Psychiatry: Field of Medicine Revolving Around Dopamine and Serotonin Levels in Brain or Just a Skill Dealing with Evil Spirits and Black Magic: Insight of a Developing Nation

Editorial

Psychiatry!!?? But why?? Always been a good student, graduating with excellent grades, why not to pursue career in medicine or surgery? A frequently asked question even by my medical school teachers, reply to which was always a simple smile.

Not only by my teachers but by others as well, a commonly asked question by people when they found my interest in mental health science was why becoming a psychologist? Answer to which required a clarification that psychiatry is a branch of medicine in which a medical doctor opts to specialize after graduation as opposed to psychology which is a separate academic discipline.

Just to put things into perspective, my 85 year old diabetic patient once asked, so will you be convincing the insane to climb down from the trees? She was seriously concerned that why her GP had opted to become a “mad handler “.

My medical and surgical colleagues often remark that psychiatrists mainly have two or three pills to offer, mainly aimed towards tranquilizing a patient or temporarily relieving his anxieties.

These reactions revolve around a specialty which deals with the disorders that are major contributor (14%) to the global burden of disease worldwide [1]. Mental disorders are a cause of disabilityadjusted life years of a large group of population [2]. These disorders not only compromise the quality of life of the patients but also rank among the most substantial causes of death worldwide [3].

Psychiatric disorders which hit mankind so badly are dealt with or perceived by both literate and illiterate groups of people in a very unscientific way. Masses of developed countries and even some qualified health professionals do not have very encouraging attitude towards understanding of mental health disorders [4,5]. In third world countries situation is even worst. People visit quacks, hakeems (traditional herbal medicine experts) and spiritual guides for physical illnesses, what to talk of mental health disorders. Studies done in India in recent past revealed that a large group of population has no idea about bio-medical model of psychiatric illness and they believe or blame evil spirits as cause of mental illnesses [6,7]. In Africa situation is not very different where mental health issues in children due to abuse or trauma are attributed to “Cen” which is a form of spirit possession where the ghost of a deceased person visits the affected individual and replaces his or her identity [8]. Even psychologists like Roger Vanderdonck wrote books in favor of ghosts and spirits as etiologies of psychiatric disorders or producing symptoms in people whom they possess very similar to that of psychiatric disorders [9].

In Pakistan where we lack even basic health facilities in many parts of the country, mental illnesses are still considered a stigma. A study conducted among university students revealed that a large proportion of most educated people of an urban society believed black magic to be cause of mental health problems and thought spiritual healers were best to treat those [10]. Many religions support the existence of ghosts or super naturals but the question is, Are they that much capable to possess the bodies of humans and overcome the best of creations. One of our professors of psychiatry used to say that “During all these years of my clinical practice I have not seen any ghost not responding to psychotropic drugs”.

Till the time people don’t understand the cause they won’t be convinced on scientific and evidence based methods of treatment. Psychiatric illnesses should be considered at par with physical illnesses in all aspects, i.e. from understanding of pathologic basis of disease till management and prognosis. If one can understand that diabetes is due to decreased production of insulin from pancreas why can’t he understand that depression is due to decreased mono-amine production in brain cells? It is duty of health professionals to educate the community that as the child with hemophilia having factor VIII deficiency in blood has increased risk of bleeding, similarly a child with abuse having various conflicts in his subconscious has increased risk of behavioral problems. So why there is a discrepancy among two diseased individuals that for one a tertiary care targeted facility be opted and for other preference may be a dirty lame person sitting in forest and doing no good to the patient.

After issues of unscientific approach towards pathogenesis of psychiatric disorders, comes the problem of attitude towards use of psychotropic drugs. Even among people of west there are reservations and fears regarding use of psychiatric medications [11]. Scenario in Pakistan is rather worse, where many people think psychiatrists have some hidden powers and they can rectify the imbalance of dopamine and serotonin in brain with their magical words. I still remember, once a highly educated father of a patient of schizophrenia; commented about a psychiatrist after they had visited her that interaction with psychiatrist was very good but worst part is that she prescribed medicines, instead of counseling only. Same response had been of majority of people in a European study [12]. I am not undermining the importance of psychotherapies, behavioral therapies and all other non-pharmacological but scientific methods of treating psychiatric illness but emphasis is on their true understanding and supportive role with appropriate pharmacological treatment. As in DM main stay of treatment is insulin or hypoglycemic agents and different systems as per requirement are supported by other modalities. Neuropathies are dealt with gablins, Gut integrity is maintained by enflour, Lipid lowering is done by statins etc. Same is the case in common psychiatric disorders. Neurotransmitter’s imbalance has to be rectified pharmacologically; however behavioral issues or instillation of hope may be catered for with different types of supportive therapies as per requirement. People should also be made aware of side effect profiles. Most people think that all psychotropic drugs are sleeping pills. Even many health professionals do not know that commonest prescribed drugs in psychiatry, SSRIs cause arousal or insomnia in most patients and need to be adjusted as morning dose. Similarly community should be educated that psychotropic drugs have equal tolerability and side effect profile as that of antibiotics, antiepileptic or hypoglycemic etc. rather many of them have a wider therapeutic index than many of other commonly prescribed drugs.

Last but not the least is the attitude towards prognosis. Many health professionals ask the question, which disease you treat in psychiatry?? Does your patient get rid of disease or it’s a just a long cycle of taking sleeping pills without any benefit?? Reply to them is very natural, rather it’s a counter question to people of general medicine that which disease you treat less infectious diseases?? You just control the symptoms and damage. Can DM, HTN, IHD, RA, epilepsy and other common noninfectious disorders be treated fully or eradicated??? Answer is a big NO. Patient has to take the medicine throughout his life in addition to all the life style modifications he has to adopt for the disease. So when this sort of treatment model is justified for insulin deficiency or coronary arteries pathology then why not for the neurotransmitter’s imbalance or for the health of most complex organ of the body. Another attitude quite commonly faced is that in addition to psychiatric disorders psychiatrist should also treat all the bad habits of individual which were even not related to actual disease. I recall here demand of mother of one of my patients. She said to me that her OCPD child has very well responded to treatment but still sometimes he is rude with his elder sister, he gives less time to his grandfather, he drives very fast etc. I had to tell her that I am a psychiatrist not a recycling factory where you will submit a patient from one side and get him remodeled according to your requirement from the other side. My job is to treat the pathology and improve his quality of life. In many cases psychiatric diseases are better. If mental health physician identifies the stressor or conflict in the unconscious mind and stressor is removed or conflict is catered for then short course of medication and psychotherapies can treat the patient once for all. Knowing the pathogenesis of mental health disorders and observing the treatment response clearly shows that prognosis of mental health disorders is similar to chronic physical diseases. Routine medication, supportive therapies and life style modifications are the keys to longevity. You leave the hypoglycemic or you take too much sugar you will land in hyperglycemic crisis which may even lead to death. Similarly you leave psychotropic drugs, expose yourself to stress full situations and you will land into mental health crisis. It’s high time now; we have to bring improvement from base line, especially in third world countries. We need not to build dialysis centers; instead we need to prevent renal failure by controlling DM, HTN and other predisposing factors. Similarly we need not to build mental asylums for treatment of mental health disorders. A lot of education of masses and health care providers and few pills treating neurotransmitter imbalance maybe sufficient. We need good psychiatrists in the community but what we badly need is, dedicated friends of psychiatry among the educated people and I hope this effort will increase them.

References

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