George Awad: The Search for a New Psychiatry: On Becoming a Psychiatrist,
a Clinical Neuroscientist and Other Fragments of Memory
(iUniverse, USA, Bloomington, Indiana; July 21, 2021, 250 pages)
Though the book was not conceived as a science book per se, it is about neurosciences, as perceived and practiced through my own experiences in three continents; in Cairo, Moscow, Rome and, finally, in Toronto. The book also marks the completion of seventy years as a physician, fifty of them as a psychiatrist and clinical neuroscientist.
The book is organized into ten major parts arranged chronologically, and according to era and location. The first eight parts document my medical journey that started in 1949, as a medical student at Cairo University, and extends to the present time as an academic professor emeritus at the University of Toronto, in both the Department of Psychiatry and on the Faculty of Graduate Studies in the Institute of Medical Science. In an interesting coincidence, my medical career corresponds well with the history of modern psychiatry that had its beginning in 1940s, and was accelerated by the transformational discovery of the first specific antipsychotic, Chlorpromazine, in the early 1950s.
Part I provides a brief outline of the social, economic and political climate that I grew up in during the 1940s and 1950s, including such experiences that encompassed significant political and economic upheavals, and compounded by struggles as a member of the religious Coptic minority. It has left a significant impact in influencing my life and my professional career. Part I also deals with how I developed an early and clear antipathy to psychiatry, following an accidental observation of a session of “insulin coma therapy” during my early years as a medical student. Such antipathy became more pronounced during my clinical study years, following clinical visits to the “lunatic asylum” in the Abbassyia district, which goes back in history to the eighth century. On the other hand, connecting the present with the ancient past, I developed an interest in the history of mental health care in Egypt, which goes back to the eighth century with the development of the earliest concepts of mental health care. Reflecting on the abysmal state of the Abbassyia Mental Asylum led me to include a chapter on colonial psychiatry during the British occupation of Egypt, between the years of 1882 to 1954, when it ended. Though the British authority may have introduced a better administrative system to the asylum management structure, it deliberately delayed the development of academic psychiatry in Egypt, for self-serving reasons. Part I also deals with the molecule RP4680 (Chlorpromazine), that changed the face and practice of psychiatry, in 1954.
Part II of the book is devoted to my first experiences as an independent physician in my role as a rural physician in one of the remote regions of Egypt. It details my unusual experiences of dealing with endemic “pellagra” and “pellagra madness”. Impressed by the almost magical response to treatment with cheap “brewer’s yeast” and Nicotinamide, a member of Vitamin B Complex, provided the first inkling of interest in neurology and neurosciences. Reflecting on the status of therapeutics at that time and how it was primitive, mostly based on prepared colourful potions such as the crimson red tonic “iron & strychnine” or the greenish carminative “rhubarb & soda”, led me to devote a chapter that included reflections on the “placebo response” and how it influenced my later research interests.
My surprising mission to Moscow, being sent there by the Egyptian government to study neuroendocrinology, including hormone bioassays, is documented in Part III and not only includes reflections on scientific matters, but also deals with politics, ideology and religion, or its absence, and also deals with other personal issues such as loneliness, perseverance and love. In Moscow, my research topic “stress” and its relevance to health and illness became my major academic research focus for years to come. My return to Cairo after completion of what I frequently referred to as my “expedition to Moscow” is documented in Part IV as a challenging event, being mis-appointed to a senior post overseeing the toxicological clearance of urgently required grains, mainly wheat. Confronting politics, corruption and bad science, I was saved by a post-doctoral award for a year in Rome, Italy, at the prestigious Research Institute of Health.
As detailed in Part V, the year in Rome not only consolidated the topic of “stress” as my continued research focus, but also gave me the opportunity to practice my free choice not to return to Cairo. Intrigued by accepting a “job” offer to join the newly opened Faculty of Medicine at the University of Calgary in Alberta, Canada, with the promise to support me in establishing a neuroendocrine experimental laboratory, I arranged a flight to Calgary, with a stop-over in Toronto for a few days. Mysteriously, I did not make it to Calgary, as a result of an unexpected and unplanned offer from the University of Toronto’s Department of Pharmacology, which is detailed in the “Interlude”.
After two years in the Department of Pharmacology and the completion of a major thyroid research study, as well as the publication of the results of a co-authored paper, with my boss and supervisor, in the prestigious journal “The Lancet”, I accepted an invitation to move to the Department of Psychiatry at the University of Toronto. At last my neuroscience background and clinical psychiatry came together and remained that way for the next fifty years. Also, Toronto became our home-base, resisting multiple offers to relocate to other universities.
The following Parts VI to Part VIII, inclusive, detail a number of what I consider to be my major academic interests and accomplishments, both planned and accidental, as well as the disappointments and missed opportunities. From the outset, as I started my first job at Lakeshore Psychiatric Hospital (the hospital that was built by its patients), my clinical and academic interest focused on schizophrenia and the many, at that time, unrecognized needs of the persons behind the illness. Issues, such as quality of care, patient-centred care, quality of life, wellness, and subjective tolerability to antipsychotics evolved as a major foci of interest, training and research.
A number of subsections in Part VI deals specifically with issues related to the complex process of new drug development and whether it can be left to market forces. The perceived need for the development of an international platform that deals with issues related to clinical trials methodology has led me and four of my colleagues to the development of ISCTM: The International Society for CNS Clinical Trials Methodology, which currently continues its success in its seventeenth year.
Part VIII, in a review of psychiatric outcomes, makes a clear argument in favour of broadening psychiatric outcomes to include issues related to quality of life adjustments and functioning. Finally, Part IX and Part X provide an analysis of the current state of psychiatric practices, which unfortunately receives a failing report. Part IX documents how modern psychiatry is failing many; patients and their families, their doctors and the society at large.
Many patients continue to be dissatisfied with current treatment approaches, whether medications or psychotherapy. Medications at best are only partly effective, carry a high liability of serious side-effects and, being non-curative, have to be taken almost for life, compromising the state of health and frequently adding to further disability.
Similarly, psychotherapy, the second important arm of psychiatric treatment, is in a state of chaos with over 400 treatment approaches in existence, many of them never having been fully validated nor their benefits adequately documented. Psychotherapy is a long-term process which poses issues of cost and accessibility, including equity, equality and competence. All that raises questions about the need for reforms and whether psychotherapy is better off in becoming an independent discipline that stands on its own, but associated with psychiatry. Such practice and design are already recognized by several academic departments of psychiatry in Europe, having been named “Department of Psychiatry and Psychotherapy”. It is time, in view of the importance of psychotherapy, to consider regulating practice of medical psychotherapy by establishing an academy or a board that can ensure qualifications, expertise, equity and equality, as well as maintenance of competence and the development of a strong academic base. The current fragmentation of psychiatric models of care add a significant burden for patients and their families, who frequently assume the burden as carers. Current fragmentation allow for many patients to fall through the cracks or receive an inadequate level of care. The increased reliance on medications has led to a devaluation of other modalities of treatment, particularly rehabilitation programs and other modalities such as arts and recreational approaches, leaving major deficits such as loneliness and social isolation unattended to.
For the doctors, the role of the psychiatrist in current psychiatric practices seems to be slowly eroding; from the top by consistent pressures for other qualified professionals to receive more of a share in services, particularly in the area of psychotherapy, and from the bottom with the role of the psychiatrist becoming more complicated by the many unmet needs in science and practice. Psychiatrists feel inadequately supported by strong science that can empower their clinical practices. In spite of the extensive research, the absence of any etiological breakthrough in understanding major psychiatric disorders, such as schizophrenia or severe depression, clearly points to several fundamental deficits in research strategies and whether it is due to a lack of theory, a misdirected search or, likely, both and many others.
The inadequacy of the diagnostic classificatory systems, with their mostly invalidated groupings of symptoms, has likely hampered rather than helped etiological research and complicated research efforts from the outset. The DSM organization of symptoms in schizophrenia under three groupings; positive, negative and cognitive, has started to unravel according to recent data showing the independence of such groups, though they are frequently associated. The recent acceptance of the FDA, after long resistance, for the development of medications that can deal with only one group of symptoms, such as negative or cognitive symptoms, is an early recognition of the need to go back and revisit the concept of schizophrenia psychopathology. After all, psychotic symptoms cut across a broad range of psychiatric disorders, such as dementia, drug-induced, etc.
Another important question that needs to be urgently raised is whether psychiatric training curricula are appropriate to prepare psychiatrists for future challenges, particularly in the area of neurosciences. Psychiatric training generally aims for the development of skills in two different and somewhat contradictory areas: psychotherapy and psychobiology. Each set of skills is grounded totally in completely different theoretical concepts, and each of them requires different tools. The required high degree of integration is frequently not achieved, or very difficult to achieve. The recent discontinuation of mandatory training in neurology has left many psychiatrists unable to understand and adequately explain to patients and their families the relationship of behaviour to brain functioning. More recently neurology has carved a new discipline, “behavioural neurology”, which, by all definitions, is our old and mostly ignored discipline of “neuropsychiatry”. It is more sensible and effective for the two disciplines to get together and consolidate their resources and expertise. Maybe a third strong discipline, “clinical neuroscience”, may emerge side by side with neurology and psychiatry. In essence, then, it is clear that the lack of strong backing from science and the pressures of increasing demands in the face of inadequate training, as well as the limited resources in a highly fragmented service model have failed many psychiatrists, leading to a noticeable state of dissatisfaction and quick burnout.
The absence in many countries, including Canada, of specialized academic and professional bodies leaves psychiatry being squeezed out in current bodies, such as the CPA or Canadian College of Physicians and Surgeons. The urgent need for such psychiatry-specific academic bodies obliges the question; who oversees the science and practice of psychiatry?
Other serious concerns relate to the increasing trends of medicalizing everyday conflicts into becoming a psychiatric disorder that already requires medications and therapy, a practice which ends in diluting efforts and resources on focusing on the major psychiatric disorders. The recent introduction in Canada of what is known as Bill C-7 will expand in two years the right to medical assistance in dying to the psychiatric population. It introduces a serious concern about the possible misuse in undermining the right of disabled persons and make it more likely for them to accept assisted suicide, rather than be properly and effectively treated. The serious question that clearly arises is how effective or appropriate are psychiatric treatments and whether efforts directed to assistance in dying can be used to improve the state of psychiatric treatments.
Chapter X presents the imperatives for the need of a new psychiatry, noting the failure or low impact of at least twenty major task forces and high level commissions over the past twenty-five years. Different thinking and different strategies are needed urgently, but have to start from the bottom and drive the process upward.
Psychiatric illnesses inflict a high cost on society, but doing nothing is more expensive by losing whatever remaining trust from patients and their families, burdening more doctors and turning psychiatry into a second class medical specialty that fails to attract the best candidates, and is left desperately struggling to secure a more effective and respected place among various medical specialties.
December 30, 2021