Heat Map of Psychiatric Criticism

On my drive home today I got the idea of a heat map of psychiatric criticism based on the principles outlined in my previous post.  I have started one as shown in the diagram below.  The heat zones on the map are general areas corresponding to the parameters outlined in the previous post on rhetoric.  In other words red and redder would correspond with more irrational and rhetorical criticism.  Green and greener would be more rational criticism and less rhetorical.  See the previous post for supporting arguments.

I have started out with a few examples in each zone.  I would like to be exhaustive here so send me your favorite one liners about the profession or your most hated psychiatrist and I will try to place it on the heat map.  Just a heads up, no personal attacks or identifiers will be tolerated.  It may be hard to believe but this is nothing personal.  I hope to provide a simple graphical solution to the question of what is and what is not appropriate psychiatric criticism.

I also thought about a couple of reasons why this is important.  Several years ago a friend of mine called me up and asked me a question about the American Board of Psychiatry and Neurology.   He wanted to know what year it was incorporated.  I told him I thought it was on my certificate and I would call him later.  When I got home I looked at the certificate and sure enough it read: "Incorporated 1934".   I called him with the information and asked him why that was important.  He is a social worker and told me that he was at a major DSM training course attended by social workers and the speaker (who was not a psychiatrist) suggested that psychiatry was such an illegitimate field that they were not even one of the original specialties and decided to form the ABPN later in order to seem more legitimate.  And this was a guy who was teaching a DSM course!  In another similar session, the presenter (also not a psychiatrist) compared the validity of psychiatric diagnoses referring to the Robins and Guze criteria to the validity of drapetomania.  For anyone not familiar with this definition, it refers to the idea by a 19th century quack that a slave running away is somehow a mental illness.  It really has no connection at all to the idea that there are valid mental illnesses that can be diagnosed and treated.  And yet here we have a professional making this comparison.  The term was also used in a periodical that is valued for its intellectual appeal, but the interview is embarrassing to read especially the tortured attempt to connect it to DSM-5.  My speculation is that the people who use this term have an additional agenda.  It is clear that there are are many uses of the loose application of this rhetoric and gaining political advantage is often an overlooked one.

As I look at my initial attempt, I am realizing that I need to figure out a way to group all of the statements at the top firmly in the red zone so that none of them touch the transition area to the green zone.

George Dawson, MD, DFAPA



Supplementary 1:

Here is a working list to consider (click to enlarge all graphics on this page).  This is the second version and as of today (2/16/2014) no outside suggestions.  The image below is formatted to print or store as a single 8.5 x 11 inch page:

Quebec beer-drinker's cardiomyopathy revisited

In the 1960's a condition called Quebec beer drinker's cardiomyopathy was described in the medical literature.  Between August 1965 and April 1966 46 men and 2 women were admitted to 8 hospitals in Quebec with acute cardiomyopathy and congestive heart failure.  Twenty of them died.  During the epidemiological analysis it was determined that they were all heavy beer drinkers.  An extensive analysis of the this phenomena is available in full text at the initial link on this page.  For those of us trained through the end of the 20th century the clinical methods in the 1960s were not that far removed.  The mystery was solved then by a combination of epidemiology and pathology:

"Suspicion of cobalt as the toxic agent was aroused after examination of the thyroid glands removed at autopsy showed changes similar to those found in cobalt intoxication. Had cobalt been added to the beer? Yes"

Similar patterns had been observed in Minneapolis, Omaha, and Louvain (Belgium).  Why am I suddenly interested?   The New England Journal of Medicine Clinical Problem-Solving case of the week entitled "Missing Elements of the History."  In this case a 59-year old women who was previously in good health develops acute congestive heart failure and a cardiomyopathy is diagnosed.  She has a complicated course with an initial pericardial effusion.  After acute treatment no etiology of the cardiomyopathy was determined and she was assessed for heart transplantation.  Her heart failure worsened and she developed cardiogenic shock and needed a left ventricular assist device.  Three months later she received a heart transplantation and was discharged home in 20 days.

Was the patient in question a drinker of cobalt laced beer?  No - but she did have cobalt in her body.  She had bilateral DuPuy ASR metal-on-metal hip prostheses that had been placed 5 years and 4 years prior to the heart transplant.  She had learned about one year prior to transplantation that the prostheses were being recalled due to a higher than expected failure rate and a protocol for follow up was sent to her.  She was advised to get repeat hip imaging and serum cobalt levels done.  Pelvic MRI showed reactive areas with fluid collection and the cobalt level was elevated at 287.6 mcg/liter with a reference value of less than 1.0 mcg/liter.  The prostheses were removed 11 and 13 months post heart transplantation.  She had a complicated course but apparently recovered.  Serial cobalt levels were done and 16 months after transplantation remained at 11.8 mcg/liter a significant drop.  She also had a chromium level determined at 248.9 mcg/liter about 8 months after transplantation.

The NEJM article points out that about 1 million people had these prostheses implanted between 2003 and 2010.  The authors here strike me as being overly modest in saying that they cannot absolutely confirm that this is a case of cobalt induced cardiomyopathy, but there is just too much evidence to hedge around.  Read their timeline of events in Table 1. and see what you think.  It would certainly seem to have implications for regulatory bodies like the FDA.  The parallel regulatory body in the UK states that any patient there needs lifetime annual follow up including imaging and blood cobalt and chromium levels.   The FDA recommendations are much more nonspecific and they appear to be placing the monitoring burden on primary care physicians and  other specialists.

What does the New York Times report about this story?  They have a story in November 2013 about $2.5 - 3 billion being award to a group of about 8,000 patients in the US.  They have another story that the manufacturer seemed to know earlier about the high than expected failure rate and need for replacement.  In that same story they quote the total number of recipients as "93,000 people, about one-third of them in the United States" as opposed to the NEJM estimate of 1 million people world wide.  Most of the stories I could find (15 of 26) were in the business section.  There is an interesting quote near the end of the article about how taking it off the American market was strictly a business decision.  In other articles there is a hint of a cover up and a hint of doctors not speaking up to warn other doctors, but the story has been out there since March 2010.  Where is the outrage?

We have just gone through a several year period of bashing psychiatrists for daring to rewrite a diagnostic manual that they use by themselves.  Further that manual explicitly says that you really can't just read the manual.  You need to be trained in medicine and psychiatry first.  There was plenty of outrage then.  Critics of all types in the New York media writing an endless stream of negatives about psychiatry and the DSM-5.  Accusations of conflict of interest (more appropriately the appearance of conflict of interest).  Outrage over various parties not being to have enough input into the book (when in fact the web site designed for that purpose took in thousands of comments that were debated by the work groups).  Outrage over whether the manual was written to appease the pharmaceutical industry that ignored the basic facts.  I could certainly go on, but what is the point?  Everyone has heard these stories.  They are commonplace.

The DSM-5 came out and nothing happened.  Clinical psychiatrists did not blink an eye or make any major changes.  Nobody ended up with elevated cobalt or chromium levels.  Nobody ended up with needing  more surgery or congestive heart failure from cardiomyopathy.   I certainly do not want to minimize what all of these hip implant patients are going through but it seems that the press and the FDA are doing just that.  I think the lesson is certainly there when you look at how the media overreacts to psychiatry they end up appearing to be very tolerant of significant problems in other fields of medicine.

My suggestion for the psychiatry critical press is that it might actually be worthwhile to critique other branches of medicine where there are significant problems.  Hold them up to the standard that you apply to psychiatry and see what happens.

If you can't there is clearly something wrong.  At the minimum I propose that outrage should be proportional to a real problem rather than the appearance of a problem.  Or better yet - it could just disappear and be replaced by a more rational analysis.

George Dawson, MD, DFAPA

Allen LA, Ambradekar AV, Devaraj KM, Maleszewski JJ, Wolfel EE.  Missing elements of the history.  N Engl J Med 2014: 320(6): 559-566.

Siegel E, Lautenbach AF.  Determination of cobalt in beer. Siebel Institute of Technology and World Brewing Academy.  Interesting historical document on why cobalt may be added to beer including the fact that the FDA apparently approved this application in 1963.

Clinical Note 1: I added this for the clinical psychiatrists out there who I know see a large number of people with hip implants.  Be on the lookout for pain, lack of follow up with their surgeon or signs and symptoms of congestive heart failure.  The FDA warning also suggests depression and cognitive changes.  MedlinePlus also has patient handouts.  It probably is also a good idea to remember that some people may be taking cobalt and/or chromium ionic forms as a supplement.  As an example poor quality information that can be seen on the Internet, there is some information on the that cobalt boosts erythropoetin (EPO) and athletic performance that is based on animal studies from the 1950s.  Trying that would obviously be an extremely bad idea.  A history of use of supplements is important for these reasons.

On the dangers of psychiatric diagnosis no longer being a process

I am inspired by a post on another blog having to do with the dangers of “premature psychiatric diagnosis”.  The author uses an anecdote to make a point about how a diagnosis of a psychotic disorder and then mismanagement of the treatment leads to a situation where there is no hope for the person affected.

From my perspective there are very few people with even severe psychiatric disorders who are hopeless.  In fact, people with some of the most severe cases of catatonia that I have treated became fully functional and were restored to their roles in their families and society.  That frequently occurred after months of inpatient treatment by a psychiatrist and staff who were interested and skilled in treating severe psychiatric disorders.  Much of what I did in 22 years of inpatient work was restoring hope and maintaining a hopeful atmosphere on my treatment team.

Diagnostic uncertainty is frequently cited as an area where mistakes are made.  Many studies document the medical comorbidity in patients with psychiatric disorders.  Despite anecdotal cases true medical causes of psychiatric disorders are rare.  I should qualify that by saying a brain disease, neurological or endocrine condition that is a direct cause for the psychiatric disorder is rare and I base that on screening patients and reviewing thousands of negative studies.  That said any acute care psychiatrist should know more about medicine and neurology than psychiatrists in outpatient settings because unlike their outpatient colleagues – they are responsible for making that determination.  On the psychiatric side, the potential list of causes of various syndromes is long and the actual diagnosis may not be evident until something happens on a long term basis.   A good example would be a drug induced psychosis.  In the ideal case, the patient is able to remain sober and any medical treatment for the associated syndrome can be tapered and discontinued.  In the real world, the chances of sobriety or even referral to a functional addiction treatment are low.

   

There are numerous limitations on psychiatrists.  The obvious one that practically all commentators leave out is managed care.  Is it reasonable to think that the diagnosis and treatment of any severe psychiatric problem like a psychotic disorder can be accomplished in 3 – 5 days?  That is the time frame that most managed care case managers are using to get people out of the hospital.  They often refer to purely proprietary guidelines on hospital lengths of stay that were clearly written by business people rather than clinicians.  I have been in the position of having a patient discharged by an administrator against my wishes so I know that it happens.  Managed care coercion is more subtle.  A managed care reviewer sitting at a desk in another state – reads chart notes and presumes to make a remote diagnosis and suggest that the person should leave the hospital.  They have no responsibility to the patient or their family.  Their only job is to get the patient out of the hospital to save the insurance company money.  Another constraint is at the level of public assistance.  Almost incredibly, many states link the availability of case management services to psychiatric diagnoses and they will clearly say in the statute that the person must have schizophrenia, major depression, bipolar disorder, schizoaffective disorder, or borderline personality disorder in order to qualify.  Having one of those diagnoses at discharge can be crucial to get housing and funded medical rather than be homeless.  That is a strong incentive to get the correct diagnosis sooner rather than later.

The work flow on inpatient units and in clinics is generally not considered.  If you have a psychiatrist seeing 12-15 inpatients and some outpatients and they are seeing 3 – 5 new patients a day that is not a lot of breathing room.  They will be (depending on other members of the team) able to collect collateral information from the family and outside sources, make direct behavioral observations, and relay treatment decisions and recommendations to the family.  In my experience occupational therapists, nurses, and social workers are all indispensable team members and often function in dual roles as a liaison with family members.  They can act as consultants to the family on legal and social issues as well as keeping them apprised of any changes in medical treatment on a day to day basis.

One of the key areas where care becomes fragmented both from a diagnostic and treatment standpoint is anytime there is a transition.  In terms of hospitals that occurs with any admission or discharge.  It also occurs between different outpatient clinics and between psychiatrists and primary care physicians.  I have been in situations where it took me two hours and calls to different physicians, pharmacies and relatives to reconcile a list of 10 medications.  At the end of that two hours I was still not absolutely certain of the patient’s correct medication list. 

The bottom line here is that good psychiatric diagnosis is a process. It is not like taking your car in to a mechanic and the mechanic plugging it in to an analyzer.  The best results occur when the patient and the family can communicate openly with the psychiatrist and any identified treatment team.  The diagnosis needs to take into account all of the available information and by definition it will only be as good as that information.   The critics of psychiatry always seem to think that this is a situation that is unique to psychiatric treatment.  As I have previously discussed it happens in all of medicine.  The basic difference being that many nonpsychiatric conditions lend themselves to analysis by a single observer.  There is something readily visible, audible or palpable that suggests an abnormality.  In psychiatry we are focused on communication, self report, and the observations of others.  We are also generally dealing with more information to make a diagnosis, especially if the patient’s capacity for self report is limited.  Psychiatrists more than anyone else need to be comfortable with diagnostic uncertainty and explaining these nuances to the patient and their family.

When the diagnosis is made it should be fully explainable to the patient and family.  Any stigma or negative reaction to the diagnosis should be discussed.  It should be evident that nobody is reducible to a psychiatric diagnosis given the fact that no two people are alike and each person is a unique individual with unique attributes.  This is true for any medical diagnosis and psychiatric diagnoses do not differ in that regard.   Nobody should leave the encounter with the idea that they are “hopeless”,  particularly in the case of a pure psychiatric diagnosis in the absence of a neurodegenerative disease.

I realize that most of us in one way or another are held hostage by a certain health plan, but if your psychiatrist or more probably your health plan does not follow that basic process – find a new one.  Getting stuck on whether or not a misdiagnosis has occurred without a plausible explanation for what has happened or continues to happen is generally not productive.  If you can’t get out of your health plan talk to the medical director and explain the deficiencies.  If that doesn’t work and you are concerned about the diagnostic and treatment process being rationed, contact your state insurance commissioner and file a complaint against the health plan.

Quality psychiatric care is possible, but it has been demonstrated that in many cases you have to fight for it.

George Dawson, MD. DFAPA

DSM5 Dead on Arrival!

That's right.  The latest sensational blast on the fate of that darling of the media the DSM5 is that it is dead on arrival.  That recent proclamation is from the Neuroskeptic and it is based on the analysis of  criticism of DSM5 criteria for Generalized Anxiety Disorder (GAD).  OK - the original proclamation was "increasingly likely DOA".  I confess that at this point I have not read the original article by Starcevic, Portman, and Beck but the Neuroskeptic provides significant excerpts and analysis.

The broad criticism is that the category has been expanded and is therefore less specific.  The authors are concerned that this will lead to more inclusion and that will have "negative consequences."  The main concern is the "overmedicalization" of the worried and the dilution of clinical trails.  All this gnashing of the teeth leads me to wonder if anyone has actually read the Generalized Anxiety Disorder DSM5 criteria that is available on line.  The proposed new criteria, the old DSM-IV criteria and the rationale for the changes are readily observed.  The basic changes include a reduction on the time criteria for excessive worry from 6 months to three months, the elimination of criteria about not being able to control worry, and the elimination of 4/6 symptoms under criteria C (easy fatigue, difficulty concentrating, irritability and sleep disturbance).  A new section on associated behaviors including avoidance behavior a well known feature of anxiety disorders is included.  The remaining sections on impairment and differential diagnosis are about the same.  The GAD-7 is included as a severity measure although I note that the Pfizer copyright is not included.

So what about all of the criticism?  The "Rationale" tab is a good read on the DSM5 web site.  I can say that clinically non-experts are generally clueless about the DSM-IV features of anxiety especially irritability.  Most psychiatrists have a natural interest in irritability because we tend to see a lot of irritable people.  There has been some isolated work on irritability but it really has not produced much probably because it is another nonspecific symptoms that cuts across multiple categories like the authors apply to cognitive problems and pain.  So I will miss irritability but not much.  Psychiatrists have to deal with it whether we have a category for it or not and hence the need for a diagnostic formulation in addition to a DSM diagnosis (managed care time constraints permitting).

But like most things psychiatric - the worried masses rarely present to psychiatrists for treatment these days.   How likely is it that a busy primary care physician is going to review ANY DSM criteria for GAD?  How likely is it that a person with a substance abuse disorder is going to disclose those details to a primary care physician as a probable cause of their anxiety disorder?  How likely is it that benzodiazepines will be avoided as a first line treatment for any anxiety disorder?  In my experience as an addiction psychiatrist I would place the probability in all three questions to be very low.  It doesn't really matter if you use DSM-IV criteria or DSM5 criteria - the results are the same.

As far as "medicalization" goes, I am sure that somebody (probably on the Huffington Blog) will whip this into another rant about how the DSM5 enables psychiatrists to overdiagnose and overprescribe in our role as stooges for Big Pharma.  But who really has an interest in treating all anxiety like a medical problem?  I have previously posted John Greist's  single handed efforts in promoting psychotherapy and computerized psychotherapy for anxiety disorders even to the point of saying that the results are superior to pharmacotherapy.  In the meantime, what has the managed care cartel been doing?  Although their published guidelines appear to be nonexistent it would be difficult to not see the parallels between approaches that use the PHQ-9 to assess and treat depression and using the parallel instrument GAD-7 in a similar manner.  The problem with both approaches is that they are acontextual and the severity component cannot be adequately assessed.  The goal of managed care approaches to treat depression is clearly to get as many people on medications as possible and call that adequate treatment.  Why would the treatment of GAD be any different?

It should be obvious at this point that I am not too concerned about the DSM5, DSM-IV, or whatever diagnostic system somebody wants to use.  The DSM5 is clearly about rearranging criteria based on recent studies with the sole exception of including valid biological markers for the sleep disorders section.  Like many my speculation is that the ultimate information based approach to psychiatric disorders rests in genomics and refined epigenetic analysis and I look forward to that information being incorporated at some point along the way.

But let's get realistic about why the results of DSM technology are limited.  As it is with DSM-IV and as it will be with DSM5, clinicians are free to interpret and diagnose basically whatever they want.  Even with the vagaries of a DSM diagnosis, I doubt that the majority of primary care treatment hinges on a DSM diagnosis of any sort.  I also doubt that the dominant managed care approach to diagnosis and treatment of GAD depends on a psychiatric diagnosis or research based treatment.  It certainly excludes psychotherapy.  Trying to pin those serious deficiencies as well as overexposure to medication on the DSM and psychiatrists is folly.

George Dawson, MD, DFAPA


1: Gorman JM. Generalized anxiety disorders. Mod Probl Pharmacopsychiatry. 1987; 22: 127-40. PubMed PMID: 3299062.

A Positive Review of DSM5? In the New York Times?

I know it is hard to believe.  Something about psychiatry in the NY Times that is not spun as negatively as possible.  One blogger referred to the phenomenon as "New York Times Psychiatry".  But today there is a positive review of the addiction section of DSM5.  No spin on how the DSM is a carefully crafted plot by psychiatry to diagnose all Americans with a mental illness or collude with Big Pharma to sell more drugs.  Instead an author suggesting that there may be a scientific basis for these decisions.  And as we all know, science is a process and not a set of definitive answers.  Could science actually be the organizing force in the DSM rather than what we typically hear in the media?

Probably.

This is a brief scholarly essay on the history of the concept of addiction and the current neurobiological underpinnings.   It should be no surprise that with the accumulation of knowledge that the concepts of what is an addiction and what is not changes over time.  Just like everything else in the DSM and just like everything else in the field of medicine.  It is not a conspiracy or a plot - it naturally happens as knowledge accumulates and we get more sophisticated.

George Dawson, MD, DFAPA


Howard Markel.  DSM 5 Gets Addiction Right.  NY Times June 5, 2012.

Why Allen Frances has it wrong

Allen Frances has been a public critic of the DSM process and as an expert he frequently gets his opinions out in the media.  Today he has an op-ed piece on the New York Times that is a more general version of a more detailed post on the Health Care blog.  His main contention is the stakeholder argument and that is that there are too many stakeholders both public and professional to allow the American Psychiatric Association to maintain its "monopoly" on psychiatric diagnosis.  I will attempt to deconstruct his argument.

He discusses the earlier DSM versions as revolutionizing the field and the associated neuroscience but then suggests that diagnostic proliferation has become a central problem and the only solution is political arbitration.  What about the issue of diagnostic proliferation?  The number of diagnostic entities per DSM are listed below:

DSM-I, 268 entities

DSM-II, 339 entities 

DSM-III, 322 entities

DSM IIIR, 312 entities

DSM-IV, 374 entities

DSM-V,  370 - 400 entities (depending on final form)

In terms of the total diagnostic entities, I have not seen any stories in the media pointing out that the total number of diagnoses may end being less than DSM-IV.  I have also not seen any discussion of major diagnoses where that is clearly true, such as the elimination of schizophrenia subtypes.   Other issues on diagnostic proliferation that are not discussed are the other required diagnostic system in medicine - the International Classification of Diseases 9th Revision or ICD-9.   The recent modification the ICD-10 has undergone a revision and the total number of diagnoses has increased from 14,000 to 68,000 diagnosis codes.  A fourfold increase.  The number of potential codes for a fractured kneecap has gone from 2 to 480 or more than the total potential codes in DSM5. 

I have also not seen any discussion of the role of psychiatrists in making a psychiatric diagnosis.  Psychiatric diagnosis does not depend on looking up a diagnosis in a catalog of symptoms.  It involves being trained in psychopathology and knowing the patterns of these illnesses.  The patterns of psychotic disorders and the other main diagnostic groupings have basically been unchanged across DSMs.  Psychiatrists make clinical diagnoses based on these major groupings and not the total number of diagnostic entities.

Further evidence that the total number of diagnostic categories is unlikely to have any impact on the number of people diagnosed with mental illness in any given year comes from the distribution of diagnostic codes in an outpatient setting. For 2006-2007, there were approximately 58 million ambulatory care visits for mental disorders. 92% of those visits were for 10 major diagnostic categories that have not changed in recent DSM revisions. It is not likely that new diagnostic categories will significantly impact the remaining 8% or 4.8 million visits per year.

In a study more specific to psychiatry, the number of psychiatric ICD-10 codes used in Danish Psychiatric Central Registry.  The data  represented 1,260,097 diagnoses from 1,041,589 discharges of 653,754 patients from in- and outpatient treatment episodes.  Forty nine of the diagnostic codes accounted for 75% of all the diagnoses (Munk-Jørgensen, et al). 

The "medicalization of normality" is another argument.  The media routinely runs stories about the percentage of the population that is "mentally ill" based on DSM diagnoses.  One of the common stories is the estimate that as many as 50% of the population has a DSM diagnosis over the course of the year.  There is never a critical look at that statistic.  The first dimension is whether any percentage should be too high or too low.  For example, would anyone be surprised to learn that 100% of the population has a medical diagnosis in the previous year?  With a high prevalence of gastroenteritis and respiratory infections - probably not.  The second dimension speaks directly to the issue of threshold for an illness.  One of the key papers in this area shows that although the one year prevalence using DSM criteria may be high, limiting the diagnoses to severe disorders reduces the prevalence to 8%.

The use of high prevalence numbers for mental illness based on DSM diagnoses also ignores the extensive Epidemiological Catchment Area (ECA) work that estimated lifetime prevalence.  Readers are generally not told that the methods used include addictive disorders and neurological disorders that cause cognitive impairment.  Would anyone doubt that 32% of adults would report a psychiatric disorder that included an addiction or cognitive impairment at any point in their lifetime?

Similarly there has been the repeated criticism that psychiatrists were going to start treating grief like clinical depression.  I have never seen that approach anywhere in my career spanning psychopathology seminars, journal articles, and continuing education courses.  Any psychiatrist with a clue knows the difference between grief and depression and at some point they have probably been tested on that difference.  What psychiatrists know that is not public knowledge is that a small number of grieving people actually develop a depression that is indistinguishable from clinical depression and it may have to be treated that way.  Knowing the difference is part of psychiatric expertise and you really cannot write it down as sentences in a manual.  In fact, it is a grave  mistake to equate a manual of diagnostic criteria with the clinical expertise and methods of psychiatry.

Dr. Frances correctly points out that the other common media theory that DSM diagnoses are driven by the pharmaceutical industry is a myth.  He continues on to suggest that the public and other mental health professionals somehow have a stake in the DSM and that organized psychiatry has frozen them out.  He concludes: “Psychiatric diagnosis is too important to be left exclusively in the hands of psychiatrists.”  I don’t understand how the specialty who invented the technology, who is trained and tested on it, and who is focused on a comprehensive view of psychopathology that extends beyond it should somehow give way to political considerations.  As he points out – there are always political considerations – even in science.  I would suggest that there is no such thing as “independent scientific review” of anything that psychiatry does.  There are many ways to address issues of professional bias in terms of including a diagnosis or not.

The arguments against the DSM and psychiatric influence vary across the usual spectrum of there being no such thing as a psychiatric diagnosis to there are too many diagnoses to the fact that psychiatric diagnoses are nonspecific.  There is no practical way to incorporate that spectrum into a diagnostic manual that is designed for psychiatrists to make clinical diagnoses and do research.  The single most important fact that is left out of these debates is that psychiatrists are effective in treating serious mental illness and they are undoubtedly more effective now than they have been in the past.  That is the only reason we need a DSM and that is why it stays squarely in psychiatry.

George Dawson, MD, DFAPA  


Frances A.  Diagnosing the DSM.  New York Times May 11, 2012.

Frances A.  DSM5 begins its belated and necessary retreat.  Health Care Blog May 10, 2012.

Kessler RC, Avenevoli S, Costello J, Green JG, Gruber MJ, McLaughlin KA,

Petukhova M, Sampson NA, Zaslavsky AM, Merikangas KR. Severity of 12-month DSM-IV disorders in the national comorbidity survey replication adolescent supplement

Arch Gen Psychiatry. 2012 Apr;69(4):381-9.

Munk-Jørgensen P, Najarraq Lund M, Bertelsen A. Use of ICD-10 diagnoses in Danish psychiatric hospital-based services in 2001-2007. World Psychiatry. 2010 Oct;9(3):183-4.

Regier D, Kaelber CT.  The Epidemiological Catchment Area Program:  Studying the Prevalence and Incidence of Psychopathology. in  Textbook in Psychiatric Epidemiology eds.  Ming T Tsuang, Mauricio Tohen, and Gwnedolyn EP Zahner.  John Wiley and Sons, 1995. p141.

Schappert SM, Rechtsteiner EA. Ambulatory medical care utilization estimates for 2007. National Center for Health Statistics. Vital Health Stat 13(169). 2011. (see Table 7.)

Radicals and Reformers for Managed Care

I was struck by a post on the Critical Psychiatry blog this AM.  Duncan Double discusses his experience at a meeting of the radical caucus at the APA on Sunday.  His main argument was the need to abolish psychiatric diagnostic systems - specifically the DSM, but he mentions that you can apparently provide psychiatric services without an ICD diagnosis in the UK.  But then he makes this astonishing comment: " The American psychiatric system has become very dependent on DSM for billing purposes, but I'm sure the insurance companies could develop an alternative system unrelated to DSM. "


I am positive that the American insurance industry would like nothing better than to establish their own "alternative system unrelated to the DSM'.  In fact, they are doing it already with a host of measures that they can use to basically deny care or dismantle systems of care.  The managed care industry in the US has selectively discriminated against psychiatric services for the past 20 years to the point that most states have little service availability.  The motivation for managed care is clear - shift hundreds of billions of dollars away from providing care to persons with mental health and chemical dependency problems and into the pockets of the insurance industry.  We are talking about an industry where the CEOs can make an annual salary of millions of dollars and in a famous case the CEO received a $1 billion dollar bonus.


Stated in another way, the "American psychiatric system" is no system at all.  There is hardly any availability of psychotherapy services.  Most people are restricted to a handful or less of 15 minute visits with a psychiatrist every year.  The length of stay in hospitals is appallingly short by UK or European standards and people are asked to leave if they are no longer "suicidal".  It is psychiatrists on the one hand being severely restricted in attempting to provide care and a predatory insurance industry trying to make disproportionately more money off policy holders with mental health problems on the other.   The government is not a passive player in this effort with most state governments abdicating their role in caring for the indigent and the uninsured often by using managed care tactics.  All of this happens independent of any DSM or ICD diagnosis.  At the national level, there is a long list of interests who favor the same tactics in order to maintain leverage over doctors and the clinical care advocated by doctors.


Critical psychiatry would rather "Occupy American Psychiatric Association" rather than "Occupy Wall Street" .    I guess we can add them to the managed care  list.  That is exactly the type of reform that the politicians want.

The Lancet has it about 40% right

The Critical Psychiatry blog listed a brief editorial in the Lancet commenting on the current state of affairs in psychiatry. The commentary describes psychiatry's current "identity crisis" as an international problem and cites recent comments by the American Psychiatric Association and the Royal College of Psychiatrists suggesting that psychiatry is not "scientific" enough, that it does not have a central role in medicine, that the image of psychiatry with other professionals is negative, and that the therapeutic interventions are weak. The conclusory statement is: “But more fundamental still, it is time for the specialty to stop devaluing itself because of its chequered history of mental asylums and pseudo-science, and to realign itself as a key biomedical specialty at the heart of mental health.”

The Lancet has it right in concluding that psychiatry has a long history of self-flagellation that continues right up until present times. The Lancet is also correct in concluding that the image of psychiatry is negative, and that was well-documented in the journal Psychiatric Treatment showing that press coverage for psychiatry is four times as negative as any other specialty. The remarks about the science of psychiatry, the lack of a central role in medicine, and weak therapeutic interventions miss the mark entirely. In fact, I think the only way an editor can lump all of those negatives together is the uncritical acceptance that all of the negatives about psychiatry must be true.

What the critics of psychiatry can never explain away is the fact that psychiatric treatment is effective. I have personally gone to work every day for over 20 years confident that I have been doing far more good than harm. When you are doing the same work for a span of decades rather than the time it takes someone to do a clinical trial and you are personally responsible to your patient and their family you need to realize that you are effective. If I did not think I was effective and doing a reasonable job for people I would have quit a long time ago.  I also work with hundreds of competent psychiatrists in my home state where being competent is the rule not the exception.

My personal sense of effectiveness is built on decades of watching people suffer. That happened before I was a psychiatrist. Many of those people were my own family members and neighbors with severe problems who did not have access to psychiatrists. They were treated by generalists and the treatment did not go well. In many cases it was worse than no treatment at all. When I was growing up, it was also a fairly common practice for counties to sequester people with mental illness at subpar facilities that were designed for containment.  In some cases that meant that people were placed in facilities that were also tuberculosis sanatoriums or “poor farms” for the indigent.  I think that many of us in the mental health field got into it to compensate for the deficiencies of the past.  Much of that “chequered” past has nothing to do with psychiatry at all.

Although the Lancet associates psychiatry with asylums it leaves out the fact that psychiatry invented the paradigm to care for people with severe mental illnesses in the community. That was the direct product of psychiatrists and their collaborators realizing that state-funded institutional care was completely inadequate. Psychiatry moved people out of asylums on a massive scale and helps them stay out.  At this time many of these programs have been in place for over 30 years.  These same programs are actively working on the health problems of the people that they serve.

The scientific basis of psychiatry has exploded in the past two decades.  The criticism of the “lack” of science in the field always astounds me.  The criticism often seems to flow from the lack of understanding of the process of science and how the scientific accomplishments within psychiatry are on par with other fields of science.  It also seems to ignore the fact that many prominent scientists like Kandel, Snyder and others are psychiatrists.

The idea that psychiatrists are ineffective seems to flow from the same biases.  Details about the effectiveness of primary care physicians are usually left out of that argument.  It is well known that 30-50% of complaints presenting to general medical and specialty outpatient clinics have no medical explanation even after extensive investigation. Other studies have shown that primary care physicians deliver error free care in uncomplicated situations 73% of the time and in complex situations 9% of the time.  It is really not possible for psychiatry to be worse than that and yet there are no movements critical of other specialities and those are specialities that generally have far more toxic treatments.

So we are left with an abundance of critics. The critics all have various motivations but one thing is clear and that is at least part of their agenda is not to recognize the fact that psychiatrists are currently effective,  care about their patients, and that their clinical practice really is not removed from the rest of medicine.  In order to recruit more psychiatrists, the best thing to do is expose students to psychiatrists working with patients and to follow those patients while they recover. It might be useful to expose them to the biases against psychiatry and why a lot of the criticism does not match reality.  The fundamental work for many psychiatrists is to stop devaluing themselves, but it also requires recognition that much of that devaluation occurs due to the uncritical internalization of criticism that is far from the reality of clinical practice.

George Dawson, MD, DFAPA