Talk:Psychiatry

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Facts

On January 28, I made a plea for some citations in the "Other criticisms" section. Today, David Kernow has done the same. Both of us it would seem have done this out of deference to providing multiple points of view. While I do not doubt that the claims being made in this section could be true, we really need someone to provide citations. There are so many instances of vague wording as to call into question the veracity of the claims: "some believe...", "there is evidence this leads...", "according to critics...", etc. The wording of these phrases indicates that some research or review has been done, and therefore a reference must exist somewhere. However if citations cannot be provided, these claims will have to be removed. So, for the anti-psychiatry-minded, could you guys please provide these sources? Semiconscious • talk 19:15, 21 February 2006 (UTC)

Hi I'm not just anti-psychiatry minded but I've added some citations. I'm sorry but I cannot yet get to grips with how to do this properly, and link cites to full references, despite trying to read the help pages on it.Franzio 11:52, 1 March 2006 (UTC)

Hi, I've just done some brief research on the supposed 'effacity' of ECT as a treatment for depression disorders (and the oft-mistreated condition of schizophrenia), and would like to request information on the positive results of ECT treatment. I've found much negative about the treatment, including long-term memory loss (http://www.ahrp.org/infomail/05/07/08.php AND http://www.healthyplace.com/communities/Bipolar/news_2005/book_1.asp), wholesale abuse (http://www.guardian.co.uk/race/story/0,,1388367,00.html) and the real results of the treatment (http://www.wildestcolts.com/mentalhealth/shock.html) but NONE for positive results, other than doctors who are pro-ECT stating that it 'works', but with no physical evidence to back the statements up.

As a result of this, I am proposing that the statement which mentions ECT as an effacious treatment be modified as soon as is reasonable to do-so. Gotheek 00:31, 13 March 2006 (UTC)

Hi, there's actually quite a bit of data on ECT's effectiveness. For instance, here's a meta-analysis from the Lancet which shows the efficacy of ECT over "sham" ECT in 6 trials and over pharmacotherapy in 18 trials:

• "Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis." Lancet 2003 Mar 8;361(9360):799-808.

I noted that all of your sources above are regular webpages -- in case you don't know, nearly all medical references can be found at http://www.pubmed.com. I found the above link by just searching on the terms "efficacy electroconvulsive therapy" Scot ^→Talk 01:56, 15 March 2006 (UTC)

Teaching/training details

I may have missed it but could anyone clarify what specialist training psychiatrists receive? This would seem to to be part of the core of what modern psychiatry is. I know the article mentions the different areas of practical experience. But, for example, how much teaching is there on the various lines of work on mental health (e.g. genetic, neurological/psychological, social). How much teaching and training on medication, how much on psychosocial interventions esp. particular ones like Cognitive Behavioural Therapy? How much on general counselling skills? Who does the training? Franzio 11:52, 1 March 2006 (UTC)

Good point, Franzio -- the article could include more specifics about the training. I'm actually in a psychiatry training program in the US now, so I'll see if I can dig up my copy of the ACGME (Accreditation Council for Graduate Medical Education) requirements for US psych residency programs and summarize them briefly. Scot ^→Talk 07:13, 15 March 2006 (UTC)

Nurse & Pharmacist prescribing

I think the introductory statement about only doctors (incl. consultants) being able to prescribe in the UK isn't accurate, not clear if it's referring only to psychiatric drugs. Qualified and registered nurses and pharmacists have had limited prescribing powers for a number of years, which are currently being extended - I'm not sure on the exact situation with regard to psychiatric drugs so will leave any amendments to others who are. Franzio 18:53, 2 March 2006 (UTC)

I've edited to avoid the possible error. See UK Dept of Health but still not entirely clear on current practice. Franzio 18:04, 13 March 2006 (UTC)

POV tags and self-reference

I removed some POV-section tags. There is no attempt being made at resolving whatever POV dispute there was originally.

I also removed a self-referential remark about Wikipedia's anti-psychiatry article. Please review Wikipedia:Avoid self-references if this is problematic.

The section "improvements and criticisms" contains a few named references with no further details in the "references" section. This is not acceptable. Could the person who inserted this material please WP:CITE. JFW | T@lk 04:56, 12 March 2006 (UTC)

I put the POV-section tags in the Psychiatry article because someone put a tag in the main Anti-psychiatry article (which I doubt it is fair). I hope someone will remove that tag too! Cesar Tort.

The assertion that "cures are not expected in psychiatry" is WP:NOR. What is this highly speculative statement based on?

The reference to the anti-psychiatry article is a self-reference. What part of the above-quoted policy don't you understand? JFW | T@lk 19:55, 12 March 2006 (UTC)

It is said that there is no cure for mental illness, so cures are not expected in psychiatry. --WikiCats 02:35, 13 March 2006 (UTC)

"It is said" does not really satisfy WP:CITE. As an aside, complete response does actually occur in psychiatry, although admittedly not as often as one would like. JFW | T@lk 04:08, 13 March 2006 (UTC)

Just to clarify:

The statement “cures are not expected in psychiatry” is not true except in most cases. And in the case of schizophrenia or bipolar disorder it is completely true.

On the issue of citations who would you accept as a reliable source? --WikiCats 08:36, 13 March 2006 (UTC)

Also, the statement that "psychiatry is the only branch of medicine in which cures are not expected" is false -- chronic, non-curable conditions are found in nearly all branches of medicine -- what's the cure for diabetes? Asthma? Lupus? Presbyopia? Psoriasis? Congestive Heart Failure? Scot ^→Talk 07:45, 15 March 2006 (UTC)

I assume the named references to which you refer are those I inserted at someone elses request, as you can see above. I wasn't sure about the procedures for full refs, seems to vary from page to page. In the end I managed to add them to the antipsychiatry page, and then didn't want to add them here because there were only about two references and it didn't seem right to have more critical references than main psychiatry ones! Please do as you wish with them. Franzio 18:12, 13 March 2006 (UTC)

Deleted page?

What's going on, this page isn't existing at the moment? --Horses In The Sky 23:08, 13 March 2006 (UTC)

Pharmaceutical Industry criticism paragraph

Regarding this paragraph, from the "Improvements and Criticisms" section:

Drug companies spend large amounts of money marketing drugs. There is evidence this leads some physicians to prescribe more drugs and to prefer advertised drugs instead of more appropriate, better, or cheaper drugs (or prescribing them when drugs are not needed at all). A 2005 UK cross-party parliamentary inquiry into the influence of the pharmaceutical industry details some of the evidence. The inquiry concludes, amongst other things, that (Pg 100) 'The influence of the pharmaceutical industry is such that it dominates clinical practice" and there are serious regulatory failings resulting in (Pg 101) "The unsafe use of drugs; and the increasing medicalisation of society." There is also a list of scientific and other references provided by the campaign organization No Free Lunch, detailing the prevalence and consequences of the acceptance by medical professionals of gifts from pharmaceutical companies.

This is an interesting topic, and a discussion of the inappropriate reach of Big Pharma into medical practice may belong somewhere -- but it's not specific to psychiatry and so doesn't really belong here. I'm going to delete it from here if there are no objections. Scot ^→Talk 07:08, 15 March 2006 (UTC)

There are a lot of people on Wikipedia who think it's awfully unethical to make money developing drugs that potentially benefit millions of people. They have a particular peeve for psychopharmaceuticals. JFW | T@lk 07:11, 15 March 2006 (UTC)

Hi Scot, I don't object to it being deleted, but it's frustrating (although not your fault) when sources for such statements were requested (see 'facts' above) but then when provided the topic becomes unsuitable. Both those sources provide information about specifically psychiatric issues, and this does appear to be the area where the use of medical drugs is most questioned and their use under force and non-consent is most frequent. The recent debacles over non-disclosed data regarding suicide and withdrawal symptoms linked to some SSRI antidepressants, leading to increased black box warnings and removal of recommendation for some or all age groups, and a huge public issue. Those links in the text include information specific to psychiatry if you want to just provide that, rather than deleting entirely. Also see Perlis et al. (2005) Industry Sponsorship and Financial Conflict of Interest in the Reporting of Clinical Trials in Psychiatry. American Journal of Psychiatry 162:1957-1960. But as I say I won't personally object if it isn't covered here in this way.

I would say to JFW that your comments misrepresent those who are concerned about adverse effects, regulations, and the influence of the pharmaceutical industry. Franzio 08:19, 15 March 2006 (UTC)

Franzio, I am concerned about adverse effects, regulations and influence like you are, but there is a strong anti-pharma sentiment on Wikipedia. If I was in charge, I would insist that clinical trials are conducted by independent research organisations who have no stake in the outcome. But don't blame pharmaceutical companies for apathy at the regulatory authorities. Adverse effects are a reality of medicine, and coverups are unacceptable, but there are many circumstances where the benefit of a drug massively outweighs the risk of adverse events. If a paranoid schizophrenic is treated, he may develop tardive diskinesia. If he is not treated, he may go into a catatonic state, harm himself or many others. That is a clinical decision.

I state again that we should stop slamming pharmaceutical companies for developing drugs. If there are unethical practices, these need to be addressed on a factual and reasonable basis and without breathless conspiracy theories. JFW | T@lk 11:36, 15 March 2006 (UTC)

JFW, I merely suggest that these are issues that deserve balanced representation and not exclusion or caricature. They relate to more than apathy or clinical risk/benefit ratios, and I agree they must be addressed on a factual and reasonable basis - by everyone.

The whole paragraph has been deleted now anyway, with nothing back in its place to mention anything about the issue, so presumably that's OK and the conspiracy against psychiatry and pharma companies has been thwarted again. Franzio 17:54, 18 March 2006 (UTC)

“cures are not expected in psychiatry”

The article is written in such a way as to give the impression that psychiatry cures schizophrenia and bipolar disorder.

Many disabled can go for many years of treatment under psychiatry and still be no closer to cure than the day they were first diagnosed. This should be stated up front.

I propose this statement: “In the two major disabilities treated, schizophrenia or bipolar disorder, psychiatry has been unable to produce a cure.”

For schizophrenia, this reference[1] from the National Mental Health Association says, “No cure for schizophrenia has been discovered”.

On bipolar, this reference[2] from the National Institute of Mental Health (the Federal agency for research on mental disorders) says, “…it is important to understand that bipolar disorder is a long-term illness that currently has no cure.” --WikiCats 09:31, 15 March 2006 (UTC)

You are incorrect. Nowhere does the article claim psychiatry cures anything. Your proposed sentence, even if factually correct, does injustice to the fact that without psychiatric treatment these people would cause immeasurable harm to themselves or others. There are hunderds of medical conditions without a cure. In none of the related articles does Wikipedia state so prominently in the intro: "Oh, by the way, apart from a transplant (for which most patients are not elegible) there is no cure for heart failure." You're grinding an axe, aren't you? JFW | T@lk 11:36, 15 March 2006 (UTC)

The original objection was that there had to be citations. Now that I have given citations and quoted what I was told:- “Of course there is no cure for the conditions…”, there are more conditions.

These are emotive objections, but we need to object on the basis of Wiki guidelines. --WikiCats 11:55, 15 March 2006 (UTC)

What exactly are you trying to achieve? Have a brief look at neurology. Most neurological conditions are incurable. Psychiatry does not stand out enough to warrant the kind of treatment you are giving it.

I reserve the right to give additional objections. Whether that is emotive or not is your assertion and of nil relevance to the actual discussion. JFW | T@lk 12:07, 15 March 2006 (UTC)

Is the purpose of Wikipedia to exclude any point of view that is not complementary to psychiatry? --WikiCats 12:39, 15 March 2006 (UTC)

I am happy to qualify the the contribution as:

“Psychiatry is an essential science, but for the two major disabilities treated, schizophrenia or bipolar disorder, it has been unable to produce a cure.” --WikiCats 12:52, 15 March 2006 (UTC)

There might be a million good reasons why this should be covered up but at the end of the day the disabled, their families and people in general have the right to know the facts. And this is factual. --WikiCats 13:30, 15 March 2006 (UTC)

"Neurology is an essential science, but for the two major disabilities treated, stroke and epilepsy, it has been unable to produce a cure". Please, WikiCats, why can't you address my arguments? JFW | T@lk 05:33, 16 March 2006 (UTC)

Sure. If there are other medical disciplines in Wikipedia that don’t have cures, then this should be clearly stated. These articles should be looked at. This is basic information that needs to be included. This is an information encyclopedia. If patients research this encyclopedia for information then they have a right to expect to find all the facts. --WikiCats 06:28, 16 March 2006 (UTC)

No, this is not basic information. It is a biased statement that can easily be taken as a personal criticism; "hey, look at those head shrinkers, they can't even cure the most common conditions they work with". I remain strongly against its inclusion. If you find this unacceptable, please consider a request for comments to clarify community opinion. JFW | T@lk 11:08, 16 March 2006 (UTC)

Are you saying that information like “Psychiatry does not cure schizophrenia[3] or bipolar disorder[4] ” is something the disabled, their families and people in general do not have the right to know? --WikiCats 11:32, 16 March 2006 (UTC)

Your withdrawal from consensus is respected. --WikiCats 12:21, 16 March 2006 (UTC)

This has nothing to do with the "right to know". This information is notable and belongs on schizophrenia and bipolar disorder. But to state it here, prominently, is a clear example of POV.

WikiCats, where is the consensus you are referring to? Have you reviewed Wikipedia:Concensus? If you are looking for consensus, we will definitely need an RFC. In fact, I will file one now and see how we stand[5]. JFW | T@lk 20:21, 16 March 2006 (UTC)

Disclaimers: Non-medical, advocate, layperson speaking here, knowledgeable about Tourette syndrome. Just some of my thoughts, because I completely agree with JFW that this discussion is not properly framed vis-a-vis the word "cure". With neuropsychiatric disorders, that is a problematic word. The example I know best is Tourette syndrome. MOST children with tics outgrow them as they pass through adolescence, and symptoms may remit to the point that DSM criterion are no longer met in adulthood. But, since persons with TS still carry the same underlying genetic difference or vulnerability, even if they show no symptoms, what is the meaning/relevance of the word "cure" in this context? Another recent example: highly-publicized claims that Deep brain stimulation "cures" Tourette's. Well, it *may* stop symptoms for some people, but if you remove the batteries, you still have tics, so again, what is the relevance of the word "cure"? People with bipolar or schizophrenia can achieve stabilization with medication, so again, why focus on the word "cure" -- isn't it more relevant to know if the person can function with the condition? Like living with cancer or asthma or diabetes? We don't necessarily "cure" asthma -- we treat it so the person can live with it. We don't "cure" diabetes -- we treat it so the person can live well. Why the focus on "cure" here? It is POV. We don't "cure" lots of medical conditions, and you can't "cure" your genetic makeup anyway. One problem with the anti-psychiatry movement, which is prevalent on internet support message boards for neuropsychiatric conditions, is that if often promotes anecdotal, alarming information (not always presented with scientific accuracy) to frighten people away from meds, without always presenting viable alternatives for those who truly need meds (e.g.; schizophrenia, bipolar, severe tics). Another example from the realm of Tourette's: the alarming side effects of neuroleptic medications are often highlighted, without noting that, for most people with tics, the dosage of neuroleptics used is far lower than those used for schizophrenia or employed in most studies, so the alarmist info isn't always relevant. POV is an issue, and scientific relevance and accuracy should be established for many anti-psychiatry claims. Sandy 16:04, 19 March 2006 (UTC)

Summary for RFC

I have been discussing, in the previous paragraph, WikiCats' addition of the statement that psychiatry cannot cure the two most common psychiatric conditions. I have objected that to state this prominently amounts to POV, as most medical conditions cannot be cured, only controlled, and that psychiatry is not the "odd one out" to the point that the article needs to mention this. Please offer your views. The relevant policies are WP:NPOV and, to a lesser extent, WP:NOR. JFW | T@lk 20:21, 16 March 2006 (UTC)

Comment

WikiCats has a perfectly valid point: there are currently no cures for schizophrenia or bipolar disorder, and these points should be clearly made. With that said, those points should be made on the schizophrenia and bipolar disorder pages. There are no cures for depression, amnesia, dementia, anorexia, alcohol abuse, drug abuse, etc. As JFW pointed out, other "main topic" medicine pages on wikipedia such as neurology, virology, immunology, etc. do not mention every major disease that has no cure.

One cannot be selectively inclusive in these matters. Perhaps there should be a link to list of mental illnesses without cures or something similar in the article, but there is no way such a list should be in the main article itself simply because it would add unnecessary clutter. Mentioning specifically that schizophrenia or bipolar disorder do not have cures in this article is a form of selection bias.

To address WikiCats's concern that "at the end of the day the disabled, their families and people in general have the right to know the facts": if someone has bipolar disorder they would likely visit that page before visiting psychiatry. On page psychiatry they should read a statement indicating the difficulty of providing cures for mental illnesses. On page bipolar disorder they will read about the specifics regarding their condition. Wikipedia is not a medical advice website. Semiconscious • talk 21:15, 16 March 2006 (UTC)

It should be noted there are now three doctors objecting that the article be written with no criticism.

The article is about Psychiatry, so it should state what psychiatry offers and what it does not offer.

There is acknowledgment that this is a point of view. Blocking a point of view is preventing NPOV. --WikiCats 02:49, 17 March 2006 (UTC)

This article has criticism. Just not your criticism. The article already states how psychiatry is practiced, and you will concede that psychiatrists would aim for cure if the means were extant.

NPOV presumes that the points of view are themselves (1) notable, (2) verifiable. Your criticism is being "blocked" because there appear to be very few people who criticise psychiatry for not finding a cure for mental illness. JFW | T@lk 02:56, 17 March 2006 (UTC)

Your comment that the main objectors are doctors is ad hominem. Please stick to the relevant facts, not the people. JFW | T@lk 02:59, 17 March 2006 (UTC)

The point is the request was put on the “Clinical and medical topics” page specifcally to attract doctors rather that in a dispute resolution process that was neutral. This is was plainly unfair. --WikiCats 04:23, 17 March 2006 (UTC)

Where else am I supposed to put it? JFW | T@lk 05:55, 17 March 2006 (UTC)

I am not a Dr. and I find the statement POV, and lacking in relevance. Perhaps my comments above should have been placed below this discussion. Sandy 16:12, 19 March 2006 (UTC)

Personally I have not finished debating, why have you given up on the debate? --WikiCats 06:16, 17 March 2006 (UTC)

In the debates I am used to, different editors rewrite the contribution until everybody is happy, then there is consensus. You are the one that told me about this. Why don’t you think about it and put it in your words. If you want to put in qualifications, then do that. --WikiCats 08:23, 17 March 2006 (UTC)

There is no need to rewrite the contribution. It shouldn't be there. What we are looking for is a statement such as the following: "Many psychiatric conditions are chronic, having a significant impact on the quality of life of patients and often decreasing life expectancy. [Person] has observed that cure is a rare commodity in psychiatry." This puts the onus on the conditions, rather than the field. This is only viable if you can find the [person] who has made this observation and is notable enough for this observation to be of relevance (e.g. president of the APA or AMA, professor of psychiatry of a prestigious medical school, statement by a nationwide patients' collective, E. Fuller Torrey, or whatever).

I don't think you have much control over the way the debate takes place, despite what you are used to. As obvious from this reply, I'm still open to debate. What I'm looking for is an indication that the POV you are trying to work into the article is actually a notable POV. JFW | T@lk 10:55, 17 March 2006 (UTC)

Done. I am happy with that. --WikiCats 11:12, 17 March 2006 (UTC)

I propose that the contribution be:

“Many psychiatric conditions are chronic, having a significant impact on the quality of life of patients and often decreasing life expectancy. Complete response does occur in psychiatry, although not as often as would be hoped for.” --WikiCats 02:39, 19 March 2006 (UTC)

I'm not sure I agree with that phrasing. I would say *some* ... are chronic, etcetera. For reference, please read the prognosis section on Tourette syndrome. Sandy 16:12, 19 March 2006 (UTC)

Sorry I've missed most of this discussion -- I think it's been a really good one. I agree, WikiCats, that the article was missing some information on prognosis, which should probably be covered more thoroughly in the "Mental Illness" article, but which the Psych article should also probably touch on. I also agree with JFW and Semiconscious that we should probably refrain from getting into treatments for specific conditions, or talk about the "curability" of specific conditions. Wiki, I'd like to expand your above-proposed passage a bit, to give a little more context on prognosis and the variability of treatment efficacy.

So far the only passage in the article which talks about prognosis is the last paragraph in the "Practice of Psychiatry" section, starting with "Historically...". The following is meant to replace that paragraph:

Psychiatric illnesses can vary widely. While some psychiatric illnesses have short time courses and only minor symptoms, many are chronic conditions which have a significant impact on patients' quality of life and life expectancy, and as such require long-term or life-long treatment. Efficacy of treatment for any given condition is also variable from patient to patient, with some patients having complete resolution of symptoms and others unfortunately having poor or minimal response to even the strongest measures. In general, however, psychiatric treatments have improved significantly over the past several decades, beginning with the advent of psychiatric medications (see History section, below). In the past, psychiatric patients were often hospitalized for six months or more, with a significant number of cases involving hospitalization for many years. Today, most psychiatric patients are managed as outpatients. If hospitalization is required, the average hospital stay is around two to three weeks, with only a small number of cases involving long-term hospitalization.

Sound good? Scot ^→Talk 06:25, 19 March 2006 (UTC)

Endorse Scot's version. Covers WikiCats' views without losing sight of context. JFW | T@lk 11:13, 19 March 2006 (UTC)

I take strong issue with contributor Spark Plug.

Jfdwolff put forward his version of the contribution and I said “Done. I am happy with that.” So that was consensus.

Then consensus was ignored. Spark Plug, after not contributing to the debate for four days, decided to throw consensus out the window and restart the debate. We really need to follow the debate, and not have contempt for consensus. --WikiCats 17:02, 19 March 2006 (UTC)

Well, as I said, I'm sorry for not being able to enter the debate sooner -- but I do have an opinion on the subject and I'd like to add it now. Do you have specific comments about the passage? Scot ^→Talk 19:53, 19 March 2006 (UTC)

Improvements and Criticisms

That section is rather a mess. I hacked a t a bit of the beginning, but I get the sense that what is really meant by the later parts is more like:- "some psychiatrists are badly trained and use worthless techniques". If that is verifiable then say it. "Problems also exist" is weasel wording, and innuendo and better lost. I'd say that one of the things about the use of drugs is that knowing how they affect a range of people, and what to look out for is part of the technique and knowledge. Although we are a much less variable species than other apes, particularly those of us whose ancestors left Africa early, it would be very optimistic to expect drugs whcih do not produce different levels of effect on people with different alleles. And yes, it will be nice to have better drugs one day but is that truly encyclopedic? Needs a severe prunign and re-writing, with a clear idea fo what it is about Midgley 18:12, 18 March 2006 (UTC)