Amid growing demand for mental health services, psychiatrists urged to abandon reductionism – Croakey Health Media


As a new report highlights the impacts of the COVID-19 pandemic on community mental health and wellbeing, Dr Amy Coopes reports on some related discussions from the first day of the Royal Australian College Congress and New Zealand psychiatrists.

Amy Coopers writes:

With the ongoing COVID-19 pandemic placing mental health services under unprecedented pressure, psychiatrists have been urged to consider the whole patient in context and to avoid any form of reductionism in favor of one model. of “radiant, harmonious and unified” biopsychosocial care.

The call was made by eminent American psychiatrist Professor Allen Frances in a rousing keynote address for the opening of the 2022 Annual Meeting of the Royal Australian and New Zealand College of Psychiatrists in Sydney, a virtual hybrid event in person presented as the largest meeting ever organized by the College.

Frances, based at Duke University, has overseen several iterations of the Diagnostic and Statistical Manual of Mental Disorders (commonly referred to as DSM, and currently in its fifth edition).

Frances lamented her siled approach to mental health, too often viewed as a neurobiological issue, the product of trauma or social ill that failed to grasp the complexity of the human condition and was a ” disaster” for patients.

“We have to realize that people are more complicated than any lab test can cover,” Frances told delegates in a virtual address from the United States.

“The biological model of mental illness has been confirmed over and over again in simple ways, but it does not explain group-level disorders.”

Frances was scathing about the so-called ‘brain decade’, with untold billions spent on genetic research and biomarkers that ‘over-promised and under-delivered’ and had ‘failed miserably’ in the quest for a solution. organic miracle to explain and treat disorders of the mind.

With more than 200 genes typically implicated in the development of a mental disorder, in a complex interplay with environmental factors, Frances said polygenic risk factors were an overrated “fudge factor” with less predictive value than a simple family history.

He described this biological reductionism as the biggest problem in psychiatry over the past 40 years, exemplified by the Sacker brothers – three psychiatrists who seeded the Valium and Xanax epidemics in the United States.

While much neuroscience research was intellectually fascinating at an academic or theoretical level, Frances said that virtually nothing of clinical significance with material benefit to patients had been discovered since the 1980s. when psychotherapy had its day in the sun, but at a fraction of the cost. .

“If you focus only on the brain, you will be blind. If you focus only on the mind, you will be brainless,” Frances said, citing a Hippocratic maxim that “knowing the patient with the disease is just as important as knowing the disease from which the patient suffers.” This, he said, has “never been more true than today”.

Supporting this, data shows that 80% of disease risk and response to treatment was due to socio-economic factors, he added.

Arguing that reductionism has always been wrong, regardless of orientation, Frances instead argued for a “radiant, harmonic, unified theory of the biopsychosocial model of mental health and its treatment” that recognized that drugs were overused in people who didn’t need it, underutilized among those who did, and never enough in isolation.

He called for a rebalancing of research funding, 90% of which he said was focused on neurobiology, arguing for improving treatment rather than establishing causation.

Instead, he said studies should look for solutions to issues such as imprisonment and homelessness and have the end goal of improving patients’ quality of life, helping people find more meaning to their lives through spirituality and connection, and integrating recovery and cognitive care models.

COVID load

This week’s Congress is the first time in two years that the RANZCP and interns have been able to meet in person in any substantial way due to COVID. The pandemic was widely discussed during the debates, with some 2,000 delegates attending face-to-face or via the online portal.

Bronnie Taylor MLC, NSW Minister for Regional Portfolios and Mental Health, said the pandemic, which preceded the bushfire crisis and the recent flooding emergency, had damaged Australia’s national psyche.

A number of speakers in Congress said they had never seen mental health services so strained due to labor shortages and growing demand.

Dr Nick O’Connor, who sits on the RANZCP board and is also clinical lead for the mental health patient safety program at the NSW Clinical Excellence Commission, said he had “never really seen the situation as difficult as it is now”, the result of years of chronic underfunding, increasing patient complexity and accelerating social inequalities.

A crisis-themed session learned that 15% of all mental health assessment activity in Mental Health Emergency Care Services (MHECS) in New South Wales was attributable to the pandemic from last year, with demand now at a new baseline.

Dr Katherine Knight, of the Sydney Children’s Hospital Network, said mental health presentations by young people had increased by 10% in relation to population growth in the decade before COVID, and her service had seen an increase from 30 to 40% between 2019 and 2021.

More troubling, Knight said, was the decreasing age of people showing up, with children seen as young as six or eight, and increasing numbers of teenagers and young teenagers.

Read the NSW Mental Health Commission report here.

Broader determinants of mental health

In her speech, Frances said the United States was currently the worst time and the worst place in human history to suffer from mental illness, with some 600,000 patients in prison or homeless, “treated like pariahs” and community psychiatry abandoned to the point of extinction.

He compared this with approaches from Trieste, Italy, which focused on psychosocial determinants and interventions in a best practice model of care.

His address was extended by a much-loved, powerful and heartfelt speech by Wiradjuri and Kamilaroi journalist Stan Grant, who shared his personal thoughts on the legacy of colonization and assimilation for Aboriginal Australians and Torres Strait Islanders.

Grant’s remarks, which will be the subject of a separate Croakey story in the coming days, were met with a prolonged standing ovation and saw his name spread across Australia on Twitter.

The day also featured a lively and lively debate on the prescribing of stimulants for ADHD, which will also be covered in detail as part of Croakey’s conference report.

Looking ahead, Tuesday’s highlights will include a session on climate change and mental health with Tim Flannery, speeches on women’s mental health and psychedelics in the treatment of mental illness, and a presidential symposium focused on the COVID.

Extending Monday’s sessions on education reform and advocacy in psychiatry, there will also be a trainee forum focusing on recent ructions within the College around representation and evaluation moving forward.

From Twitter

See Coopers’ Twitter feed of Professor Allen Frances’ keynote here.

Follow the news

Dr. Amy Coopes will participate virtually in the Croakey Conference News Service. Follow her on @coopesdetatwith additional coverage via @croakeynews and @wepublichealth. Coopers viewed Congress here.

See a broad overview of the discussions from the first day of Congress in this thread by Alison Barrett for @CroakeyNews.

Also follow the Twitter #RANZCP2022 listing.

The RANZCP Congress takes place from May 15-19 at the Sydney International Convention Centre.

Click to access the full in-person and virtual programs.

Bookmark this link to see all of our conference coverage and join the conversation at #RANZCP2022.

Listen to the #RANZCP2022 Spotify playlist, curated by Dr Ralf Ilchef.


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