Why Psychiatry Needs Therapy
A manual's draft reflects how diagnoses have grown foggier, drugs more ineffective
By EDWARD SHORTER
To flip through the latest draft of the American Psychiatric Association's Diagnostic and Statistical Manual, in the works for seven years now, is to see the discipline's floundering writ large. Psychiatry seems to have lost its way in a forest of poorly verified diagnoses and ineffectual medications. Patients who seek psychiatric help today for mood disorders stand a good chance of being diagnosed with a disease that doesn't exist and treated with a medication little more effective than a placebo.
Psychopharmacology, or the treatment of the mind and brain with drugs, has come to dominate the field. The positive side is that many illnesses respond readily to medication. The negative side is that the pharmaceutical industry seeks the largest possible market for a given drug, and advertises huge diseases, such as major depression and schizophrenia, the scientific status of which makes insiders uneasy.
In the 1950s and '60s, when psychiatry was still under the influence of the European scientific tradition, reasonably accurate diagnoses still sat at center stage.
Psychiatry ended up with two brand-new depression diagnoses with criteria so broad that huge numbers of people could qualify for them.
New drugs appeared to match the new diseases. In the late 1980s, the Prozac-type agents began to hit the market, the "SSRIs," or selective serotonin reuptake inhibitors, such as Zoloft, Paxil, Celexa and Lexapro. They were supposedly effective by increasing the amount of serotonin available to the brain.
The SSRIs are effective for certain indications, such as obsessive-compulsive disorder and for some patients with anxiety. But many people believe they're not often effective for serious depression, even though they fit wonderfully with the heterogeneous concept of "major depression." So, hand in hand, these antidepressants and major depression marched off together into the sunset. These were drugs that don't work for diseases that don't exist, as it were.
The latest draft of the DSM fixes none of the problems with the previous DSM series, and even creates some new ones.
DSM-V accelerates the trend of making variants on the spectrum of everyday behavior into diseases: turning grief into depression, apprehension into anxiety, and boyishness into hyperactivity.
If there were specific treatments for these various niches, you could argue this is good diagnostics. But, as with other forms of anxiety-depression, the SSRIs are thought good for everything.
Where is psychiatry headed? What the discipline badly needs is close attention to patients and their individual symptoms, in order to carve out the real diseases from the vast pool of symptoms that DSM keeps reshuffling into different "disorders." This kind of careful attention to what patients actually have is called "psychopathology," and its absence distinguishes American psychiatry from the European tradition. With DSM-V, American psychiatry is headed in exactly the opposite direction: defining ever-widening circles of the population as mentally ill with vague and undifferentiated diagnoses and treating them with powerful drugs.
—Edward Shorter is professor of the history of medicine and psychiatry in the Faculty of Medicine of the University of Toronto. His latest book, written with Max Fink, "Endocrine Psychiatry: Solving the Riddle of Melancholia," is forthcoming from Oxford University Press.
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