Why A Diagnosis Is Not Stigmatizing and What Is...

 

 

The topic came up last week and it happens on a recurrent basis – diagnoses especially psychiatric diagnoses are not good because they are stigmatizing.  I addressed this fairly comprehensively in a post on this blog 10 years ago, but the persistent antipsychiatry rhetoric out there keeps repeating inaccuracies.  Since then there has been a comprehensive academic definition of stigma that makes things clearer.

Before that academic definition the standard dictionary definition was “a stain or reproach, as on one’s reputation” (1).  There is also a medical definition that is used to designate obvious pathognomonic findings: “visible evidence of disease” (2) and a long list of signs that apply.  There are additional definitions that do not apply to the specific situation of how mental illness is stigmatizing. The American Psychiatric Association has a web page on stigma and the adverse effects.  The web page does a good job of breaking it down to the public, personal, and structural levels.  Specific evidence-based interventions are suggested. They typically involve first-hand experience of persons with mental illnesses.

More sophisticated definitions of stigma are available today.  For the purpose of this post I am using one by Andersen, et al (3) that modifies previous work done by Link and Phelan (4).  According to the authors, stigma is a social process that involves “labelling, negative stereotyping, separation, and power asymmetry.” (p. 852).  They state further that stigma is not present unless all these criteria are met – specifically stigma exists “if and only if” all these criteria are present. 

Labelling in this case is defined as “social selection of human differences”.  The authors give an example of associating alcohol use with homelessness and whether it is a matter of “cognitive efficiency” based on personal experience and probabilities. The labelling that occurs is a result of these socially observed differences. Although these labelled associations can be positive, for the definition of stigma only negative associations are relevant for stigma.  That results in the negative stereotyping.

Separation creates a false barrier between the negatively stereotyped and everyone else.   It suggests that there cannot possibly be any overlap between the characteristics of the stereotyped and everyone else.  Earlier in their paper, the authors use the example of obesity, where it is obvious that there are several almost universal stereotypical qualities and overt discrimination. The same thing is true of ageism, where it is often assumed that elderly people are universally frail, cognitively impaired, and have negative personality traits. It is an us versus them mentality that is currently popular in right wing politics in the US.

Power asymmetry is attributed to the fact that is takes social, economic, and political power to label and negatively stereotype. This is inconsistent with the idea that it happens at an individual level and those individuals together can form a power structure. 

The authors cite an example from Link and Phelan: “They notice that mentally ill patients might label clinicians as e.g. “pill pushers” and link them to the stereotypes of being cold, paternalistic, and arrogant. But the clinicians will not, therefore, be a stigmatized group, because this group of patients simply do not possess the sufficient power to “(…) imbue their cognitions about staff with serious discriminatory consequences.”   

The social and pollical dimensions of the pill pusher characterization ignores history and the prevalence factor.  On a historical basis, Osler suggested that medications being used over a century ago were either worthless or cause more harm than good.  At the turn of the century "dope doctors" ran large practices by keeping people addicted to opiates. On the prevalence side, does the number of people with that characterization equal or exceed the number of people with other common important stigmatizing biases like obesity or ageism?  I doubt it. We do see an excessive amount of rhetoric directed at psychiatrists that is largely inaccurate and contrived and it is not without professional, social, and pollical fallout (5,6).  Very few reasonable people seem willing to discuss that.  The other reality that is rarely discussed is the fact that doctors are not powerful and certainly are not trained to use or exert power.  Today they are ordered around by middle level managers with no training in medicine exerting whatever form of administrative power that they choose.

There are much better examples of stigmatizing processes that are obvious but never discussed in today’s world.  I come back to the entertainment industry at the top of the list.  Apart from movie reviews psychiatrists have been curiously silent about this process that has gone on unabated for decades.  To cite a recent obvious example, I would refer anyone to the most recent episode of The Penguin an HBO series.  In season 1 Episode 4, we see one of the protagonists falsely diagnosed with mental illness to keep her from disclosing several homicides committed by her father.  She is placed in a medieval Arkham asylum where the patients are shackled by the neck and treated inhumanely.  She is eventually baited into committing a very violent homicide against another patient who is trying to befriend her.  The psychiatrists there are portrayed as indifferent at best and of course using electroconvulsive therapy as a punishment (there has not been any progress on that issue since One Flew Over the Cuckoo’s nest in 1975).  There may be people who argue these problems may have existed in 18^th and 19^th century asylums – but the problem is this is set in modern times.  The Penguin is driving a 2013 Maserati Quattroporte VI.  This episode plays the familiar stigma as the mentally ill being excessively violent and psychiatrists as agents of the state conspiring against people, using psychiatric treatments as punishments, and not caring at all about individual patients.

Right wing politics is a second source of stigmatization on almost a daily basis.  Trump and affiliated MAGA politicians routinely suggest that mass shooting and gun violence are attributable to mental illness – even though it clearly correlates with firearm availability and density.  In the case of undocumented immigrants, they are triply stigmatized as criminals, mentally ill, and invaders of the country when there is no evidence for it.

A final source is a carry over from my previous post.  Businesses and healthcare companies actively discriminate against mental illness despite parity legislation.  That should be obvious by the lack of resources that people face when trying to find treatment for a severe mental illness. It is easy to find state-of-the-art care and subspeciality care for any other bodily symptom – but not psychiatric care.  Getting an appointment to see a psychiatrist even in large metropolitan areas is often impossible.  Inpatient bed capacity in the United States is somewhere below the bed capacity of developing countries in the world. The majority of people with mental illnesses are not treated.

That is my update on stigma.  The only thing that has changed in the last 10 years is the current spin that a psychiatric diagnosis or treatment is stigma or stigmatizing and of course it is not at all.  As a reminder, a diagnosis is for the information of the patient and other treating professionals, it is confidential, and it is used by people who are professionally obligated to act in the best interest of the patient and incorporate that person's preferences.       

 

George Dawson, MD, DFAPA

 

1:  Random House.  Webster’s College Dictionary.  Random House, New York, 1996: p. 1314.

2:   Steadman’s Medical Dictionary.  The Williams and Wilkins Company, Baltimore1976: p.1338

3:  Andersen MM, Varga S, Folker AP. On the definition of stigma. J Eval Clin Pract. 2022 Oct;28(5):847-853. doi: 10.1111/jep.13684. Epub 2022 Apr 23. PMID: 35462457; PMCID: PMC9790447.

4:  Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001; 27(1):363‐385.

5:  Perlis RH, Jones DS. High-Impact Medical Journals Reflect Negative Sentiment Toward Psychiatry. NEJM AI. 2023 Dec 11;1(1):AIcs2300066.

6:  Bithell C. Why psychiatry should engage with the media. Advances in psychiatric treatment. 2011 Mar;17(2):82-4.

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Stigma and Addiction

The basic position that I take on this blog is that stigma is an overblown concept.  Certainly no professional should ever be in the position of treating a person with a mental illness or addiction in any way that conforms to stereotypes.  I have been in many situations where that occurred during my training.  In those days a lot of alcoholics were admitted to medicine services because they needed detoxification by people who knew what they were doing .  They also needed close monitoring by nursing staff.  That did not mean that they were treated like all of the other medical patients.  There was usually a sense of hopelessness on the part of the house staff who could see several of these men admitted repeatedly during a 3 month rotation.  Men with hepatic encephalopathy, recurrent pancreatitis, alcoholic hepatitis, and upper GI bleeding from varices.  During one of the rotations, I encountered the term "incorrigible alcoholic" right there in the PGY3 note countersigning my intern note.  I had never seen a term in a medical chart like that before.  I had to look it up to make sure I knew what it meant and sure enough the first definition was bad beyond reform.

These reactions extended far beyond alcohol use problems.  Young addicts using various street and prescriptions drugs would present confused and aggressive.  At times paranoia and aggressive behavior were also prominent problems.  Nursing staff and house staff were frequently injured and in these emotionally charged encounters, the word "dirtball" was frequently uttered.  It was clear that at least some professionals viewed the confusion or aggressive behavior as volitional on the part of the patient and classified them as people who were intentionally trying to injure the staff.  The only way that you can make it in psychiatry is if you realize that aggressive behavior is a component of the illness.  It needs to be contained, but it does not need to be seen as a conscious "choice" of the patient involved.  Neither does their hygiene, cognitive problems, general lack of self care, inability to follow through with discharge instructions or stay away from drugs or alcohol.  That is not "excusing" them because you don't think they have a legitimate illness or can't prove that their behavior  is biologically based.  It is treating them like a human being and recognizing that you might be bringing too much emotion into the equation yourself.  There is nobody who needs a doctor with a cool head more than an addict or an alcoholic.

Those experiences led me to pay close attention to an opinion piece in JAMA about stigma and addiction.  One of the authors was from the White House Office of National Dug Control Policy.  The other was from Harvard T.H. Chan School of Public Health.  I looked even closer when it became apparent that their arguments were focused on the stigma arguments that were used for mental illness.  The authors use mental illness and the early days of the HIV epidemic as examples of how the language used to describe these patients implied moral deficiencies and led to discrimination.  They go on to cite studies of how differences in words can affect how treatment decision made by professionals can be similarly biased depending  on how loaded the stigmatizing term is.  They describe how the fear of stigma keeps people out of treatment.  Finally they outline the government's approach to changing the language about addiction and how that will help.  The White House Office of National Drug Control Policy is releasing Changing the Language of Addiction for guidance on these issues.  Common examples include changing "substance abuser" or person with a drug "habit" to a "person with a substance use disorder."  Near the end of the essay they acknowledge language changes are not enough.

Their initiative will not have any impact for the same the same reason that the anti-stigma campaigns for mental illness don't have any impact and here is why:


1.  The real bias occurs at the level of the insurance industry -  Coverage for addictive disorders varies widely and the only unifying theme seems to be rationing of treatment resources.  That rationing has been going on for 30 years and has led to inadequate treatment capacity.  The best time to provide treatment is right at the point that the affected person needs help.  Setting them up for an appointment 2 - 4 weeks later does not make any sense and can be dangerous if they are using dangerous levels of addictive compounds.  It makes absolutely no sense at all to deny care to a person who is using dangerous levels of addictive drugs simply because they have not yet tried outpatient treatment.

2.  Clinicians don't resist evidence based treatment  - there is nobody around to deliver it -  It is well known that psychiatric and addiction services are understaffed and have been for decades and the situation will probably get worse.  The number of addiction psychiatrists and addictionologists is even lower on population based metrics.  Policy makers seem to have the idea that primary care physicians will start actively treating addiction because treatment is currently described as being contained in a medication.  A recent study showed the underutilization of buprenorphine by these physicians.  They expressed in that same survey that they wished that they had someone who they could refer their patient to.  It is very difficult to go from prescribing opioids for a pain diagnosis to diagnosing and treating addiction in the  same setting.  It is also very difficult to provide treatment without adequate cross coverage.  There need to be adequate numbers of clinicians in any primary care clinic who are interested and competent to treat addictions.  In the case of buprenorphine maintenance. they need to be licensed to prescribe it.  Even then they need referrals sources to physicians who specialize in treating addictions and have some access to more resources.

3.  Community factors are prominent -  Insurance companies still discriminate against anyone with a substance use disorder.  I had a recent conversation with a person who needed some form of treatment. but was concerned about what would happen once the medical records got out to a long term insurance carrier.  Previous experience suggests that company takes 5 years to reconsider any application from a person with an alcohol or drug use disorder.  He  declined any form of treatment that would become part of the medical record that could be accessed by the insurance carrier.

4.  The Mental Health Parity and Addiction Equity Act of 2008 is a bust - time to stop pretending that it means much -    This is the highly acclaimed parity act started by Senators Paul Wellstone and Pete Domenici.  Discrimination and unfair treatment are widespread and contrary to what was expected there has been no boom in treatment for addictions.  Addiction and mental illnesses are still subjected to the same rationing policies and lack of infrastructure as they were before this act.

5.  It all starts and ends with the government -  This essay has that familiar ring to it:  "We are from the government and we are here to help you."  Let's not forget who started the system of discrimination against people with mental illness and addiction in the first place - the government at all levels.  The government invented the managed care industry as its surrogate in the first place.  If they were really interested in solving the problem - they could use the same top down approach that they used to create it in the first place.  They could provide medical detoxification in hospitals and coordinate the development of those guidelines.  They could provide access to Addiction Psychiatrists and  Addiction medicine practitioners.  They could open up bed capacity for residential and sober house care.  They could fund clinics where medication assisted treatments for opioid use and alcohol use are conducted.  They could fund addiction centers of excellence.  They could fund research on treatment for court ordered offenders and whether it is effective.  This is all evidence-based care, but the article suggests that primary care physicians who are currently overworked by government mismanagement are going to suddenly see hundreds or thousands of new patients with addictions.  Suggesting that this is a language based problem put the blames directly on clinicians.  It is clear to me that there are no psychiatrists blaming people for mental illness or addiction.  Who are these people and how extensive is the problem?  The idea that everyone needs to be reformed or reeducated is a familiar tactic used by politicians and policy makers.  It was the rationale for managed care rationing in the first place.

6.  Prevention is a priority - The prevention of drug use is the surest way to prevent increasing number of people from experiencing morbidity and mortality due to drug and alcohol use.  Prevention of drug use at this point in time is historically difficult as the country swings into another era of permissive attitudes toward drug use.  Individuals not abusing their first opioids will have a much greater impact on the prevalence of addiction than all of treatments after an addiction has started.

All of these factors are what clinicians like me see as everyday interference with helping patients who have a substance use disorder.  Semantics may help some.  Training and recruiting physicians who know that it is only luck that separates them from people with addictions and mental illnesses will help more.  Ending insurance company dominance over clinicians will help the most.

In the end - words don't keep people with addictions from lifesaving treatment.

The government and health insurance companies do.             

  



George Dawson, MD, DFAPA


Reference:   

1: Botticelli MP, Koh HK. Changing the Language of Addiction. JAMA. 2016 Oct 4;316(13):1361-1362. doi: 10.1001/jama.2016.11874. PubMed PMID: 27701667. (free full text).

Stigma Rhetoric

I have always been skeptical of the value of the stigma concept in advocating for the rights of people with mental illness.  It seems to imply that a person with a mental illness is obvious to everyone and nothing could be further from the truth.  The usual advocacy groups certainly jumped on it and it was later picked up by professional organizations.  My basic problem with the entire argument is that nobody should know that you have a mental health problem anymore than people should know that I have asthma.  It is a problem of medical confidentiality rather than a problem with stigma.  Anyone who thinks that is not the case just needs to consider what prospective employers think about hiring people with back pain, asthma, or any pre-existing condition that potentially impacts their group health insurance coverage.  Any confidential medical condition is potentially stigmatizing and it certainly is nobody else's business.  If people want to disclose that information that is certainly up to them and as I have posted here in many cases it can be a useful public service.  And I do realize that health insurance companies force you to disclose pre-existing conditions using various methods but that does not mean that your employer should know.

The other problem is that there has been broad and systematic discrimination against people with mental illness and addictions at all levels of government and the business community.  These are the people who have access to protected medical information and make decisions about health care based on it.  That discrimination occurs with full knowledge of a diagnosis and often a recommended treatment plan.  Multiple posts here document that problem and yet nobody comes right out and attacks that issue.  If anything social activism with a stigma focus seems to cast a wide discrimination net rather than focusing on the few people and agencies that can make a critical difference.  It  suggests that the general public is the problem and that educating the general public will solve the problem.

This morning a friend of mine posted this link on Facebook and asked me for my impressions of the argument that neuroscientific explanations potentially lead to more stigma.  That is probably what has me fired up.  If you are trained in science, you realize that there are  internal politics but in general that is not the same as the politics of the barbarians at the gate.  The problem is that all types of science from climate science to neuroscience gets co-opted and interpreted by people who don't know what they are talking about.  I think that is illustrated by one of the summary points in this article:

"As this revolution gathers force, we need to be mindful that biogenetic explanations for mental health problems can have troubling implications for the people who suffer them."

I think it should be obvious that there will be "troubling implications" for anyone who is ignorant on either end of a "biogenetic explanation".  Further, it is really impossible to separate allegedly biogenetic explanations from decades of conditioning by governments, businesses, and the media.  Troubling implications start when you realize that your employer's health plan does not have coverage for mental illnesses or addictions and you have a family member that needs that insurance.


What are the take home points about stigma in all of this?

1.  Businesses that discriminate against mental illness by rationing current services and destroying any infrastructure necessary to treat mental health are stigmatizing.  The message is clearly that they can't be bothered to treat these problems seriously by offering much of anything beyond a crisis stay in a hospital and a 10-20 minute "med check" by a "provider or prescriber" in an outpatient clinic every 3 - 6 months.   No research proven modalities to treat mental illness and a severe push to send people with addictions and serious mental illnesses to county detox, jail, or the street.

But even the businesses not involved can get into the act.  Practically every local market has a business some who is offering "crazy deals."  If you doubt it, Google "crazy deals" or the equivalent "insane deals" and see what you come up with.  Don't forget to look at some of the images.

2.  Governments that ration and destroy the mental health infrastructure and collude with rationing by businesses are stigmatizing.  Examples include empowering insurance companies to decide how they can deconstruct the billing and services of mental health providers and clinics to their advantage (the arbitrary insurance company audit),  empowering business to discount services, legitimizing utilization review and prior authorization (tools for arbitrary denials), and allowing for proprietary business guidelines to dictate who can receive treatment and who can not.  What could be more stigmatizing than to have a business suggest that a person is not "dangerous" enough to be treated and use that as a basis for medical decision making?  Why aren't there any rules about admitting only the "dangerous" myocardial infarctions and sending everybody else home?

3.  Court systems that treat the mentally ill like they are criminals are stigmatizing.  This includes practically all court systems because as any forensic psychiatrist will tell you, despite the myths about the so-called insanity defense - it is practically impossible for anyone to get off with that defense.  There are significant numbers of people who are incarcerated for minor nonviolent crimes that were the product of mental illness.  Ask yourself if it is more stigmatizing to have a confidential diagnosis of a mental illness or be listed in the paper as being incarcerated or having been convicted of a crime?

4.   The press has a very poor track record in the area of stigma.  It is well known that the press covers psychiatry more than other medical specialties and has a consistently negative view about the specialty.  How would you feel if you had an illness that resulted in you being seen by a physician whose specialty is consistently portrayed negatively in the media.   For the past two years the press has produced nonstop political arguments about a diagnostic manual that is practically little more than a guidebook for billing codes with many of the esoteric codes only of interest to researchers.  One of the main arguments in those articles was that the diagnostic manual led to arbitrary diagnosis and treatment for the benefit of the pharmaceutical industry.  For anyone with a serious mental illness, could there be a more stigmatizing argument?

5.  The entertainment industry never hesitates to make a buck off of mental illness.  The film Halloween is classic example of equating mental illness with an evil so unstoppable that the psychiatrist involved has to pack a .44 magnum.  That same message has been carried forward in recent television shows.  Some of the efforts in this area are so bad that it takes an incredible bias to justify the product as entertainment.

These are all much better examples than suggesting that science somehow stigmatizes people.  The associated problem is the misunderstanding of science.  We all understand that the media needs to sell stories and the truth about science is that it is a process and not the ultimate truth.  Every story about new fads based on an experimental finding that will never be replicated in the absence of a discussion of scientific method is corrosive to the public's confidence in science.  In this case using "chemical imbalance" as a scientific theory is about as ill informed as anyone could be about the neurobiology of mental illness or normal brain functioning.  At that level this story is more about press induced stigma than anything that neuroscience or neurobiology has to say.

The lesson for today is that the brain is not a sack full of neurotransmitters that is balanced or unbalanced.  If you believe that, you can either stay ignorant about the problem and talk about "chemical imbalance" as though it means something, educate yourself about neuroscience (there are many free sites on the Internet) or you can join any number of psychiatry bashing web sites that claim that psychiatrists believe there is a chemical imbalance.  Your first neuroscience assignment is to read about Eric Kandel and why he got the Nobel Prize.

And where does conflict of interest enter into the stigma equation?  In other words who benefits from mental health stigma as an operative social concept?  Advocacy organizations certainly do.  In many cases is it their raison d'être.  Interestingly concern over stigma has prevented some advocacy organizations from dealing effectively with the issue of people with mental illness who are violent.  They considered violence and aggression to be stigmatizing rather than a fact of some mental illnesses.  Professional organizations like the American Psychiatric Association benefit in that it enhances their credibility with the advocacy organizations but any counterattacks on the forces that ration and deny mental health services have been weak and ineffectual.  Those rationing entities including politicians, government agencies, pharmacy benefit managers and managed care companies benefit tremendously.  After all they have added hundreds of billions of dollars to their bottom lines by basically denying or rationing treatment and in many cases denying that there is any problem at all.

Stigma rhetoric makes it seem like this is a problem inherent in our society with no better solution than an enlightened public.  We will not be able to solve it until enough people are enlightened while the rationing schemes continue.

At that level you could say that stigma is a concept that can be spun for everyone, but let's agree that science has nothing to do with it.

George Dawson, MD, DFAPA



Supplementary 1:  I was asked by a reader to summarize the above post.  Here it is:

There are societal wide biases (business, government, legal, entertainment, etc) that stigmatize the mentally ill.  Some aspects of that process involve the distortion of science (e.g. "chemical imbalance theory").

Now what happens if I decide to run an experiment that asks people about how happy they would be if they had a biologically determined mental illness in that culture? Of course they would react strongly because:

a)  They are from a culture that stigmatizes people with significant mental illness.  They know how the various players would react if they found out that a person has a significant mental illness. Mental illness by itself does not produce a stigma. People are stigmatized by other people with biases and clear agendas.

b)  They really don't know what the scientific implications are because they have been hearing about false theories or reading overt propaganda or they don't know enough about the process or implications of science.

"Doctors don't label"

In a rare statement of clarity amid the usual sensational spin this comment jumped out at me:

"Doctors don't label...Doctors diagnose, take care of, and treat.  That's not to say that something cannot be stigmatizing, but 'labeling' kind of gets right into the antipsychiatry component of it."  William T. Carpenter, MD  - Clinical Psychiatry News September 2012; p 3.

Dr. Carpenter is right and every psychiatrist knows it.  Psychiatrists don't label.  Psychiatrists diagnose.  Psychiatrists are very aware of the limitations of diagnosis given the the sociocultural and medical  contexts.  The psychiatric orientation is to be helpful to patients and the diagnosis is the focus of that treatment.  Furthermore, all psychiatric diagnosis and treatment is supposed to be confidential and there is no group of physicians who has tried to hold the line more against government and insurance companies eroding patient-physician confidentiality than psychiatrists. 

A significant part of this article about the content of a letter from the Society for Humanistic Psychology (Division 32 of the American Psychological Association).  Read the letter and draw your own conclusions.  The points of contention listed in the letter have been exposed in several other media contexts.  As I read through the letter there are several problems:

"This document was composed in recognition of, and with sensitivity to, the longstanding and congenial relationship between American psychologists and our psychiatrist colleagues."

I don't think that this is an accurate statement.  When I started out in psychiatry and was in my third year of residency the American Psychological Association decided to get more aggressive politically and their target was basically American psychiatry.   I won't rehash all of that ugliness but simply point out that things were far from congenial and in many areas remain problematic.   Much of those political efforts were based on the idea that organized psychiatry had an inordinate amount of control  over the treatment of mental illness.  Any observer - biased or unbiased should recognize that psychiatrists and physicians in general have been marginalized and the American Psychiatric Association is politically ineffective and weak.  Of course any other group of mental health providers is in the same boat. 

"Given lack of consensus as to the “primary” causes of mental distress, this proposed change may result in the labeling of sociopolitical deviance as mental disorder."

This is a comment on the new DSM5 definition of a mental illness, specifically that the new definition does not explicitly say that deviant behavior and conflicts with society are not mental disorders.  The current version states that these conflicts need to be the result of dysfunction within the individual.  It is hard for me to see a situation where this is relevant to the practice of psychiatry.  Is there really a case where I am going to diagnose a person in this situation with a mental disorder?  Definitely not and the reason is that I have been confronted with the situation many times before and pointed out that the conflict was not the product of a mental illness.  The authors here have focused primarily  on a lower threshold for diagnosis and how they are not confident about the clinical decision making skills of practitioners - but do not comment on the threshold part of the definition.  

"Increasing the number of people who qualify for a diagnosis may lead to excessive medicalization and stigmatization of transitive, even normative distress."

The risk of "medicalization" needs to be considered for a moment.  What is "medicalization"?  The implication of this letter at a practical level is that it involves an excessive use of medications.  Suspending the poor quality of many of those studies for a moment, what is the real driver of medication use in today's practice environment?  The minority of people taking any kind of psychiatric medication see psychiatrists.  The managed care industry and the government are clearly the driving force.  Current "evidence based" approaches are linked directly to medication use.  A checklist diagnosis and rating scale approach has been used to rapidly treat patients with antidepressants in primary care settings.  That approach alone has easily outpaced any DSM5 modifications.  Direct to consumer drug advertising compounds the issue of getting as many people on medications as possible.  You don't even have to read the DSM5 to see that medicalization has little to do with medical doctors.  In fact, managed care companies would clearly like to replace as many doctors as possible with "prescribers" who can fill prescriptions according to these protocols.  The pharmaceutical and managed care industries are far more interested in distilling psychiatric treatment down to a pill or a capsule than psychiatrists are.

The associated idea that psychiatrists may be the initiators of this medicalization or at least collude with it ignores psychiatric innovation that does not involve the prescription of medications.  On this blog alone, I have posted excellent examples of work done by Greist and Gunderson on innovative and highly successful non medication approaches to significant problems.  Dr. Greist's ideas have been presented to a wide audience that includes pharmaceutical companies.  His ideas about how to make effective psychotherapy widely available have been successfully applied in other countries.  Ignoring psychiatric innovation outside  of psychopharmacology is a curious phenomena, but it definitely makes it easier to see psychiatrists as the "medicalizers".  I am sure that both Greist and Gunderson would not see medications as the primary treatment for anxiety disorders or borderline personality disorder.

Once again, the focus on problems in the DSM5 leading to medicalization and stigmatization is clearly overemphasized.  There is no group of people more aware of the limitations of the current diagnostic system than psychiatrists.  There is no group of people better equipped to compensate for these deficiencies.  There is no group of people more aware of the stigma of mental illness and addiction.  Psychiatrists have a unique perspective in observing first hand how health care systems institutionalize stigma and use it to reduce the resources dedicated to treat these problems.  There should be no doubt that the DSM5 is being produced in what is considered the best interest of the American Psychiatric Association.  There should also be no doubt that the critiques of the process have their own interests and their opinions should be evaluated in that context.

George Dawson, MD, DFAPA