What Does the DEA Drug Trafficking Report Really Mean?

 

The DEA just published a significant report on the drug threat in the United States. I read the entire document and will review a few of the high spots here highlighting why it is not too relevant for most parts of the country.  I am on record in several places on this blog making similar comments. My basic argument has not changed significantly and that is that the demand for illegal and often fatal drugs is driven by the culture in the US and I would not expect law enforcement to make much of a difference. The case in point is Prohibition and the ban on alcohol.  Of course it was not a real ban.  Criminals still bootlegged alcohol into the country, religious groups found a way to circumvent the law, and there are always people producing illegal alcohol as a significant percentage of alcohol consumed every year.

These facts are most often distorted into the argument that Prohibition or any War on Drugs is doomed from the outset. That argument is most frequently used to implicitly suggest that any attempt to legally restrict intoxicants will be righteously overcome by people with a natural right to pursue intoxication.  That is extrapolated to practically any scenario short of negligent homicide due to intoxication or drug dealing. But even the drug dealing scenarios are being rapidly modified to allow possession of certain amount of cannabis or in some cases legitimizing drug dealing as a useful occupation. The direct and indirect costs of drug use to both individuals and society are typically ignored by anyone without a medical or public health interest. Intoxication is a cultural right, a right of passage, and every effort of being made to expand the availability of intoxicants to everyone in the US.

The DEA (1) states their role is to expand awareness, preserves lives, and provide intelligence to law enforcement that might be useful for resource allocation and prioritization.   Synthetic opioids and stimulants are described as the biggest threats.  Both can be easily mass-produced by the cartels in Mexico.  Fentanyl alone has accounted for a massive increase in mortality due to its potency and low therapeutic index – accounting for 74,225 deaths in 2022.  China is implicated as the main source of precursor drugs to produce fentanyl.

The report clearly states that two Mexican cartels are responsible for the drug flow into the US and the most significant drug crisis in the history of the US.  Further – the cartels have penetrated most states in the US to varying degrees.  The Internet has facilitated drug sales in the US and made these transactions more difficult to track.  The cartels are also producing methamphetamine leading to an increase in stimulant associated deaths.  There is also a China connection.  Chinese criminal operations supply precursors for the synthesis of opioids and methamphetamine as well as money laundering operations to make the money from illegal drugs sales useable. 

One of the strategies these criminal enterprises are using is adding additional intoxicants to the drug that users are purchasing.  This has the effect enhancing the intoxicating effects but with a much higher risk of overdose and death – especially if the user is naïve to that drug or the seller is ignorant about the potency of the additional intoxicant.  I became aware of this phenomenon about a decade ago when I was being told that users witnessed fentanyl being pressed into alprazolam tablets and sold as alprazolam.  A secondary phenomenon was that many people were not averse to fentanyl but actively sought it out to enhance the period of intoxication.  The DEA report describes the following combinations:  

Fentanyl plus:

Heroin, cocaine, methamphetamine, xylazine, Counterfeit prescription drugs: (oxycodone (M30, Percocet); hydrocodone (Vicodin); or alprazolam (Xanax)

 

The DEA report addresses many of the logistics of the substance use problem and it does raise awareness – especially of the dangers of getting adulterated drugs and the severe side effects including death. It also highlights drug counterfeiting and it gives a great example of an Adderall tablet counterfeited from methamphetamine (see below).  That is especially problematic during a time of Adderall shortages from legitimate suppliers.

 

The unaddressed problem is American culture.  I don’t want to suggest that large groups of sociopaths intent on making money no matter how many people they kill don’t bear some responsibility. I also don’t want to suggest that reducing the availability of these drugs by any means is not a good idea.  But one of the takeaways from reading this report is that law enforcement is clearly not winning and it is a huge burden on them in both the US and Mexico.  Former President of Mexico Vincente Fox characterized the problem well as “America’s insatiable appetite for drugs.”  Right now, it is a multigenerational chronic problem. People can get effective treatment and recover but too many die and too many become chronic users. There needs to be an effective strategy for primary prevention or preventing use in the first place. Suggestions along these lines typically end up caricatured as the 1980s “just say no” public service ads or the "failed war on drugs", but this strategy was clearly effective in reducing cigarette consumption and decreasing the population of smokers. It has had the expected effects of decreasing smoking related mortality in both the general population and in smokers who quit.  The same population-wide benefits would be expected from any public health measure that effectively reduced the use of alcohol, stimulants, opioids, cannabis, or any other intoxicants.  What are the cultural factors that keep this drug epidemic going?  Here are a few:

1:  Cultural acceptance of substance use as a rite of passage:  The stories are endless. Fraternity and sorority hazing involving excessive alcohol use.  High school graduation parties associated with multiple driving while intoxicated deaths. Incarceration from assaults and homicides from barroom fights. Consumption of alcohol and other intoxicants in high school well before the legal age for consumption has been reached. Much of this has to do with immaturity.  The Decade of the Brain did inform us that just on a biological basis human brains do not mature until the mid 20s and in the case of men possibly even later. Immersing an immature brain in intoxicants is generally not a recipe for success and may be a developmental risk for substance use disorders and mental illnesses.

2:  Consumerism and the selling of intoxicants:  This is a widespread phenomenon in the US.  Alcohol commercials typically suggest success, sexual attractiveness, popularity, sophistication, and glamour.  Identification with Hollywood A-listers is a plus and many of them are marketing their own brands to capitalize on that fact. The expensive packaging is often more significant than any difference in taste or quality. The only downsides are a very brief allusion to the Surgeon General’s warning about alcohol use in pregnancy or a disclaimer to “use responsibly.”  Not much about alcohol poisoning, cancer, cirrhosis, pancreatitis, cardiac problems, dementia risk, or substance induced psychiatric disorders. For a long time alcohol was hyped as a heart health beverage.

3:  Your right to intoxicants:  The subculture of users has a mixed agenda in promoting this idea.  There are a few people who believe that their lives are better by using drugs or alcohol, that they are using these substances in a controlled manner and “not hurting anybody.” And therefore, anyone should have the right to use them under these conditions.  On the face of it – few people would argue that point – even though it does assume that self-report about use and its consequences are always accurate.  A subgroup is promoting widespread intoxicant use as a business.  Many in this group see it as a get rich quick scheme. Many see it as a diversity equity inclusion (DEI) issue.  That is – minority groups sustained harm from excessive legal penalties against cannabis and other drug possession and therefore they should be given advantages in setting up businesses that profit from legalization.  Many want to extend cannabis law changes to include all drugs and legalize access to everything. The DEA report stands in contrast to mass legalization because it estimates how much the country would be awash in fentanyl if it was legal. It also ignores why substances were controlled in the first place and what happened when physicians started to prescribe more opioids both as "dope doctors" in the early 20th century maintaining people in addiction and in the late 1990s leading to the beginning of the current opioid epidemic.

4:  Cannabis misinformation:  There has not been much reflection of the medical cannabis period of the early 21^st century.  Cannabis was touted as a miracle drug whose benefit was being neglected due to archaic drug laws and the lack of modern research. Nothing was said about cannabis being around for over 700 years and having no clear cut indications for use or the fact that earlier cannabis compounds fell into disuse with modern therapeutics. That led to a patchwork of state-level medical cannabis laws, making each of those states a Mini-FDA with their own indications for use and in some cases limited forms of cannabis that could be dispensed for those indications.  Just as it became apparent that cannabis really was not much good for medical applications or even pain – the real motivation for the medical cannabis Trojan Horse became apparent.  That was of course recreational use. The Biden administration is currently considering rescheduling cannabis from a Schedule I to a Schedule III substance. That takes it off the experimental/no medical application category but still suggests that it will be prescribed and supervised by a physician.

5:  Widespread promotion of hallucinogens and psychedelics as miracle drugs: Building on the success of promoting cannabis as a medicine – we are now seeing frequent hype about the wonderful effects of psychedelics along with practically no discussion of the side effects. MDMA and LSD are being seen as wonder drugs that successfully treat depression, anxiety, PTSD, and substance use disorders. The cannabis promoters successfully promoted cannabis as a nearly completely benign substance and the hallucinogen/psychedelic promoters have used the same tactic.  I only recently read an account where the following side effects during a clinical trial of an LSD based drug were listed: illusion, nausea, euphoric mood, headache, visual hallucination, mydriasis, altered state of consciousness, anxiety, blood pressure increase, and abnormal thinking (all in significant numbers). In my clinical experience I have treated people with permanent side effects from this drug class after a single dose.

6:  Better living through chemistry:  There is a current wave of euphoria in the popular culture about GLP-1 agonists like Ozempic and Monjauro. It has been accompanied by FDA approved indications but also a very public reexamination of the usual prescriptions of diet and exercise for weight loss. The pendulum seems to have swung to the point that all excessive weight is a disease state that can only be approached with a powerful drug that has potentially powerful side effects.  From a cultural perspective this class of drugs reinforces the American dream that we can tune our bodies like we tune our cars and if we have the right drugs – we can have whatever kind of body or mind that we want. More longstanding evidence of this attitude is evident from anabolic androgenic steroid use and stimulant use for - both for performance enhancement.  All three are grand illusions. Hominid biology has evolved to incredible complexity over the past 2 millions years.  Any group of people may look alike but there are hidden differences in physiology and pharmacological response. One person’s medication is another person’s poison. As a result there are very few miracle drugs and some intoxicants have been around for centuries making it even less likely.

7:  Sobriety as a subculture:  In most societies certain religions and life philosophies are the most likely promoters of sobriety.   Most sobriety in the US is not thought about too much.  There are about 60% of people who never drink. There is a group of people in active recovery who had a problem with intoxicants and were successful in discontinuing them.  There is a small movement right now of young people who are not in recovery promoting sobriety.  The cultural resistance against substance use in the US seems trivial compared with the promotions.

8:  Treatment is secondary prevention: A standard political approach to the drug epidemic these days is to suggest that more availability of treatment centers and providers is a needed approach.  This is correct in so far as treatment for these conditions has always been deficient. Treatment has had a role in terminating localized drug epidemics in both Chicago and Washington DC.  There is a question about how well it will work now that just about every county in the US is awash with opioids and methamphetamine.   A logical approach may be to prevent new users from entering this cycle – in other words decreasing the incidence of the problem. Unfortunately there are fewer resources to address this problem and a lot of pessimism about that approach.  

9: Intoxicant use is a choice: Even though there is obvious evidence out there that a significant percentage of the population develops uncontrolled use of drugs and/or alcohol denial and rationalizations about this continues to persist. It has to in order to maintain the myth that people with substance abuse disorders really have a moral defect rather than a biological propensity.  In other words – repeatedly telling them to stop and blaming them for the problem is all that is required. That approach ignores the real problem that if you are biologically disposed – all it takes is access to substances to keep that process going. The moral approach also allows for a legalization position by simply stating that the people who cannot control their use are irresponsible.  

10:  Deaths of despair: This concept was popularized by Dean and Case (2) to explain increased mortality due to intentional injury and drug overdoses caused by hopelessness due to economic problems and the associated stress. Deaths due to alcohol and drug use were seen because of economic stress rather than a consequence of excessive use for other reasons including the cultural factors that have been specified. The concept minimizes the fact that severe alcohol and drug problems exist in populations that have no economic stress and that most of the people with severe economic stress do not have drug and alcohol problems. It also minimizes the fact that we are still in the midst of a multi-decade drug epidemic and there is no end in sight.  

11:  Legalizing drugs will put the cartels out of business:  This has always been an extremely naïve argument.  Alcohol and tobacco sales are legal and taxed but that does not prevent their illegal sales.  Prescribing opioids, stimulants, and benzodiazepines does not prevent their illegal sales.  The DEA report highlights continued involvement by organized crime in cannabis production and sales - even after it has been legalized. Illegal production has led to violent crime and adverse environmental impact.  These same organizations are currently producing counterfeit name brand pharmaceuticals.  There is no reason to expect that legalizing very high risk drugs will stop criminals from producing or selling them.

12:  No education about who may be at higher risk:  To an addiction psychiatrist seeing people after acute events the risks are obvious.  People who use intoxicants and get extremely euphoric or aggressive to the point that it impairs their judgment are clearly at high risk and should consider not using them at all. Unfortunately that self examination often does not happen until there has been a life changing event.  People with a strong family history of substance related problems are another high risk group.  Some individuals come to the conclusion that intoxicants are too risky for them to use.  I have heard this in many psychiatric evaluations: "My father and his father were alcoholics.  I knew I should probably not drink on that basis."  But this knowledge does not seem to be widely disseminated.  

Where does all of this leave us?  Not in a very good place. The DEA is describing its efforts to intercede in what is a massive effort originating from several countries to import highly dangerous substances into the United States. Although it is never overtly discussed this is clearly a national security problem. The immediate problems of deaths and morbidity from drug addiction seem to depend very little on how successful the DEA is in its efforts. The reason for that is the massive promotion of drugs at the cultural level both in direct advertising and false political philosophy equating drug use with freedom. It parallels the use of the Second Amendment to promote the widespread dissemination of firearms – even though there is no similar amendment for drug use. All the popular myths about drug use need to be actively countered and the advantages of a sober life need to be promoted. Those myths are a more subtle but equally dangerous threat to what the DEA is describing in this report.   

 

George Dawson, MD, DFAPA

 

References:

1:  Drug Enforcement Administration. National Drug Threat Assessment.  US Department of Justice.  May 2024.  57p.

2:  Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci U S A. 2015 Dec 8;112(49):15078-83. doi: 10.1073/pnas.1518393112. Epub 2015 Nov 2. PMID: 26575631; PMCID: PMC4679063

The Retired Consultant Redux – A Conversation With Two Internists

In retirement I run into colleagues who are interested in the process and how it is going. I was greeted with a “How is my favorite retired psychiatrist” yesterday. It originated from a highly qualified subspecialist who was immersed in hospital work when I first met him. We talked briefly about his changing roles over the years going from hospital based acute care practice, to an outpatient specialty practice, to his current role of tertiary consultant seeing the most difficult problems in his field. I told him that was the role I miss the most – seeing the most difficult to diagnose and treat cases and being the one to figure out what to do.

It is not an easy life – especially if you are as neurotic as me.  It involves constant research and revision of approaches. It involves close follow up.  It involves sleepless nights and anxiety.  It involves balancing innovation against not wanting to make a mistake.  Sometimes it involves convincing other people to go along with you when they may be reluctant. It also involves tolerating the suffocating routine of excessive documentation and jumping through unnecessary administrative hoops as well as the occasional overt harassment. But in the end – you end up being a physician that both your patients and colleagues can count on and that’s something.

We discussed the nature of treating these populations. He told me he likened his practice to neurology because of the reputation that the level of esoteric diagnoses are not matched by esoteric treatments and often there is not much that you can do. I never understood this degree of pessimism.  I have been confronted with people who told me their last doctor told them: “Look there is nothing more I can do for you.”  And we were able to make some progress.     

Finally – we discussed the 2 year milestone and how many people leave retirement and have to go back into active practice at that point.  He made the observation that this seems to happen across professions where possible – and it seemed to depend on attitudes to retirement and whether you had anything to do.  He did not think retirement would be a problem.  I estimated he had about another 8-10 years of practice left.  I had my usual thoughts about all of the people I knew who never made it to retirement.  I also thought about retirement from physically taxing work and the problems that involves - not the least of which is adjusting caloric intake to prevent excessive weight gain.  

The second conversation was more technical. It was an opinion about gabapentin.  The patient in question was taking it long term for back pain and had a history of back surgeries. More recently she was on diuretics and other medications for atrial fibrillation and congestive heart failure. She was seeing several specialists and they were dutifully getting all of the correct labs but nobody seemed to notice the gradual increase in creatinine to 1.7 and 2.4.  That correlated clinically with increasing somnolence, ataxia, and falls.  After reading the package insert on gabapentin he called me to discuss a dosage adjustment with renal insufficiency.

I recalled a healthy young man I was treating who became acutely confused and ataxic after he was started on simvastatin by a consultant. In psychiatry, this scenario raises suspicions of intoxicants even in a hospital setting. But given the circumstances I decided to also look for a cause of delirium.  The acute labs showed that he had acute renal failure as an idiosyncratic reaction to the statin and he was transferred to medicine to treat the problem.  The acute renal failure led to the accumulation of gabapentin and the delirium and ataxia.

As we discussed the cases, the internist pointed out the difficulty with today’s fragmented medical care.  All of the medication were ordered and the labs were done – but nobody seemed to be paying any attention to how the patient was doing. It reminded him of a quote from one of his mentors George Magnin, MD who used to say to his Medicine residents: “What are you going to do until the doctor gets here?”

That quote struck me as genius both as a motivating factor and the immediate reality of the situation. When you are confronted with a patient who is having a problem – you need to be able to do something about it. That doesn’t mean that you will always know what to do – and if you don’t you at least need to know how to triage the problem so that the patient gets the correct care.  We try to increase the likelihood that will happen by specialization, subspecialization, and settings to match the illnesses with the specialists, but those matches are far from perfect.

I had this experience to illustrate.  I got a call from an emergency medicine physician who was seeing a patient I was treating for bipolar disorder. I knew him and his family very well from years of treatment. The ED doc wanted me to hospitalize him for acute mania but his wife who was with him said he was not manic and she did not want him admitted to a psychiatric unit.  After a brief description of his symptoms I said: “Put him on the phone so I can talk with him.”  Within 30 seconds I could tell he had a fluent aphasia with paraphasic speech errors.  When the ED doc came back on I told him that this was not mania – but most likely an acute stroke syndrome and he was hospitalized on Neurology where the stroke diagnosis was confirmed.

“What are you going to do until the doctor gets here?” – means that doctor.  The one who can diagnose and treat your problem.  That is the one that matters.  In this era of health apps, checklists, self-diagnosis, electronic health records, telemedicine, and so-called artificial intelligence that is still all that matters.

Being that person is hard to attain and hard to walk away from.

 

George Dawson, MD, DFAPA 

Image credit:  Wikimedia Commons per their CC licensing the details of which are available by clicking on the graphic.

Additional:  The identities of the physicians were anonymized in this post. I doubt that any physician benefits from being associated with me or this blog.

Rick Sings - poetry by Phill Taggart

“Well I woke up this morning and I had myself a beer.” Roadhouse Blues (1970) Jim Morrison Lyrics The Doors Composition

Many years ago, I was asking a patient about his morning routine and he replied with the Roadhouse Blues lyric and started laughing. At the time he was taking medications that I prescribed but also seeing a naturopath who was giving him a complex solution of minerals that was supposed to treat his mental illness. His family was more concerned about him than he was concerned about himself.  Severe mental illness leaves a person focused on irrelevant pieces of information out in the environment for amusement/entertainment/meaning while ignoring the basics – like self-care and not standing out too far in public.  Clinicians refer to some of that as inappropriate social behavior, but it is a complex multi-layered problem. The same process can result in a great deal of difficulty staying focused on the necessary day-to-day routine. In that mix, there are boundary problems that can contaminate the most altruistic impulses and affect personal safety.  Phil Taggart does a great job of painting that picture in his book of poetry Rick Sings.

In a brief introduction we meet his brother Rick.  Rick has a severe mental illness that clearly affects his ability to function. I am writing that after reading the entire book and all the poetic descriptions. We find out that Rick has a lot of problems in living, managing his self-care and medications.  There are times when he is not eating well, where he is in an agitated state, where his hygiene is affected, and where he puts his housing security at risk by taking in women who have lost housing or were the victims of violence. His brother is a force to help keep him on track and check in with him.  Those encounters are the basis for this book.

The first images we get are family chaos – the product of mental illness, alcoholism, aggression and violence, and the death of a young sibling.  Rick’s modern-day world is tied in with that early history. Here are two stanzas from the poem Morning Coffee

 

The rest of this poem has stark images of people who come into your life and leave with you liking or not linking them or yourself along the way.  At some point it is hard to know if the memory is that sad or current sadness clouds the memory.

I recently read an essay on how art can be rhetorical in the persuasive sense. This poetry consists of observations and emotions that the imagery elicits. There is no hint of bias – only the empathy elicited by images and situations.  I had not thought of this before but Taggart’s poetry is the perfect medium to communicate the major problems facing people with severe mental illnesses and anyone trying to help them. You can’t help being pulled in when he advises his brother to stay away from the police for his own protection or when he has to let a security guard know that “he’s with me” to avoid awkward social situations.

There is a stream of consciousness flow to the poetry with associations across the lifetimes of Taggart and his brother. I liked this feature because it is the way a lot of people (including myself) think. Focus on the present and in some downtime – think about an event that happened in 1975. When your brother is in the picture – think about common events. Several of those themes run through this book of poetry and it is masterfully done.   No associated explanations – just a description of an event with a universal emotion.

I liked this book of poetry.  In keeping with my book reviews, I like the idea of conditional recommendations.  In this case – liking poetry will help.  It will even be better if poetry stimulates your mental imagery and emotions. I call the writing style of this poetry free verse like E.E. Cummings.  The phrases are also arranged differently on the page to emphasize different thoughts and actions.  If you like that style, you will like this book even more. Beyond liking poetry, this book will potentially help you understand the problem of severe mental illness and its effects on people and their families. Even though there are efforts out there to decrease stigma and attributing stigma to a lack of understanding of the problem – stigma has always been a problematic concept for me. If more people experienced what Phil Taggart puts into his poems there would be a greater understanding. He is a strong voice in this area.  Read this book if you are interested in a deeper understanding the problem.

 

George Dawson, MD, DFAPA

 

Reference:

Phil Taggart.  Rick Sings.  Santa Barbara, California. Brandenberg Press 2014: 67pp.  https://philtaggartpoet.com/

 

 

What The Economist doesn’t know about Psychiatry

It is always good to take an in depth look at articles in the popular press about psychiatry – because of the clear antipsychiatry bias. An article from the Economist was posted recently that seemed to get a positive reception in some areas.  In my estimation that reception was not warranted.  Interestingly the same principles of analyzing rhetoric can be applied to this article as the last post on this blog about “doing your own research.”  I will use the same concept by concept approach to examine this article that I used for that video.  At the time the article was posted I read it for free online and I hope it is still available so that any reader here can appreciate the full text.  The author was not listed.

1:  “But her local hospital, in Durham, England, was dismissive, suggesting she had anxiety, a mental-health condition, and that she was probably spending too much time watching videos on TikTok. Her mother describes the experience as “belittling”:

The author begins with a story about an autoimmune condition with many neuropsychiatric manifestations Pediatric Autoimmune-Neuropsychiatric Disorders Associated with Streptococcus (PANDAS).  This is a condition that is known within psychiatry for at least 25 years and is covered in major psychiatric textbooks.  The author proceeds to conflate the lack of a definitive diagnosis with deficiencies in psychiatry as if it is totally unknown in the field. It is not and the pathophysiology and neuropsychiatric manifestations are known and taught within the field.  Secondarily if I had to speculate on the medical specialists who are most likely to see people who are told by a physician or family member that “it’s all in your head” – they would be psychiatrists.  We tend to see more of these people than anybody else.  

2: And infections are one small piece of the puzzle. It is increasingly clear that inflammatory disorders and metabolic conditions can also have sizeable effects on mental health, though psychiatrists rarely look for them. All this is symptomatic of large problems in psychiatry.

Psychiatrists have always been more interested in inflammatory and infectious conditions affecting the brain than most other specialists.  Griesinger mentions inflammation as a mechanism affecting brain function in his 1845 text on psychiatry (2). It is highly likely that in any community - psychiatrists are making more of these diagnoses than primary care physicians because they know the manifestations and they need to rule out physical causes of mental illnesses to make a psychiatric diagnosis.  All psychiatrists are trained in making these diagnoses and not mistaking them for a mental illness occurring in a healthy person or a person with chronic illnesses not affecting brain function.  The only large problem here is the lack of knowledge about how psychiatrists are really trained.

Inflammatory disorders were used as treatments in the early 20^th century.  In the pre-antibiotic era, 5-10% of asylum admissions were due to neurosyphilis and the associated psychiatric manifestations. Some of the early treatments were based on inducing fevers.  Austrian psychiatrist Julius Wagner-Jauregg was awarded the Nobel Prize in Medicine in 1927 for successful treatment of neurosyphilis by inoculating patients with malaria (2).  This work was replicated and additional agents were used to induce fevers by other investigators with similar results. In addition to the experimental results, this represented a sea change in the general attitude of treating psychosis in asylums where a previous biological treatment did not exist.  Subsequent innovations occurred when neuromodulation techniques were introduced in 1932 (5) and psychopharmacology in 1952 (6).

The early focus on gross neuropathology and transition to microanatomy led to the discovery of Alzheimer's Disease in 1906 and Binswanger's Disease a form of vascular dementia in 1894.  Both Alzheimer and Binswanger were considered psychiatrists - Alzheimer by his own designation and training and Binswanger was eventually appointed to head an asylum by age 30.  

As far as "rarely looking for them" goes the top 4 medical conditions I diagnosed in newly seen patients were probably Type 2 diabetes mellitus, hypothyroidism, hypertension, and atrial fibrillation. Any psychiatrist practicing in the last 30 years is aware that psychiatric disorders and pharmacological treatment can be associated with metabolic syndrome and the need to monitor for and prevent that condition. 

3:  Chronic conditions are poorly treated – apparently because they are not cured (paraphrased):

This is always an interesting rhetorical sleight-of-hand. In what other specialty is the expectation that chronic conditions will be cured? It does not take a lot of research to show that nobody is curing most diabetics, hypertensives, asthmatics, arthritics, or patients with a multitude of other chronic conditions. In fact most of these patients remain symptomatic even when they are treated. These are all conditions with clear cut laboratory tests and other disease markers.  These are all conditions where there is at least a speculative biological hypothesis of pathophysiology.  And yet – there is no expectation of cure and in fact much more expected mortality in other specialties. Why is psychiatry different?  It is not.

4:  Some people in the profession believe that biological psychiatry will lead to better characterizations of psychiatric problems including pathophysiology, drug treatment, and pharmacological targets/precision psychiatry (paraphrased):

It is obvious that biological psychiatrists have been at it for decades and much longer.  The journal Biological Psychiatry was founded in 1969 but biology has been a focus of psychiatric research dating back to mid-19^th century when attempts were made to observe brain dissection correlates with behavior.  Griesinger (2) documents efforts by both Pinel and Esquirol to document brain abnormalities in severe mental illnesses. In his text he documents brain diseases leading to psychiatric care and associated organ dysfunction at autopsy in patients identified as having severe mental illness.

In the days of asylum care before biological psychiatry, delirious mania had a mortality rate of 75% (7).  That has essentially been reduced to zero with advances in modern biological psychiatry including electroconvulsive therapy and psychopharmacology.  There is probably no better example of advances due to biological psychiatry occurring over decades.

Like all other medical specialties, biological psychiatry is an active area of research with new journals like Molecular Psychiatry (1997) and Translational Psychiatry (2011) that are focused on the latest innovations in biological psychiatry and potential treatment applications.

5:  The DSM or the Bible of Psychiatry does not specify pathophysiology

Any time you see that the DSM is the “Bible of psychiatry” that is a red flag that indicates the author either lacks knowledge about the Bible or the DSM.  Here is a brief primer on the DSM to correct some misconceptions.  That primer emphasizes that the person using it (typically for diagnostic codes used for administrative purposes) is a trained professional and understands its limitations. Chief among those limitations includes ruling out medical causes of psychiatric symptomatology and understanding that it is not a guide for everyman to use for diagnosis and treatment.  Kendler (8) and others have taken it a step further to point out that it is an index of disorders and therefore a starting point – rather than an actual diagnostic guide.  In other words, meeting criteria for a diagnosis is not that same as having the diagnosis.  This is generally true of all codified systems of medical diagnosis.  An example would be the American College of Rheumatology classification criteria.  There is an extensive discussion of these classification criteria compared with diagnostic criteria and why the ACR currently endorses only the former (9).  It is basically the same discussion that Kendler uses in describing the indexing system – that there is sufficient heterogeneity in clinical presentations over time and geographical areas that every case needs to be individually considered. Here is the rationale from the leading text on systemic lupus erythematosus (SLE) (10):  

“The classification criteria do not contain a complete list of all the possible manifestations of lupus.  The manifestations of SLE often develop over a period of time, sometimes years, making the diagnosis more difficult at initial presentation. The diagnosis of lupus is made on clinical grounds, supported by laboratory data and depends highly on the physician’s knowledge and experience. (author’s emphasis)”

Despite the title, the DSM is not a guide to diagnosis or treatment. People who do not “meet criteria” are not automatically excluded from treatment consideration. Separate knowledge about psychopathology and diagnostic formulation is necessary. Speaking to the author’s concern about the lack of specific etiologies – even the skeletal classification and indexing framework of the DSM has chapters on clear medical, toxicological, and neurological causes of mental disorders.

The Economist dates psychiatry’s “Bible” back to 1952.  That would have been the DSM-I.  I encourage anyone who is interested to read the 6 page Forward to that document.  It started initially to standardize nomenclature. Each training program was using their own version of nomenclature as well as the military.  When trained psychiatrists went out to practice in the community – there was no standard nomenclature being used to described similar phenomenon and the requirements of military and civilian nomenclature were different. The secondary goal was to use this nomenclature to collect statistics that could be used to improve the necessary infrastructure and resources to treat these disorders.  All of this can be done without any specific reference to pathophysiology in both psychiatry and the rest of medicine.    

And here is a news flash from the DSM-5,  my estimate is that 69% of all of the diagnoses listed have a clear pathophysiology or medical test equivalent to any other branch of medicine.  Given the classification problems with all medical diagnoses that overall figure probably compares well with any other branch of medicine.   

Whatever your take away from this post, The Economist knows very little about psychiatry and medicine. But that should not be too surprising.  The tone and factual content clearly resemble much of what you see on the Internet and in the press about psychiatry. That does not make it any less wrong.  If you are really interested in what is going on in the field – I would recommend reading the general literature in the field or summaries about it. The popular press – newspapers and magazines – is clearly not up to the task.

6:  Attempts to find causal mechanisms for mental illnesses have failed (paraphrased):

News flash – that is true of every other complex disease as well as the medication used to treat them.  This post illustrates that fact with medication used to treat multiple sclerosis.  The table lists 18 FDA approved drugs – many of which modify the course of the illness but in every case the specific mechanism of action of the drug is unknown.

7:  Genetics has been a clinical “flop” (paraphrased):

It would probably be a good idea to get the opinion of an expert in psychiatric genetics.  The article seems to focus on the issue of polygenic risk analysis (PRA) and those studies generally have low effect sizes due to the number of genes studied.  Any commercial assessment of a genome will result in hundreds of these profiles – most of them for non-psychiatric illnesses. The example given above illustrates polygenic risk scores (PRS) when the small risk factors (both protective and potentially causative) are summed and compared to a standard sample so that 100% is highest percentile risk in the sample and 0% is the lowest. This is only one approach and there are major psychiatric initiatives in this space doing ongoing research. PRA/PRS is accepted science at this point but the widespread clinical utility is not known for practically all polygenic disorders.

Recent examples given by Kendler (11) in his commentary on whether psychiatric disorders are brain diseases points to the importance of genetics in psychiatry.  To this day there are endless debates, typically by people who are not trained to be psychiatrists that psychiatric disorders are somehow independent of brain substrate. In other words, even though it is widely acknowledged that a brain is required for mental life – there is no evidence at the molecular level that an alteration in brain function causes mental illness. Contrary to The Economist, Kendler states: “I use the most robust empirical findings in all of psychiatry—that genetic risk factors impact causally and substantially on liability to all major psychiatric disorders.”  He quotes the recent literature illustrating that risk variants for schizophrenia are located only in brain tissue.  Similar evidence is accumulating for bipolar disorder and major depression. This correlation of strongest known risk factors and brain substrate location is good evidence of specific genetic effects in the brain. Similar work is being done to identify signaling systems, proteins, and physiological processes underlying the DSM classifiers.  Once again, this is similar to the approaches being taken with all complex non-psychiatric diseases. 

8:  Biology is coming, whether psychiatry is ready or not:

When I saw this caption – it seemed like a joke.  Over the 40 years of my career there has been a constant battle based on the false dichotomy of biological psychiatrists and psychotherapy focused psychiatrists. That left out important additional identities including medical psychiatrists, neuropsychiatrists, and community psychiatrists. Practically all the criticism in the press has been that psychiatrists are too biological. I could probably write a book about this – but in this case suffice it to say that The Economist has not done much homework. The smattering of research projects listed in the last several paragraphs about immunology and metabolism ignores that this type of research has been going on for decades and gradually making progress. 

Every psychiatrist is trained in the biology of medicine and psychiatry - just like me.  We are willing to incorporate the latest research innovations and look forward to them. Biology comes as no surprise.

 

George Dawson, MD, DFAPA

 

 

 

References:

1:  “Many mental-health conditions have bodily triggers: Psychiatrists are at long last starting to connect the dots.:  April 24, 2024.  In the print edition this story is under the general heading "Psychiatry’s blind spots".  No author was listed for the online version that I read.

2:  Griesinger W: Die Pathologie und Therapie der Psychischen Krankheiten: für Aerzte und Studirende. (The pathology and therapy of mental illnesses, for doctors and students). Stuttgart, Germany, Verlagvon Adolph Krabbe, 1845  https://www.deutschestextarchiv.de/book/view/griesinger_psychische_1845?p=47

3:  Wagner-Jauregg J. The treatment of general paresis by inoculation of malaria. J Nerv Ment Dis. 1922;55:369–375. [Google Scholar] [Ref list]

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5:  Gazdag G, Ungvari GS. Electroconvulsive therapy: 80 years old and still going strong. World J Psychiatry. 2019 Jan 4;9(1):1-6. doi: 10.5498/wjp.v9.i1.1. PMID: 30631748; PMCID: PMC6323557.

6:  Ban TA. Fifty years chlorpromazine: a historical perspective. Neuropsychiatr Dis Treat. 2007 Aug;3(4):495-500. PMID: 19300578; PMCID: PMC2655089.

7:  Bell, L., 1849. On a form of disease resembling some advanced stage of mania and fever.  Am. J. Insanity 6, 97–127. 

8:  Kendler KS. The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria. Am J Psychiatry. 2016 Aug 1;173(8):771-80. doi: 10.1176/appi.ajp.2016.15121509. Epub 2016 May 3. PMID: 27138588.

9:  Aggarwal R, Ringold S, Khanna D, Neogi T, Johnson SR, Miller A, Brunner HI, Ogawa R, Felson D, Ogdie A, Aletaha D, Feldman BM. Distinctions between diagnostic and classification criteria? Arthritis Care Res (Hoboken). 2015 Jul;67(7):891-7. doi: 10.1002/acr.22583. PMID: 25776731; PMCID: PMC4482786.

10:  Rudinskaya A, Reyes-Thomas J, Lahita R.  The clinical presentation of systemic lupus erythematosus and laboratory diagnosis. In: Lahita RG, Costenbader KH, Bucala R, Mani S, Khamashta MA.  Lahita’s Systemic Lupus Erythematosus. 6^th ed.  London, England:  Elsevier, 2021: 316.

11:  Kendler KS. Are Psychiatric Disorders Brain Diseases?-A New Look at an Old Question. JAMA Psychiatry. 2024 Apr 1;81(4):325-326. doi: 10.1001/jamapsychiatry.2024.0036. PMID: 38416478.