Dean Charles E
Minneapolis Veterans Administration Medical Center, Mental Health Service Line, One Veterans Drive, Minneapolis, MN, 55417, USA.
Philos Ethics Humanit Med. 2017 Dec 19;12(1):10. doi: 10.1186/s13010-017-0052-x.
Despite five decades of increasingly elegant studies aimed at advancing the pathophysiology and treatment of mental illness, the results have not met expectations. Diagnoses are still based on observation, the clinical history, and an outmoded diagnostic system that stresses the historic goal of disease specificity. Psychotropic drugs are still based on molecular targets developed decades ago, with no increase in efficacy. Numerous biomarkers have been proposed, but none have the requisite degree of sensitivity and specificity, and therefore have no usefulness in the clinic. The obvious lack of progress in psychiatry needs exploration.
The historical goals of psychiatry are reviewed, including parity with medicine, a focus on diagnostic reliability rather than validity, and an emphasis on reductionism at the expense of socioeconomic issues. Data are used from Thomas Picketty and others to argue that our failure to advance clinical care may rest in part on the rise in social and economic inequality that began in the 1970s, and in part on our inability to move beyond the medical model of specificity of disease and treatment.
It is demonstrated herein that the historical goal of specificity of disease and treatment has not only impeded the advance of diagnosis and treatment of mental illness, but, in combination with a rapid increase in socioeconomic inequality, has led to poorer outcomes and rising mortality rates in a number of disorders, including schizophrenia, anxiety, and depression.
It is proposed that Psychiatry should recognize the fact of socioeconomic inequality and its effects on mental disorders. The medical model, with its emphasis on diagnostic and treatment specificity, may not be appropriate for investigation of the brain, given its complexity. The rise of scientific inequality, with billions allocated to connectomics and genetics, may shift attention away from the need for improvements in clinical care. Unfortunately, the future prospects of those suffering from mental illness appear dim.
尽管五十年来开展了越来越精细的研究以推进精神疾病的病理生理学及治疗，但结果并未达到预期。诊断仍基于观察、临床病史以及一个过时的诊断系统，该系统强调疾病特异性这一历史目标。精神药物仍基于数十年前开发的分子靶点，疗效并未提高。众多生物标志物已被提出，但无一具有所需的敏感性和特异性程度，因此在临床中毫无用处。精神病学明显缺乏进展的情况需要探究。
回顾了精神病学的历史目标，包括与医学平起平坐、专注于诊断可靠性而非有效性，以及以牺牲社会经济问题为代价强调还原论。引用托马斯·皮凯蒂等人的数据来论证，我们在推进临床护理方面的失败可能部分归因于始于20世纪70年代的社会和经济不平等的加剧，部分归因于我们无法超越疾病和治疗特异性的医学模式。
本文证明，疾病和治疗特异性的历史目标不仅阻碍了精神疾病诊断和治疗的进展，而且与社会经济不平等的迅速加剧相结合，导致包括精神分裂症、焦虑症和抑郁症在内的多种疾病的预后更差，死亡率上升。
建议精神病学应认识到社会经济不平等这一事实及其对精神障碍的影响。鉴于大脑的复杂性，强调诊断和治疗特异性的医学模式可能不适用于对大脑的研究。科学不平等的加剧，数十亿资金被分配用于连接组学和遗传学研究，可能会将注意力从改善临床护理的需求上转移开。不幸的是，精神疾病患者的未来前景似乎黯淡。
