Psychiatry in the future

In an era of evidence-based medicine, policy-makers and researchers are preoccupied by the task of ensuring that advances in research are implemented in routine clinical practice. This preoccupation has spawned a small but growing research industry of its own, with the development of resources such as the Cochrane Collaboration database and journals such as Evidence-Based Mental Health. In this paper, I adopt a philosophically quite unfashionable methodology - introspection - to address the question: how has research affected my practice?

Change over a career

This year I have reached 25 years as a practising psychiatrist. The first 3 years of basic training led to my taking and passing the MRCPsych Part II examination: the day I sat the written examination in 1982 probably represented my broadest grasp of the (then understood) knowledge base of my profession, or at least the received wisdom at that time. Since then, this knowledge base has expanded at an increasingly rapid rate, with startling advances in neurobiology, genomics and informatics. We have also seen the resurgence of psychological treatments for major mental illness, significant shifts in the social policy of mental health, and the rise of postmodernism - a fashionable and intellectually corrosive discipline, neatly deflated by Sokal (1996). We have even seen the birth of a new illness, the somewhat ineffective treatment of which now consumes approximately 20% of the resources of my inner-urban acute service: post-traumatic stress disorder.

The challenge of information

Of the estimated 40 million or so biomedical papers published and the 10 million papers added to Medline in the past 20 years, perhaps 400 000 might have had some relevance to my clinical role, with some 40 000 alone on the topic of schizophrenia, the most common disorder on my case-load. Increasingly, clinicians rely on the methodologies developed within evidence-based medicine, notably the meta-analytic review, to digest this literature. Evidence-based medicine cannot, of course, provide understanding of conceptual or scientific advances that are unknown to the practitioner or provide the skills to offer an innovative treatment or service arrangement (unless it is a pill).

Research and my clinical practice

I identified ten publications directly pertaining to the treatment and care of people with schizophrenia that had influenced my practice over the past 20 years. Surprisingly in this era of evidence-based medicine, four of the ten were books (Brown et al, 1966; Wing & Brown, 1970; Kendell, 1975; Kingdon & Turkington, 1994). A fifth, as a Homicide Inquiry Report, is in the not-readily-accessible grey literature (Ritchie, 1994). Depressingly for research workers, the most recent members of my top ten were published in 1994; this reflects the lag between important ideas and their acceptance, the painstakingly slow nature of true scientific advance (and arguably my intellectual conservatism). My two personal favourite publications, encountered post-MRCPsych, date back to 1966 and 1970 (Brown et al, 1966; Wing & Brown, 1970). The now hugely influential literature on the family management of schizophrenia can be dated back to a key paper in 1976 (Vaughn & Leff, 1976).

There was marked evidence of bias in my selection, with only three publications from the USA compared with seven from the UK (in reality, the US outpublishes the UK by a factor of more than 4 (May, 1997)), although two are the product of large-scale international collaborations (Kendell, 1975; Leff et al, 1992). Five reported work carried out at the Institute of Psychiatry, to which I am affiliated. Most strikingly, all but one of the publications that I identified as affecting my practice concerned areas that I can claim some expertise in, having encountered them within my own rather modest research work. I have accessed many of the important intellectual advances in psychiatry through a range of secondary sources and some of these advances remain quite obscure to me.

Three papers in my top ten deserve a special mention for illustrative purposes. The first is the seminal controlled trial of clozapine in treatment-resistant schizophrenia by Kane et al (1988). The clozapine story has transformed drug treatment in schizophrenia and profoundly affected my practice well before the National Institute for Clinical Excellence guidelines. However, in truth, the original paper had no impact on my treatment practice at the time. Rather, it required product champions, and later practical experience, to overcome my personal scepticism and the resistance of funders.

The second is the study of assertive community treatment by Stein & Test (1980). A model of clarity and concision, this work has spawned a huge research literature, to which I have modestly contributed, and continues to influence mental health services in England through the Policy Implementation Guidance on assertive outreach. The possibility that something could be absolutely right for Madison, Wisconsin, in the mid-1970s but not particularly relevant to Croydon in the early-2000s does not seem to have crossed the minds of UK policy-makers.

My final illustrative paper is a little-known by-product of very big science. Davidson & Strauss (1992) reported on the narratives of individuals with schizophrenia who were followed up over many years, identifying those small or large things that had led to an experience of ‘recovery’. It was written before the narrative became fashionable and without a hint of post-modernist irony, and has underlined for me the perhaps obvious necessity of treating patients with respect.

Conclusions

Undoubtedly my practice has changed in the past two decades, often in ways that I do not recognise. Some of these changes have been as a direct result of the research literature. To have this direct effect requires two conditions: good writing and a conceptual basis that I already understand. I suspect that rather more often my practice has changed as a result of broader cultural changes within the profession or managerial influences. There is a clear need to expand the evidence base underlying mental health services: to this end researchers need to provide evidence that is directly relevant to clinical practice and to communicate more effectively their conceptual advances.