Social inequality,scientific inequality,and the future of mental illness

Background

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.

Methods

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.

Results

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.

Conclusions

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.

     

Information Mismatch: Cancer Risk Counseling with Diverse Underserved Patients

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Career researchers have focused on the mechanisms related to career progression. Although less studied, situations in which traumatic life events necessitate a discontinuous career transition are becoming increasingly prevalent. Employing a multiple case study method, we offer a deeper understanding of such transitions by studying an extreme case: soldiers and Marines disabled by wartime combat. Our study highlights obstacles to future employment that are counterintuitive and stem from the discontinuous and traumatic nature of job loss. Effective management of this type of transitioning appears to stem from efforts positioned to formulate a coherent narrative of the traumatic experience and thus to reconstruct foundational assumptions about the world, humanity, and self. These foundational assumptions form the basis for enacting future-orientated career strategies, such that progress toward establishing a new career path is greatest for those who can orientate themselves away from the past (trauma), away from the present (obstacles to a new career), and toward an envisioned future career positioned to confer meaning and purpose through work.