Neurohawks fight back

Bullmore et al ¹ falteringly attempt to challenge ‘neurophobic’ positions in psychiatry, and then fail to present a persuasive argument for the increasing prominence of the neurosciences in psychiatry. They also contradict themselves in a number of places. For example, they argue that psychiatrists implicitly rely on neuroscience through prescribing drugs, suggesting that psychiatrists would not do so unless they believed that mental disorders are related to abnormal signalling between nerve cells, but later on admit that the true mechanism of action of psychiatric drugs and the pathophysiology of mental disorders are unknown. Despite this, they conclude by advocating for more psychopharmacology in the MRCPsych curriculum.

Bullmore et al correctly highlight the false dichotomy between functional and organic disorders. However, they fail to acknowledge that disorders previously conceived as psychiatric, for which a neuropathology has been elucidated, are now considered neurological disorders and the preserve of neurologists. Huntington's disease and neurosyphilis are two examples. Consequently, they do not consider whether, if future neuroscientific research elucidates a neuropathology for the major mental disorders, these disorders would still be under the remit of psychiatrists. If not, perhaps there is little need for clinical psychiatrists to embrace the neurosciences.

They further note that objections to neurobiological research are based on concerns that the doctor–patient relationship would be fundamentally altered, to the patient's detriment. They argue that this is not the case for other medical specialties, where empathy and understanding are still important. However, Kleinman ² notes that the doctor–patient relationship did indeed become a casualty of an increasingly scientific and technological medicine. Bullmore et al suggest that the neurosciences will reduce the stigma of mental illness. Yet, there is evidence that neurobiological models of mental disorder may actually increase stigmatising attitudes to the mentally ill and that clinicians who hold such views are less likely to involve patients in decisions about their care. ³

They note the contention that physical models have not made any difference to clinical psychiatry, yet they provide no defence, only an optimistic future prediction that this will happen.

It is difficult to object to neurobiological research, but it is important to temper enthusiasm for its potential to revolutionise psychiatry. Not a single patient has benefitted from neurobiological research into psychiatry, and although psychopharmacology is one of the success stories of modern psychiatry, our drugs are the result of serendipity rather than a true understanding of the neural and molecular basis of the mental phenomena that underpin the experiences diagnosed as mental disorder. This research is extremely expensive and may be occurring at the cost of social, epidemiological and psychological research for which it is increasingly difficult to secure funding. In contrast, such research has created evidenced-based interventions for mental illness. For example, the finding that high expressed emotion in families is associated with greater relapse in schizophrenia led to the development of family intervention, ⁴ and the finding that life events of an interpersonal nature were associated with the onset of depression led to the development of interpersonal therapy. ⁵ Perhaps psychiatry cannot afford to be neurophobic, but no evidence for this has thus far been provided.