Wednesday, November 7, 2012

A Non-Psychiatrist Dares to Comment on Psychiatry

I have occasionally posted about the controversy aroused by the American Psychiatric Association's (APA)forthcoming DSM-V classification of mental illnesses, for example:

I will now offer a further comment based on two posts, first, Dr. Bernard Carroll over on Health Care Renewal:
--who in turn cites the 1 Boring Old Man blog run by a retired psychiatrist:

The short form of these two posts is that the APA has antagonized so many folks with the way they have mishandled the DSM-V business that they risk making both DSM-V and themselves irrelevant to mental health, and that smart people will ignore DSM-V and turn elsewhere for classifications of mental illness.

What follows is my attempt to synthesize some important ideas from these two recent posts, and I'll use the excuse that even though I am not a psychiatrist, the other two bloggers are, and so I am simply trying to pass along what they have said.

1 Boring Old Man recalls what it was like to practice psychiatry in the 1970s and 1980s. He recalls that a thousand flowers bloomed. There were many disparate, incompatible theories and schools of psychiatry--and that was good. Psychiatrists read Freud and benefited from the reading, but very few were the cardboard-caricarture Freudians that now are derided and are trotted out as the excuse as to why psychiatry had to reform itself. When the DSM-III (the first modern version) came out, most psychiatrists realized why it had been created, and basically supported the idea that some sort of standard diagnostic approach was necessary; but hardly anyone found it clinically useful. The eclectic mix of disparate schools and theories was confusing to the statisticians and epidemiologists, but a rich mine ideas for the psychiatrist who had to confront a wide variety of symptoms in a wide variety of people. The eclectic mix gave them the freedom to do what worked best under any given circumstance.

This state of affairs, these psychiatrists say, has evolved from toolbox to straitjacket as the new DSM-V seems a further attempt to impose a rigid orthodoxy on the field that stresses brain biology and drug treatment--so much so that many are now saying they'll have none of it and the APA can go take a hike.

Okay, now I'll add my own ideas. When eclecticism is working for a field, and people decide to throw out the eclecticism and replace it with something clinically much less helpful, that's bad. What this blog is mostly concerned about is the impact of industry-driven commercialization on medicine. So the next question is, how much of this bad stuff can be traced to drug industry influence.

In a previous post:
--I recounted journalist Robert Whitaker's history of the APA (in his Anatomy of an Epidemic) giving the specific dates (between 1974 and 1980) when the APA decided they had major problems on their hands, that those problems could be solved by a big influx of Pharma dollars, and that their policies therefore should shift to make APA an extremely Pharma-friendly venue. The above-listed posts further document how the new DSM-V appears to be an even bolder move toward allowing the Pharma fox to guard the psychiatric-diagnosis henhouse, in ways that maximize industry profits and the drugging of patients with even mild symptoms.

So does this shift in the DSM, that results in a further flight from clinical utility, have something to do with Pharma influence? Yes.


Sildenafil Citrate said...

Psychiatry is not questioned, there are lot of categories, some people will ignore DMS-V these because of mental health. i had gone through the blog, the flowers are bloomed, DMS-V irrelevant .

Bernard Carroll said...

Thanks for the shout-out, Howard. My take on the influence of Pharma is not exactly the same as Robert Whitaker’s. As I observed events unfold through the 1980s and 1990s, my impression was that Pharma just capitalized on their good luck: the APA/DSM-III handed them a wide opening for disease mongering, mass marketing, and diagnostic inflation, and Pharma took that ball and ran with it. But I don’t think Pharma can claim credit for making DSM-III the mess that it was. The APA owns that issue.

Also, we need to keep in mind that DSM-III was silent on the issue of treatments – it did not positively promote medications. By adopting that approach for political reasons, everybody could feel at home with the DSM-III: psychotherapy? Great! Pharmacotherapy? Great! Nothing was stated as a standard of care. Nothing connected the dots between diagnosis and treatment. Thirty years later, none of that has changed, and the DSM-5 people, well intentioned as they may have been, are not going to change it.