October 31, 2006

Psychiatry Is Politics

Psychiatry is politics, it is politics in the way that running for office is politics.  It is not a science, it is not even close to science, it is much closer to politics.

A doctor makes a diagnosis of a patient and writes it down on the chart.  If it were science, then I should be able to evaluate the patient myself and come up with the same diagnosis.  If it is a science but not an exact science, I should be able to come up with the same diagnosis most of the time, and the other times where I disagree I should be able to see why the other person thought what he thought.

But if I can guess the diagnosis without actually seeing the patient at all—but by knowing the doctor—then we do not have science, we have politics.

If you are watching the TV news with the sound turned down, and a Republican senator is talking, and the caption reads, “Tax Breaks for the Rich?” you can guess  his position.   In fact, the actual issue doesn’t matter—what matters is his party affiliation.  Everything follows from there.  Not always, certainly, but enough times that you don’t bother to turn the sound back up on the TV.

Psychiatry is the same way.  It is very easy to determine who is considered a “great” psychiatrist, or a “thought leader in psychiatry” based on who is making the evaluation, and not on any merits of the psychiatrist himself.  Down one hallway Freud is lauded; down the other he is villified; Kay Redfield Jameson is the hero.  But their value, of course, is not at all dependent on what they did—it is dependent on who you are.  Ronald Reagan was either a god or a devil depending on who you are, not who he was.  It doesn’t seem to matter that most people can’t  name one specific thing he did in office, what wars and battles he presided over, what he did or did not do to taxes.  Ronald Reagan isn’t a person, he is a sign.

It’s even possible for me to guess the medications a patient is taking based solely on who prescribed them, and not on the symptoms of the patient.  Importantly, the possible medications vary widely from doctor to doctor; it is wrong to think my predictive accuracy is based on any fundamental logic or science to medication selection that should be true across all psychiatrists.  It's just his regular, unthinking, habit.  "I like Risperdal."  Are you an idiot?  Are there internists  saying, "I like insulin?"

Let me be clear: I’m not talking about doctors having unique insights into which medication might benefit a certain patient.  (“I think Geodon could work really well here.”)  I’m talking about each doctor having a set of drugs he prescribes with such regularity that I can guess them.  


It stems from a lack of appreciation that mental illness is not a genetic disease, or even primarily a biological one, or even, surprisingly, a psychological one.  It is a social disruption.  On a desert island, no one can tell you are insane.

The key evidence against my position is that biology is so obviously relevant. There is a hereditary component to many mental illnesses; twins raised apart still often have higher concordance rates than non-twins.  But this misses the point of the problem entirely.  Consider diabetes: it is obviously a biological disease, with a heritable component.  Much more biological than any mental disorder, because you can point to the dysfunctional biology in diabetes, but you can’t do that in bipolar disorder.  But despite this biology, the environment is so massively important as to often overwhelm this biological component.

We can consider even further the actual relevance of genetics.  Things that we assume are simple genetic outcomes are often more complicated than they seem.  Eye color is every 7th grader’s primer for Mendelian genetics.  But—surprise—there is no gene for eye color.  There are in fact three genes for eye color, and the color is determined by the interplay of all three.  So while you can guess eye color based on the parents, you are not always right—because each parent is giving three different genes.

It may be, in fact, true, that bipolar disorder is genetic.  Perhaps overwhelmingly genetic, let’s say 40%.  We go wrong because we consider genetics a “fixed variable”—we think we can only affect the other 60% of the factors.  Right?  Wrong; genetics is not fixed.  Having a gene may be a fixed, but whether you express this gene or not is most certainly under outside control.  Consider gender; absolutely genetic, correct?  Not much one can do about it?  But lizards can alter the sex of the progeny by changing the incubation temperature of the egg.  Think about this.  Now, is it not probable that the expression of the genes for bipolar have a lot to do with how you are raised?  And we already know that environment affects gene expression, so I’m not speculating here.