context influences such problems.

Drugs are often a necessary step to recovery, but are always an insufficient one.

To assert these ideas should complement, rather than threaten, a biomedical model. Psychiatry needs to be "mindful" as well as "brainy": but it also needs to be meaningful. If we can achieve that, our recruitment problem will disappear.

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Conflict of interest: None declared

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The global mental health field fails the tests set by Arthur Kleinman's own work

Derek Summerfield, Honorary Senior Lecturer
19 December 2012

Arthur Kleinman makes one misjudgement in his cogent editorial on ourpaper. He has been deceived by the claims of the global mental health field to represent humanistic and context-sensitive practice of the kind he has long advocated. Whilst their rhetoric is of respect for local traditions and perspectives, the reality is of the global deployment of the narrowly biomedical model of mental disorder which Kleinman is criticising. The field gives itself away when it says the task is to address the 'treatment gap': this means exporting what we have and they donot, and are judged to need. 'Local initiatives' here means training localworkers to administer Western mental health technologies. But to assume that Western psychiatric categories like 'depression' are universal is to commit what Kleinman has called a 'category fallacy', which is the issue of validity in psychiatric research and practice. Invalid approaches are those which fail to address the felt 'nature of reality' of subjects, and thus cannot be humanistic and cannot work. To cast Western knowledge as universal, whereas indigenous knowledge is merely local and ignorable, is to propagate a new imperialism. Global mental health workers are the new missionaries. (1)

Global mental health is a 'top-down' movement whose effect is to sellthe products of the Western mental health industry to the non-Western world. Good news for the pharmaceutical industry.Yet, as we discuss in ourpaper, the evidence base for, say, antidepressants or talk therapies is weak and contested even in the West. Most of the variance of outcome is accounted for by non-specific/placebo factors.

And what of context? The World Bank calculates that 1.4 billion people in the world are in 'absolute poverty', which is to say they will never have a decent meal in their whole lives. As many again are scarcely better off, similarly mired in bare survivalist modes of existence. The UNChildren's Fund (UNICEF) says that 3.5 million children under the age of 5die of starvation every year. (2) These are "the wretched of the earth", to use Fanon's phrase: would anti-depressants and Western talk therapy improve their lot? Who in the non-Western world is asking for them?

1. Summerfield D. Afterword: Against 'global mental health'. Transcultural Psychiatry 2012; 49: 519-530.2. Dembitzer B. Sleep Walking into Global Famine. Ethical Events, London 2012.

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The Academy Teaches Too

Simon Bradstreet, Director
05 December 2012

Here at the Scottish Recovery Network we welcome Arthur Kleiman's suggestion that Academic Psychiatry look beyond biological confines to newand wider domains of human experience and distress. We would though suggest that during the period of reflection prompted by this piece that we don't lose sight of what our future Psychiatrists are being taught in the very same Academies.

In recent years we have seen enormous changes to the pre-registrationprogramme for Psychiatric Nursing in Scotland so that learning is underpinned by a strong emphasis on recovery focused, and person centred, principles and their associated competencies and practices (NHS Education for Scotland, 2102). What we would now like to see is that process mirrored for Psychiatry to ensure that their practice is similarly informed by the lived experience of people in recovery and that they are skilled in supporting the key facilitators of personal recovery - connectedness, hope, identity, meaning and purpose and empowerment (Leamy et al 2012).

Arthur Kleiman draws attention to "health professionals and students for whom social justice and care for the suffering of the poor are central, and have moral force." In our experience there is widespread interest in social justice and the social context that supports recovery from which to build.

References

Leamy, M., Bird, V.J., Le Boutillier, C., Williams, J. & Slade, M. (2011) A conceptual framework for personal recovery in mental health: systematic review and narrative synthesis. British Journal of Psychiatry, 199:445-452

NHS Education for Scotland. (2012). The National Framework for Pre-registration Mental Health Nursing Field Programmes in Scotland 2012. Edinburgh: NHS Education for Scotland

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