Psychiatry Today

Long time readers of this blog know that I have been critical of the way psychiatry is practiced in America today.

Only yesterday, I joined Susan Cain in deriding psychiatrists for being too eager to classify character traits, like shyness, as psychiatric symptoms and then to offer to medicate them.

In the past I have reported that medication has now replaced talk therapy as the treatment of choice, not only because allows psychiatrists to make more money, but also because it seems to work better.

Whether this reflects the sorry state of most talk therapy or the wondrous power of medication has yet to be established.

Having no qualification to comment on biomedical facts, I have generally avoided passing judgment on how well the new medications work. Nor have I commented on the suggestions that they can actually be harmful.

I would maintain that psychopharmacology has been a boon to psychotics and to those who suffer from bipolar illness. You do not really want to deal with an unmedicated schizophrenic. This despite some of the bad side-effects of anti-psychotic medication.

Nevertheless, America is now awash in mental illness, and people are beginning to suspect that it’s not just because we have all become crazier.

All things considered, I am very grateful to the friend who drew my attention to a two part article by Harvard professor Marcia Angell that has appeared in the most recent issues of the New York Review of Books. Links here and here.

Angell is a former editor-in-chief of the New England Journal of Medicine, thus, she is eminently qualified to judge the current state of psychiatry.

Written as a book review of recent studies in the field, Angell’s view of the current state of psychiatry is, if anything, more negative than mine.

She begins by noting that, if we follow the accepted psychiatric guidelines, America has been suffering from an epidemic of mental illness.

But if, as psychiatry now believes, these illnesses are based on biology, it does not make a great deal of sense for there to have been such a notable increase in their prevalence. And f medicine works so well, why are there so many more people suffering from mental illness. Shouldn’t they all have been cured?

In her words: “Is the prevalence of mental illness really that high and still climbing? Particularly if these disorders are biologically determined and not a result of environmental influences, is it plausible to suppose that such an increase is real? Or are we learning to recognize and diagnose mental disorders that were always there? On the other hand, are we simply expanding the criteria for mental illness so that nearly everyone has one? And what about the drugs that are now the mainstay of treatment? Do they work? If they do, shouldn’t we expect the prevalence of mental illness to be declining, not rising?”

Summarizing the research findings of books by Irving Kirsch, Robert Whitaker, and Daniel Carlat, she observes: “First, they agree on the disturbing extent to which the companies that sell psychoactive drugs—through various forms of marketing, both legal and illegal, and what many people would describe as bribery—have come to determine what constitutes a mental illness and how the disorders should be diagnosed and treated.”

Of course, pharmaceutical manufacturers lavish attention on all physicians. Yet, psychiatrists tend to receive more than their fair share of largesse.

Why should this be? Angell explains: “Unlike the conditions treated in most other branches of medicine, there are no objective signs or tests for mental illness—no lab data or MRIfindings—and the boundaries between normal and abnormal are often unclear. That makes it possible to expand diagnostic boundaries or even create new diagnoses, in ways that would be impossible, say, in a field like cardiology. And drug companies have every interest in inducing psychiatrists to do just that.”

Psychiatrists have embraced the theory of biomedical causation because it is in their interest to do so. Facing competition from other mental health professionals and non-medical professionals, they have found an excellent way to distinguish themselves and to control their market.

Angell writes: “Since psychiatrists must qualify as MDs, they have the legal authority to write prescriptions. By fully embracing the biological model of mental illness and the use of psychoactive drugs to treat it, psychiatry was able to relegate other mental health care providers to ancillary positions and also to identify itself as a scientific discipline along with the rest of the medical profession. Most important, by emphasizing drug treatment, psychiatry became the darling of the pharmaceutical industry, which soon made its gratitude tangible.”

Angell also addresses larger issues about whether the new psychoactive medications cause more harm than good. I recommend you to her extensive explanations.

As for the looming question, of how we should treat depression if we are not to rely on antidpressants, Angell offers an opinion that coincides well with my own: “Both psychotherapy and exercise have been shown to be as effective as drugs for depression, and their effects are longer-lasting, but unfortunately, there is no industry to push these alternatives and Americans have come to believe that pills must be more potent.”

I would qualify the assertion by pointing out that the kinds of psychotherapy that are most effective in dealing with depression are either based on cognitive-behavioral principles or involve treatments where patient and therapist establish a solid human connection.

This would preclude any therapy based on psychoanalytic principles, since the latter treatment, by definition, insists that patient and therapist should not connect in any meaningful human way.

I and many others have come to see that aerobic exercise is an effective treatment for many kinds of depression, but that Americans are hesitant to involve themselves in it because it requires work, because there is no industry pushing it on us, and because it’s a lot easier and feels more American to take a pill.