Saturday, October 12, 2013

Does psychiatry need to cut back on mental illness?

Reducing mental illness to biology, as part of a larger trend in research circles, without adequate evidence for such a reduction, could well constitute medical mal-practice. The medical fraternity has been so inundated by pharmaceutical corporations and insurance companies, that, for example, in the U.S. only those patients whose condition qualifies under the DSM (Diagnostic Statistical Manual) will receive insurance coverage for their psychiatric treatment. The latest example is the qualification of mourning following the death of an important loved one as part of a group labelled Major Depressive Disorder. Previously, it was considered normal "grief".
Even members of the psychiatric profession recognize and acknowledge that, in the dramatic spike of illnesses covered in the DSM, originally there were 14 mental disorders, whereas now there are 250, the profession is over-reaching, driven by the profession's grasp for new business (covered by insurance) and the pharmaceutical industry's galloping greed for new consumers of their newest products, whose specific deployment does not and cannot work effectively for all patients.
It was President Dwight Eisenhower who warned of the dangers of the military-industrial complex. Who will it take to warn effectively of the equally dangerous, if not even more dangerous, impact of the psychiatric-pharmaceutical complex?
We are medicating ourselves into a Huxleyan stupor with technology and both prescribed and non-prescription drugs. And our doctors, both family practitioners and psychiatrists, are responding more and more to "consumer demands" for "that drug I heard about in the evening news last night" for whatever it is that is ailing us.
We have argued in these pages previously that a health care system built on the model of doctors' compensation for prescriptions written and a piling up of office visits in numbers not in effective treatments points us in the direction of over-medication, and almost telegraphic encounters in which one or two symptoms that jump out at the doctor are medicated, while the gestalt of the patient's life is practically never even considered, even if and when the patient is prepared to have a full discussion. The doctor can't afford the time for such an exploration, because of the remuneration structure of the health care system.
In short, the system itself is sick, and requires serious re-structuring, based on an objective outcome of  healthy patients, and not on a sickness/symptom model reinforced by a doctor compensation model of volume as opposed to quality.
We have reduced human lives, and their current condition, in the doctor's office, to another push-button instant remedy....almost like the proverbial "take this pill and call me in the morning"  of yesteryear.
This is not to argue that there are not seriously ill humans who require and deserve the best possible treatment from the most appropriate medical practitioner(s) even if that treatment requires a full complement of professional training. Yet, today, when the doctor's visit is compressed into a matter of seconds, not even minutes in most cases, how can the best and most effective treatment be the order of the day, given the primary motivation of the practitioner to turn over as many face-to-face encounters in a given hour as possible.
Add to that the ease with which prescriptions are  both available and demanded and it is not rocket science to discern a medical profession simply responding to "consumer demand" and then covering their backsides with a DSM for both legal and insurance purposes. And, it is well known and even acknowledged by many physicians that most professional education following graduation is sourced in the pharmaceutical industry, whose "educators" lay on extravagant retreats in luxurious hotels in romantic locations, free to the doctors and their partners, in the hope and expectation that such training sessions will produce sales spikes in the latest "wonder drug".
And ordinary people, as patients, are the consumers driving the the slightest sign of something being amiss.
The medical profession, and in this case, psychiatry, must bear a heavy portion of the burden of their own over-reach, recalibrate their focus and de-couple their profession from the voracious, even insatiable appetite for new patients and new diseases of the pharmaceutical behemoth.

Dozens of mental disorders don't exist

By Cherrill Hicks, The Daily Telegraph, from Ottawa Citizen, October 8, 2013

In his riveting tale of how psychiatrists "medicalise" human suffering, Gary Greenberg recounts that, in 1850, a physician called Samuel Cartwright reported a new disease in the highly respected New Orleans Medical and Surgical Journal. Cartwright named it drapetomania, from the ancient Greek drapetes for a runaway slave; in other words, here was a disease that "caused Negroes to run away". It had one primary diagnostic symptom - "absconding from service" - and a few secondary ones, including "sulkiness and dissatisfaction just prior to flight".
Drapetomania was, of course, consigned to the dustbin of medical history. It never made it into the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), the leading authority on mental health diagnosis and research. But, Greenberg suggests in his scathing critique of the DSM, it might well have done - had the manual existed at the time.
After all, he notes, homosexuality was listed as a "sociopathic personality disorder" when the DSM was first published in 1952, and remained so until 1973. "Doctors were paid to treat it, scientists to search for its causes and cures," he writes in The Book of Woe: The DSM and the Unmaking of Psychiatry. "Gay people themselves underwent countless therapies including electric shocks, years on the couch, behaviour modification and surrogate sex."
Greenberg, 56, is a US psychotherapist of 30 years' experience and a prolific writer on mental illness (including his own depression after the collapse of his first marriage). But the target of his latest book is the DSM itself, the so-called "psychiatrist's bible", which aims to provide a definitive list of all mental health conditions, along with their diagnostic criteria.
Updated at regular intervals - DSM-5, the fifth edition, was published in May - it has considerable influence worldwide, including in the UK, where it underpins several clinical guidelines on mental health. Yet Greenberg holds that by imposing a pseudoscientific model on our "hopelessly complex" inner world, it creates a "charade" of non-existent disorders.
As World Mental Health Day approaches this week, he argues that, thanks to the DSM, "countless millions" are hooked on powerful antidepressants to cure a mythical "chemical imbalance", while rates of mental disorders in children, including autism, bipolar illness and ADHD, have rocketed. The DSM is, he says, a "fiction" which medicalises human experience and allows psychiatrists "dominion over the landscape of mental suffering".
Greenberg's language may at times sound overblown but he isn't alone. DSM-5, 14 years in the writing, has been criticised by many for the unhealthy influence of the pharmaceutical industry and its tendency to medicalise behaviours and moods that many would argue fall within the normal range.
"Few professionals are happy with the DSM," Greenberg says on the phone from his home in Connecticut, where he lives with his wife, teenage son, cat, dog and "a dozen or so" hens. "We are forced to engage with a charade of diagnostic disorders that we don't believe our patients have for the crassest of reasons - money." (In the US, people have to have their diagnosis confirmed by the DSM to access insurance funds for treatment.) "It's not just psychotherapists - even psychiatrists admit this is a deeply flawed document."
The rot set in during the 19th century, he says, when expectations of medicine changed dramatically after the discovery of micro-organisms. "It created a desire for all mental suffering to be understood in the same way as physical suffering, such as smallpox or cholera. To consider craziness as another treatable disease which originates in biology had tremendous appeal."
Playing into this is another factor, the influence of the pharmaceutical industry. Despite an attempted clean-up in recent years by the American Psychiatric Association, 67 per cent of the "task force" members responsible for DSM-5 are reported to have industry links.
Yet Greenberg believes that many psychiatrists - and even drug reps - are well-meaning. "It is intellectual rather than financial corruption. The idea that human suffering can be reduced to a biochemical imbalance - this is about ideology rather than money."
Greenberg's book tracks in painstaking detail how the DSM's decisions have created "false epidemics" of over-diagnosis and over-treatment. In 1994, for example, the diagnostic threshold for bipolar disorder was lowered to cover people without full-blown mania (instead, they have elevated moods that doctors call hypomania, but which Greenberg describes as exuberance). As a result, bipolar diagnoses soared, as did prescriptions for mood stabilisers and antipsychotic drugs, which in the US were for the first time being advertised directly to the public. "Suddenly, everyone and his brother was bipolar," says Greenberg. About six million people are now diagnosed as bipolar in the US, and in the UK, it's one in 100.
He also describes how a loophole in the DSM criteria was exploited "by one of the few real bad guys in psychiatry" to establish a juvenile version of the disorder, without any solid evidence. This was at a time, coincidentally, when powerful antipsychotics were being rebranded as mood stabilisers. As a result, diagnoses of child bipolar illness increased 40-fold over a decade. "In 2007 alone half a million children, 20,000 of them under six, were prescribed drugs that a decade before would have been prescribed only in the most dire circumstances," says Greenberg.
The side effects of some of the drug cocktails children were prescribed included obesity, diabetes and suicidal thoughts.
In an attempt to reduce bipolar diagnoses in children, DSM-5 has introduced a new illness, called Disruptive Mood Dysregulation Disorder (DMDD), to cover intensive temper tantrums. But this too is proving controversial, with fears that it may capture some children who may be volatile, but who are not ill. "Clinical trials of treatments for DMDD are probably already under way and may well lead to another treatment epidemic," he says.
A different tale concerns Asperger's syndrome, which was first included by the DSM in 1994. Greenberg explains that this had some beneficial effects. "It may not have been a disease but calling it one gave a hitherto neglected group of children access to support and educational services, as well as a sense of identity and community." The result though, was that from a worldwide prevalence of four in 10,000 for autism disorders (including Asperger's) in 1988, 20 years later this was one in 88. Alarmed at diagnostic rates "getting out of hand", DSM-5 has removed Asperger's, replacing it with the umbrella term Autistic Spectrum Disorders. This means a "higher threshold for diagnosis", according to Greenberg, and possibly less access to educational benefits for future generations.
He is unimpressed with the DSM-5's new Hoarding Disorder - "Is an eccentric old man living amid his junk sicker than a billionaire who is always thinking of the next way to make a buck?" - and argues that anyone over the age of 50, including himself, would qualify for another new entry: Mild Cognitive Disorder.
Greenberg is particularly dismissive about DSM-5's changes to the criteria for Major Depressive Disorder. Until now, this diagnosis was specifically excluded in cases of recent bereavement, on the grounds that grief is normal. That exemption has been removed in DSM-5, leading critics to argue that grief has been medicalised.
"The exemption clause was an embarrassment because it challenged the idea that depression is caused by biology and led critics to demand that other external factors, such as divorce and redundancy, be exempt too," he says. "So they got rid of it, which means that if you are depressed while bereaved you can be classified as mentally ill." Not that bereaved people who are depressed shouldn't be helped, he adds. "But is it really a medical problem?"
So what needs to happen? Psychiatrists, he believes, must narrow their scope - to make a "reasonable claim" for certain mental illnesses falling within their domain. "When the DSM was published there were 14 mental disorders and now there are 250 - it needs to scale back."
There is a place for drug treatments, he says, although "you only have to look at the clinical trials to see they help some people but not all."
Above all, psychiatrists need to be more honest with their patients, he believes. "They shouldn't tell people their illness is caused by a chemical imbalance when there is no evidence this exists. Psychiatry has little knowledge of the underlying processes governing mental health and it should not pretend otherwise."
'The Book of Woe: The DSM and the Unmaking of Psychiatry' by Gary Greenberg is published by Ingram International Inc

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