News Flash From Channel 5: "There is a shortage of psychiatrists"

This was an actual headline from a local news channel.  Of course the first question is where have they been for the last 30 years?  That was about the last time Anoka Metro Regional Treatment Center (AMRTC) was adequately staffed by psychiatrists.  In fact, at that point some of the psychiatrists working there considered it to be a high point in the education of medical students from the University of Minnesota.  One of them told me that their clinical rotation was the highest rated of any in the department.  The gist of this story is that the shortage of psychiatrists has led to inconsistent staffing for patients who need consistency.  The reporter emphasis was on Minnesota Department of Human Services hiring three psychiatrists with disciplinary actions on record with the Board of Medical Practice.  They also make the point that many of their psychiatrists are flown in for a few weeks at a time to see patients and this disrupts continuity of care.  The mother of a patient and a State Ombudsman comment about the importance of continuity of care.  If you watch the entire clip, the end is rather anticlimactic as the reporter points out that Minnesota is really no different than other states.  They are all suffering from the shortage of psychiatrists.

All in all a very dramatic presentation of a problem that nobody wants to solve.  After all, I just pointed out that in the late 1980s and early 1990s staffing at this same hospital was excellent.  The psychiatric staff there was first rate and one of the best hospital staffs that could be found anywhere.  So what happened?   In a word that I have used frequently on this blog mismanagement.  At some point professional managers decided to ignore the once popular theories of Peter Drucker and manage professional workers like production workers.  They saw psychiatry as a production job and eliminated the systems aspects critical for a team approach to psychiatric treatment.  That team approach is also critical to the practice environment and the practice environment and patient care also suffers when governments and insurance companies start telling physicians what to do and what to prescribe.  The outcome is as predictable as the current failed state hospital system.

None of those basics are in this sensational piece from Channel 5 News.  The only narrative I can detect in this story is that there are long distance psychiatrists and problematic psychiatrists practicing problematic psychiatry at the state hospital - at least until the main reporter starts with a focus on the shortage of psychiatrists.  Psychiatrists in this story function only as scapegoats.  That is easy to do when you limit the practice and hire people who are willing to work in a compromised treatment environment.  It is also easy to do when you eliminate psychiatrists and experienced psychiatric nursing staff from the management and planning aspects of the system.   Just last week I pointed out that there were no psychiatrists on a Governor's Task Force on Mental Health.  There are no psychiatric experts discussing hospital care or what it will take to repair the system in the news piece.  It is as if we are in a parallel universe, pretending that politicians and bureaucrats can do the job of psychiatrists without any training.  They can turn around and ration access to psychiatrists and then blame psychiatrists for all of the problems they have created.    Luckily,  I have been writing about this curious set of circumstances here for a few years.  You can follow my commentary in the links below and see how it compares to the skewed news version.

The additional question any reader should ask is why psychiatrists are never consulted and why attorneys and bureaucrats with no psychiatric training are in charge of these facilities?  This the cultural trend that started 30 years ago.  Throw out the doctors and run the healthcare system with politicians and bureaucrats that tell the doctors what to do.  Make is seem like doctors in state hospitals can operate in a vacuum rather than on teams and have the bureaucrats tell them how to manage clinical problems.  For a good portion of that 30 year period the word on the street was that the State of Minnesota was shutting down state hospitals and they were going to shut down AMRTC.  Those rumors do not inspire the confidence or commitment from medical or nursing professionals that you need to build a first rate state hospital system.  Who wants to go through credentialing and all that professional applications involve to apply to a hospital that is rumored to be closing soon?

The problem in Minnesota is not about trusting psychiatrists, no matter how bad a media article attempts to portray them.  This article is about trusting the politicians and bureaucrats that run this system.  In 30 years those politicians and bureaucrats have done nothing to merit anyone's trust in managing the public system of mental health care.  The failed state mental health system in Minnesota is an excellent example of what happens when you leave the management of a profession up to amateurs.


George Dawson, MD, DFAPA



Previous posts on the management deficiencies in the Minnesota state mental health system (click on the last word in each line for the post):


Executive Order: No Psychiatrists On Governor's Task Force On Mental Health [ 5/4/2016 ]

Minnesota's Mental Health Crisis - The Logical Conclusion of 30 years of Rationing [11/2/2015 ]

Minnesota State Hospitals Need To Be Managed To Minimize Aggression [1/6/2016 ]

Minnesota Psychiatrist Workforce Shortage [12/2/2015 ]

The CMS Investigation Of Anoka Metro Regional Treatment Center [1/19/2016 ]

Minnesota Finally Rejects Managed Care [5/29/2015]

More On Violence And Aggression In Minnesota Hospitals [12/11/2014 ]

Minnesota Continues A Flawed Approach To Serious Mental Illness And Aggression [12/9/2014 ]

The Shadow State Hospital System [ 11/6/2014 ]

The News Media and Mental Illness - A Continued Problem

Although the media can certainly pump up the volume on trivia like the DSM-5 their coverage of the critical day-to-day issues involving mental illness continue to be lacking in both depth and breadth.  It is weak.  From a depth perspective I will point to an article about a man convicted of shooting at people on the I-96 freeway in southeastern Michigan.  His reason for the shootings?  He thought he was getting coded messages from the Detroit Tigers to shoot people.  He also believed that military helicopters were hovering above his home and that his home contained "advanced technologies" that caused his daughter to develop a skin disease and his wife have a miscarriage.  The article contains a layman's description of a not guilty by reason of mental disorder defense and that defense was never advanced based on a judges ruling.  As a psychiatrist familiar with these criteria there is an overwhelming bias to convict people who are mentally ill and mentally compromised.  That is why the defense is generally a failure.  In this case the defendant did not have the opportunity to present that defense because as the article explains:

"Diminished capacity is a claim that says a defendant was unable to form specific intent required to commit a crime under the law by reason of mental illness, and as a result, the defendant’s responsibility in the alleged crime is diminished. The judge earlier ruled that the defense could not make this argument because it failed to give proper notice of a defense of insanity."

In other portions of the article we learn that he has been treated for an unnamed mental illness since 2009.  The symptoms are described as delusions that respond to medication and the delusions associated with the shooting incidents are currently in remission.  When the defendant is asked about whether he knew that firing a gun into an automobile might hurt someone.  His response was "In hindsight - yes".  I have not seen the final sentencing after a no contest plea but he faces up to 12 years in prison on firearms and assault charges after they decided to drop a terrorism charge.

From a breadth of coverage perspective, I will suggest a second article that points out the critical shortage in acute care inpatient beds with the capacity to address severe mental illness and aggressive behavior.  In those case Virginia State Senator Creigh Deeds discusses an incident where his son stabbed him and subsequently shot himself.  After the incident Senator Deeds states that the read his son's diary and it said that if he killed his father he would go directly to heaven.  In his taped discussion he talks about all of the relevant points that I try to cover here involving stigma, a lack of respect for providers, and diversion of resources to more areas of care that are viewed as more prestigious - like Cardiology.  Amazingly, Virginia apparently has a rule where you must be released from the emergency department if they can't find a psychiatric bed within 6 hours.  Based on his proposed reforms it doesn't seem like there has to be much of an effort to look elsewhere.  The sequence of events has been managed care companies shutting down psychiatric bed capacity by defunding it.  That is followed by states deciding to act like managed care companies and either shutting down their capacity or getting completely out of the field.  The end result is a pool of people who cycle in and out of short stays on inpatient units to overcrowded emergency departments to the street and back again.  Many permanently drop out of that cycle when they become homeless or go to America's newest mental hospitals - the county jail.  This is a problem everywhere in the United States.  I used to qualify that by saying it was a problem in areas of high managed care penetration.  Today that is everywhere.

Apart from the isolated pieces that are written with the obvious intent to get somebody a Pulitzer Prize, these stories are typical of what you see in the press.  The first article lacks basic information on what mental illness is and how decision making in a delusional state bears no resemblance to answering questions "in hindsight" after the delusions are gone.  It lacks psychiatric perspective.  Any newspaper reporter probably has access to acute care psychiatrists to tell them about those problems.  In that situation reporters always want a "diagnosis" of the person in the news and psychiatrists cannot speculate on that without having examined the patient and getting their release for that information.  But they can provide a rich perspective based on their clinical experience treating thousands of similar problems and the effect of delusions on a person's conscious state.  They can also provide an opinion on the mental illness defense in this country as well as the state of psychiatric services to treat the problem.  I know that I would be happy to provide those details.  At the minimum somebody in charge of journalism school curricula needs to examine how reporters can come out and ignore all of those facts.  I might even suggest objective criteria for coverage as at least 5 times the words used to cover the least relevant mental illness story that year.  I would give the least relevant story this year as anything having to do with the DSM-5.  On that basis a lot of additional writing needs to be done on these two stories.

In the case of Senator Deeds, his analysis of the problem in this brief soundbite is spot on.  He needs a broader platform to advocate for his plan and support against the people who are opposing him and the 6 hour rule in state of Virginia.  He should work the the American Psychiatric Association, receive their support, and have access to their social media venues.  The APA should come out with their own solution to this problem.  I cannot think of anything more absurd and more consistent with a managed business approach to treating severe health problems than this 6 hour rule.  At some point the patient and their severe problem is totally meaningless relative to business concerns.  And Senator Deeds is right.  That doesn't happen with any other medical problem in the emergency department.

It only happens with mental illness.

George Dawson, MD, DFAPA

The Lancet's Illogical Digression

The latest editorial in the Lancet has an illogical digression.  The brief note starts out by stating that there will soon be a revolution in psychiatry based on a genomics study published in the Lancet.  It concludes with a digression to a discussion of about the provision of mental health services across the lifespan with a pejorative connotation:

"The child with ADHD at 7 years could be seen by a child psychiatrist, but at the age of 18 often loses access to mental health services altogether, until he presents with a so-called adult mental health problem. Substance misuse and personality disorders may complicate the picture."

It seems to me that practically all adult psychiatrists would not have any difficulty at all in getting a history of an earlier diagnosis of ADHD and deciding how that would be treated.  I wonder if the Lancet's editors would make the same commentary on childhood asthma presenting to an Internal Medicine clinic.  Would that be "so-called adult asthma"?  The asthma example is instructive because it turns out that what physicians have been calling asthma for decades is more complicated than that.  Recent research has adopted the endophenotype/endotype methodology that has been used to study schizophrenia.  The reason why adults are seen by adult psychiatrists rather than child psychiatrists is the same reason why people stop seeing their pediatricians as adults.  Treating cormorbid substance misuse and personality disorders is just a part of that reason.

As far as the idea that the future of psychiatry is set to change any more than the future of the rest of medicine consider the statement:

"The future of psychiatry looks set to change from the current model, in which ADHD, bipolar disorder, or schizophrenia are considered as totally different illnesses, to a model in which the underlying cause of a spectrum of symptoms determines the treatment."

If that were true, psychiatry would have suddenly catapulted into the most scientifically advanced medical specialty because currently there is no other medical specialty that treats illness based on an underlying genetic cause.   The Lancet's attached paragraph on access to services across the lifespan is accurate, but it really has nothing to do with the possible genetic revolution in psychiatric diagnosis.  If the services are anywhere near as bad in the UK as they are in the United States (Is public health rationing as bad as rationing done by corporations?) there is a widespread lack of services and disproportionate rationing relative to the rest of medicine.

Until psychiatrists, psychiatric services, and mental illness are destigmatized there is no reason to think that a genetic revolution will mean more access to services.

George Dawson, MD, DFAPA

The Lancet.  A revolution in psychiatry.  The Lancet - 1 June 2013 ( Vol. 381, Issue 9881, Page 1878 ) DOI: 10.1016/S0140-6736(13)61143-5.

Cross-Disorder Group of the Psychiatric Genomics Consortium.  Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysis.  The Lancet - 20 April 2013 ( Vol. 381, Issue 9875, Pages 1371-1379 ) DOI: 10.1016/S0140-6736(12)62129-1

Hamshere ML, Stergiakouli E, Langley K, Martin J, Holmans P, Kent L, Owen MJ, Gill M, Thapar A, O'Donovan M, Craddock N. A shared polygenic contribution between childhood ADHD and adult schizophrenia. Br J Psychiatry. 2013 May 23.  [Epub ahead of print] PubMed PMID: 23703318.

Larsson H, Rydén E, Boman M, Långström N, Lichtenstein P, Landén M. Risk of bipolar disorder and schizophrenia in relatives of people with attention-deficit hyperactivity disorder.  Br J Psychiatry. 2013 May 23. [Epub ahead of print] PubMed PMID: 23703314.

Brooks on Psychiatrists As "Heroes of Uncertainty"

Well I suppose it is slightly better than the usual characterizations that we see in the New York Times, but David Brooks recent column on the "improvisation, knowledge and artistry" involved in psychiatry is little more than damning with faint praise.  His flaws include using the term "technical expertise" and comparing psychiatry to "physics and biology".  Psychiatry is certainly comparable to biology but not to physics.   And what is it about psychiatry that is unscientific?  The idea that psychiatry seeks to legitimize itself by appearing to be scientific is a popular antipsychiatry theme.  It is probably why many authors seek to equate psychiatry with the DSM.  The science of psychiatry is out there in many technical journals that are scarcely ever mentioned in the public commentary about psychiatry.  The idea that the science of psychiatry is collapsed into a modest (at best) diagnostic manual is a convenient way to deny that fact and portray psychiatrists as unscientific and perhaps not very much like physicians either.  

Brooks characterization of the DSM shows a continued lack of understanding of this manual by  every journalist who writes about it.  There is practically no psychiatrist I know of who considers it to be authoritative.  Very few psychiatrists  actually go about their diagnostic business by reading through DSM criteria.  That activity would be limited to novices and medical students.    It is well known that only a fraction of the diagnoses listed are ever used in clinical practice.  After familiarizing themselves with the major changes, few psychiatrists will every open it again.   Like most physicians, psychiatrists are looking for patterns of illness that are based more on their clinical experience than criteria listed in a manual.  The idea that this text has "an impressive aura of scientific authority" is certainly consistent with Brook's thesis, but that is not what a psychiatrist experiences when looking at it.  Despite all of the concern about the public impact - psychiatrists are the target audience here.  Psychiatrists are much more aware of the limitations of the approach than the media critics who write about it.  I guess a lay person might be impressed, but I never met a psychiatrist who was.  

Brooks is also confused about the nature of the DSM when he states that it contains "a vast body of technical knowledge that will allow her (your psychiatrist) to solve your problems".  That vast body of technical knowledge is firmly outside of the DSM and it is in the form of training and ongoing education of a psychiatrist.   That technical knowledge is contained in a vast literature, much of it written by psychiatrists.  It is the reason that ongoing training and education of physicians is a career long commitment.  In the general scope of things, the DSM would contribute a percentage point or two at most to that body of knowledge.

There is the associated question about whether physicians are scientists or not.  I have seen Kandel himself interviewed about this issue and he states quite definitely that they are not.  That is quite different from suggesting that physicians are unscientific.  There are certainly not many physicians who are performing scientific experiments and publishing papers.  I suppose that you have to do that to be a professional scientist.  On the other hand, physicians are certainly accountable for learning immense amounts of of scientific principles and data that can be applied in clinical situations and used in critical thinking about patients and teaching it to successive generations of physicians..  I teach Dr. Kandel's plasticity concept and how it applies to addictions in about 30 lectures a year.  Reducing scientific knowledge to "artistry" is really inconsistent with "technical expertise".  There really is no art in medicine.  The most technically competent doctors know the science, have seen more patterns of illness and can recognize those patterns.  They can apply that knowledge to patient care.  In complex medical (and psychiatric) care, a special plan can be designed for each individual patient and most aspects of that plan are rooted in science.

This essay strains under the weight of needing to place psychiatry outside of the scope of science and mainstream medicine.  My study of psychiatry finds it in neither of those locations.  There is a reason that psychiatrists need to go to medical school.  The cross section of basic science and clinical science that all physicians are exposed to is necessary to be a psychiatrist.  Using Brooks reasoning, I suppose he could say that this is just an effort to "legitimize" psychiatry by making it seem like it is on scientific par with the other fields of medicine.   When I am face to face with a severely ill patient who has liver disease, heart disease, diabetes, alcoholism and a refractory psychiatric disorder - the science involved is much more than a political exercise.   

Like every other branch of medicine, psychiatry is an amalgam of the clinical and basic sciences.  Biology especially neuroscience but also the anatomy and physiology of the human body is the central focus.  I will give Brooks partial credit when he writes about the DSM.  Unlike many of his colleagues at the NY Times - he does not refer to it as a "Bible".  When it comes to the issue of whether I am a scientist or not, I certainly realize that I am no Eric Kandel.   But I also know that I am not rolling the dice or taking a leap of faith.   I am  doctor seeing people, trying to understand their unique set of problems, and applying medical science to help them get better.

George Dawson, MD. DFAPA

David Brooks.  Heroes of Uncertainty.  NYTimes May 27, 2013.

The Latest Proclamation by Allen Frances

Just when you think that Allen Frances has run out of editorial venues for his anti DSM5 critiques another one pops up.  This time it is in the Annals of Internal Medicine.  This is a note about that process before I get into addressing his repetitive critiques.  The Annals is a respected medical journal.  For a number of years I was an ACP member and subscribed to it myself.  Why would the Annals go along with publishing an editorial piece that is basically a rehash of what has been published in the New York Times and the Huffington blog and who knows where else?  There is really precious little science involved.  I think the only logical explanation is that the staff of the Annals has jumped on the popular bias against psychiatry that has been widely noted in the press by Claire Bithell and her group that studies these issues.  I am not a current subscriber to the Annals but the question is whether there was equal time for rebuttal.  If not is this professional bias against psychiatry?

Probably the best way to address this rehash of old criticisms is to link up to previous blog posts here where that occurs.  Beginning in paragraph one Dr. Frances cites a famous study about pseudopatients as though it has some applicability to the issue of “unreliable and inaccurate” psychiatric diagnosis.  He cites this study as if it is somehow relevant to the problem.  All of the considerable scholarship refuting this study as meaningful by various authors including Spitzer and Kety is ignored.   Using this as a premise for a scholarly article on the validity of psychiatric diagnosis should raise an eyebrow or two, but on the other hand I doubt that there is anyone on the editorial board at this Internal Medicine journal who is familiar with this literature.

The issue of diagnostic inflation is a frequent critique used by Frances and others to suggest that this invalidates the DSM5.  Most people are very surprised to learn that compared to previous editions and the ICD-10 this is really not an issue.  The previous blog post illustrates that compared to the ICD-10, the possible increase in diagnostic categories in the DSM is trivial.  The increase in the number of codes for a knee fracture alone approximates the total codes in the DSM!  Contrary to his description of “holding the line” with DSM-IV diagnoses – the data presented in that post shows that the DSM-IV added twice as many diagnoses as the DSM5 will.

Dr. Frances uses the “no bright line” approach to say that there is no way to separate the worried well from people with disorders.  There certainly is no written “bright line” in the DSM.  Every DSM has a section with qualifying statements about its use and that fact that diagnostic criteria alone are not sufficient.  A psychiatric diagnosis, especially a diagnosis made by psychiatrists in the same group with the same focus is very consistent and it is a reliable marker of illness severity.  Professional judgment is required.  The “no bright line” issue is not a problem that is unique to psychiatry.  It is omnipresent in general medicine with regard to chronic pain diagnoses, chronic pain treatment, and in the overprescription of pain medications and antibiotics.  The overprescription of antibiotics has been identified as a problem by the Centers for Disease Control (CDC) for 20 years and recent authors suggest that minimal progress has been made.  It seems that other specialties are subject to the “fallible subjective judgments” suggested in this article.

Another implicit myth used by Dr. Frances and other critics of psychiatry is that there is some magical diagnostic process that occurs in medicine and surgery that makes them better than psychiatric diagnoses.  What happens when we test that theory by looking at the reliability of general medical diagnoses?  Looking at that data, it is clear that the published reliability data from medicine and surgery is no better than the frequently criticized data from psychiatry even when objective medical tests are used.  Practically everyone I know has a favorite story about a misdiagnosis and/or ineffective treatment of a medical or surgical problem.  That evidence does not support the contention that psychiatry is somehow less accurate or effective than the rest of medicine.  Some medical specialties used similar descriptive techniques even when they have numerous biological markers of the illness.  The other elephant in the room on this diagnosis issue is medically unexplained symptoms.  The studies of all patients coming in to a clinic setting suggest that 30%  do not get a diagnosis to explain their symptoms.  These patients often get multiple tests looking for a cause for their problem.  This is by far the most significant problem that I hear from relatives, acquaintances, and the public in general.  If nonpsychiatric medical diagnoses are supposed to be highly accurate based on biological tests – a substantial number of people never actually experience that.

On the fuzzy diagnosis in psychiatry critique, a common theme here is to go after the bereavement exclusion and suggest that normal bereavement will be treated like depression.  I have an extensive response to this when it was posted in a newspaper article and invite any interested reader to look at the previous blog post and the fact that this approach to grieving patients who come to the attention of psychiatrists has been written about for over 30 years (see last 5 paragraphs at link).  Practically every point in this section of the editorial can be disputed but the point of the article is not a scientific review, it is basically a selection of comments to support a specific viewpoint.

To Dr. Frances credit he references an excellent meta-analysis by Leucht, et al on how the results of psychiatric treatment are as good or better than the results of other medical specialties.  He is silent on how that occurs if psychiatric diagnosis is so unreliable and inaccurate.  How is it possible to get results that good compared with other specialties?  Maybe it is because as I have just suggested, the “special problems” in psychiatric diagnosis are really general problems that are shared by all medical specialists?

The criticism is less focused in the final paragraphs with some commentary on style points about the DSM political process, the issue of conflict of interest focused on publishing profits, and the idea that the APA should submit the DSM to oversight by a broad coalition of “50 mental health associations”.  Let me take the last point first.  There are a number of other diagnostic approaches and manuals that have been completed by coalitions of several other mental health organizations.  With the number of different approaches, I would encourage any organization to publish their own approach to the diagnosis of mental disorders.  Contrary to the rhetoric suggesting that there is a DSM monopoly, nothing could be further from the truth.  The entire text of the World Health Organization’s (WHO) ICD-10 is available free online.  The Mental and Behavioral Disorders section of the ICD-10 gives detailed descriptions of each disorder.  The detailed research criteria for ICD-10 can be purchased for about ¼ the cost of a DSM5.  It seems to me that there is a marketplace of ideas and plenty of competition.  If I was not a psychiatrist with an interest in reading about developments in my field, I would not be compelled to purchase a DSM5.  I would probably take a few courses in the changes to DSM-IV and stick with that for a while.

On the issue of submitting the DSM5 to outside groups there are several compelling reasons why that would not be a good idea for most psychiatrists.  Some critiques have suggested that psychiatry should be open to forced collaboration by others based on previous relationships.  Over the span of my career, I have noted that there is often an adversarial approach by other organizations rather than an affiliative one.  And why wouldn’t there be?  This is the United States and everyone here is familiar with the competitive and politicized atmosphere.  It seems like that has been left out of the equation when charges of “conflict of interest” are leveled at the APA in the area of publishing a DSM.  A recent critique of the DSM5 also suggested broader collaboration with social scientists and I critique that article here.  The political slant of all of these articles is that the APA needs the input of others to improve descriptive psychiatry.  Including that in an article that has a basic thesis that: “We will be stuck with descriptive psychiatry for the forseeable future.” (line 27-28) being a negative is inconsistent.  If anything Dr. Frances seems to be suggesting that we should be moving more to the biomedical side and  distancing ourselves from the social scientists.  The bottom line here is that the DSM5 is a diagnostic guideline for psychiatrists to use in clinical practice.  It is not synonymous with a psychiatric diagnosis and it is used at some level by psychiatrists to understand mental disorders.  It is not designed for anyone to read and act like a psychiatrist and it has nothing to do with people who do not have psychiatric problems.  It is not a “Bible” like the New York Times suggests.  It is a tool for psychiatrists and if you are not a psychiatrist there may be no reason for you to buy it or even think that it is relevant to you.

On the issue of Dr. Frances serial DSM5 critiques - this seems like a war of attrition to me.  Dr. Frances has an infinite number of venues that are quite willing to publish his very finite and repetitive criticisms of the DSM5 and the associated process.  Outside of myself – there appears to be nobody else including the American Psychiatric Association who is willing to offer the obvious counterpoints.  He has more time on his hands and many more connections than I do.  So in terms of sheer volume I guess this is a Pyrrhic victory of sorts.  I will have to be content with expressing the opinion of a psychiatrist who practices real psychiatry,  making diagnoses and helping people every day and knowing that my results are on par with anybody else in medicine and that there is nothing random about it.

George Dawson, MD, DFAPA

Even more DSM bashing - is it a fever pitch yet?

Just when you think you have seen it all, you run into an article like this one in The Atlantic.  A psychotherapist with a long antipsychiatry monologue.  It is written in interview format with psychotherapist Gary Greenberg as the discussant.  I thought it was interesting because the title  describes this diatribe as the "real problems" with psychiatry.  Of course what he writes about has nothing to do with the real problems that specifically are the rationing and decimation of psychiatric services by managed care companies and the government.  The entire article can be discredited on a point by point basis but I will focus on a few broad brush strokes.

The author here spins a tale that the entire impetus for a diagnostic manual and a biomedical orientation for psychiatry is strictly political in nature and it has to do with wanting to establish credibility with the rest of medicine.  That is quite a revision of history.  Psychiatry pretty much exists now because psychiatrists would take care of the problems that nobody else wanted to.  I have immediate credibility when another physician is seeing a person with a mental illness, they don't know what to do about it, and I do.  It is less clear today, but psychiatry professional organizations were asylum focused and the goal was to treat people in asylums initially and then figure out a way to get them back home.  Part of the psychiatric nosology was based on the people who would get out of asylums at some point and those who did not.  The credibility of psychiatry has nothing to do with a diagnostic manual.  It has to do with the fact that psychiatrists have a history of treating people with serious problems and helping them get well.  There is no discussion of how the numbers of people institutionalized in the 1950s and 1960s fell to the levels of current European levels as a result of psychiatric intervention that included the use of new medications but also a community psychiatry movement that was socially based. (see Harcourt Figure II.2)

The author uses the idea of "chemical imbalance" rhetorically here as further proof that psychiatrists are using a false premise for political purposes.  He presumes to tell his readers that during the time he is giving the interview there is some psychiatrist out there using the term chemical imbalance to convince a patient to take antidepressants.  Since I have never used that term and generally discourage it when patients bring it up, I wonder if he is right.  Any psychiatrist trained in the past three decades knows the situation is much more complex than that.  Eric Kandel describes the situation very well in his 1979 classic article on "Psychotherapy and the Single Synapse".  Any antipsychiatrist using "chemical imbalance" against psychiatry in a rhetorical manner suggests that there is no biomedical basis for mental disorders.  There should be nobody out here who believes that is true and in fact this article acknowledges that.

The basic position here is to deny that anything psychiatric exists.  Psychiatrists  don't know what they are doing.  Psychiatrists are driven by the conflict of interest that nets them "hundreds of millions of dollars".  He doesn't mention how much money he makes as an outspoken critic of psychiatry.  He tries to outflank his rhetoric by suggesting any psychiatrists who disagrees with him and suggests that it is typical antipsychiatry jargon is "diagnosing him".   He doesn't mention the fact that antipsychiatry movements are studied and classified by philosophers.

I think the most revealing part of this "interview" is that it appears to be orchestrated to enhance the author's rhetoric.  The evidence for that is the question about "drapetomania" and implying that has something to do with coming up with DSM diagnoses and the decision to drop homosexuality as a diagnostic category.   That is more than a stretch that is a clear distortion and of course the question is where the interviewer comes up with a question about "drapetomania".  I wonder how that happened?

This column is an excellent ad for the author's antipsychiatry work.  Apart from that it contains contains the standard "chemical imbalance" and psychiatric disorders are not "real illnesses".  To that he adds the conflicting positions of saying there appear to be biological correlates of mental disorders but they would never correlate with an existing diagnosis and the idea of a chemical imbalance metaphor is nonsense.  He uses colorful language to boost his rhetoric:  "They'll (those wacky psychiatrists - my  clarification) bob and weave, talk about the "living document," and unleash their line of bullshit." 

His conclusory paragraph and the idea to "take the thing (DSM) away from them" has been a common refrain from the DSM critics.  In fact as I have repeatedly pointed out, there is nothing to stop any other organization from coming up with a competing document.  In fact, sitting on my shelf right now (next to DSM-IV) is a reference called the Psychodynamic Diagnostic Manual.  It is listed as a collaborative effort of six different organizations of mental health professionals.  It was published 12 years after the last edition of the DSM - it is newer.  I have texts written by several of the collaborators of this volume.  When I talk with psychiatrists from the east coast, they frequently ask me about whether or not I am familiar with the volume.   My point here is that if the author's contentions about the reality basis of DSM diagnoses are correct, it should be very easy to come up with a different system.  I encourage anyone or group of people to develop their own diagnostic system and compete with the DSM.

So the last minute attacks on psychiatry with the release of the DSM seem to be at a fever pitch.  The myth of the psychiatric bogeyman is alive and well.  Add The Atlantic to the list of uncritical critics of psychiatry.

George Dawson, MD, DFAPA

1.  Hope Reese.  The Real Problems with Psychiatry.  The Atlantic.  May 2, 2013.

2.  Bernard E. Harcourt.  From the asylum to the prison: rethinking the incarceration revolution.  The Law School, University of Chicago, 2007.

3.  Psychodynamic Diagnostic Manual (PDM).  A collaborative effort of the American Psychoanalytic Association, International Psychoanalytic Association, Division of Psychoanalysis (38) of the American Psychological Association, American Academy of Psychoanalysis and Dynamic Psychiatry, National Membership Committee on Psychoanalysis in Clinical Social Work.  Published by the Alliance of Psychoanalytic Organizations.  Silver Spring, MD (2006).

4.  Kandel ER. Psychotherapy and the single synapse. The impact of psychiatric thought on neurobiologic research. N Engl J Med. 1979 Nov 8;301(19):1028-37. PubMed PMID: 40128.

The Ultimate Antipsychiatry Movie?

Side Effects may qualify as a new level of antipsychiatry film.  I went to see this film last night with a vague notion that it was a thriller with some surprise plot twists and that it may have something to do with psychiatry. I walked out one hour and 46 minutes later with the impression that I had seen an antipsychiatry movie on a grander scale than previously observed. My previous standard was the psychiatrist who happened to be a serial killer and cannibal. The psychiatrists portrayed in this film were not as aggressive but certainly had their fair share of criminal activity, unethical behavior, and boundary violations.  The sheer scope of that behavior was striking.

The plot unfolds as we get to know Emily Taylor (Rooney Mara).  She appears to be depressed and even suicidal at times. This depression occurs in the context of significant life stressors including the incarceration and subsequent release of her husband Martin (Channing Tatum) for securities fraud. There is an overall impression that the couple lost quite a bit of status and financial resources as a result of that problem. We see her struggling at work and eventually intentionally injuring herself. That leads to her initial encounter with Dr. Jonathan Banks (Jude Law).  Dr. Banks initiates treatment with antidepressant medication and Emily seems to be experiencing intolerable side effects from the initial SSRIs.  In the meantime, Dr. Banks is in touch with Emily's previous psychiatrist Dr. Victoria Siebert (Catherine Zeta-Jones) who suggests a new recently approved antidepressant.  Emily takes this new medication and appears to be experiencing even more side effects right up to the point that she kills Martin while she is apparently “sleepwalking” as a medication related side effect.

From the initial perspective, it seemed like a heavy-handed “psychiatrists corrupted by Big Pharma” film until that point. After all Emily seems to be clearly made ill by the drugs and that point is emphasized cinematically by slowing down the entire scene in what seems to be her drug addled perspective.  Her psychiatrist seems indifferent to the problem and the fact that her spouse is getting more angry about the situation.  At one point the representative of a pharmaceutical company offers to pay Dr. Banks a considerable sum of money for doing research on the new antidepressant. There is a suggestion that Dr. Banks is already spread too thin. In that same scene, the representative emphasizes that she can buy psychiatrists meals and they banter about consulting fees.  Dr. Siebert hands Dr. Banks a pharmaceutical company branded pen with the name of the new drug printed on the side.  The sum of the cinematic effect at that point is to suggest that antidepressants are very toxic drugs, psychiatrists inflict more problems on people with these drugs, and that psychiatrists essentially prescribe these drugs because they are pawns for Big Pharma.  Admittedly nothing more than you might read in the Washington Post.

The plot lurched forward at that point to the issue of a not guilty by reason of insanity defense and the interactions of Dr. Banks with his patient even after she was sent away to a forensics facility. There was also considerable emphasis on the interaction between Dr. Banks and Dr. Siebert.  I will try to point out problems that occur along the way without giving away the rest of the plot. The first problem at that point in the movie was both the defense attorney and the prosecuting attorney suggesting that Dr. Banks should consult for their side. The fact that Dr. Banks has a treatment relationship with Emily makes his consulting with either side a clear conflict of interest, even in a non-criminal matter. He continues to see Emily at the state forensics facility.  At that time he is seeing her only to advance his interests and they no longer have a therapeutic relationship.  He threatens her, essentially blackmails her, and administers a questionable treatment in an unethical manner.  We later learn that Dr. Siebert also has an inappropriate relationship with Emily and has been involved in criminal activity with her.

At one point, Dr. Siebert attempts to ruin Dr. Banks’ professional reputation and relationship with his wife by releasing a letter from a former patient and manipulated photographs of Dr. Banks and Emily. His partners react strongly and fire him from their practice. An investigator from the state medical board seems suspicious of Dr. Banks.  Part of this side plot seems to be the only plausible aspect of this film and only insofar as complaints against physicians and psychiatrists are common and greatly outnumber the incidence of inappropriate physician behavior. The reaction of Dr. Banks’ partners to this material as well as an adverse outcome is overdone.  Any psychiatrist treating people with severe mental illnesses has adverse outcomes.  Most reasonable people agree that an adverse outcome in medicine and psychiatry does not imply either negligence or criminal intent.

I am generally focused on the purely cinematic aspects of any film that portrays psychiatrists. I explained my rationale for this approach in a previous review.  My approach is based on the low likelihood of seeing an accurate cinematic portrayal of a psychiatrist.  I imagine that other professionals have the same experience. The problem with this film is that the actions of psychiatrists are the major part of the plot and it is difficult to focus on the motivations and personalities of the other characters.  The character of Emily is not developed very well and her actions are difficult to understand.  Dr. Banks and Dr. Siebert are certainly much more active but their de novo sociopathy and unethical behavior have no context.  This lack of character development, dominant scenes by psychiatrists, and the implausibility of those scenes makes this a difficult film to watch.

Regarding the entire issue of why I referred to this as an anti-psychiatry movie that is based on the classification from the Oxford Textbook of Philosophy and Psychiatry. It can be found in the footnote to this post (reference 2).  This film is a good illustration of the biomedical psychiatry as political control cliché.  The psychiatrists in this film are unhindered by any legal, ethical, or professional barrier in promoting their own self interests.  Their obnoxious behavior seems on par or worse than the actual crimes that were the focus of the story line and seems to be more than the typical antipsychiatry bias that is expected in the media. 

The psychiatrist as bogeyman is alive and well at the cinema.

George Dawson, MD, DFAPA