the controversy continues
Written & Illustrated by Andrew Neff
8-12 minute read
History has a troubled relationship with the mentally ill.
Start exhibiting some behavioral irregularities in the 1500’s,
and maybe you’ll be burned alive for being a witch (Schoenman, 1977).
Alternatively, instead of being assigned a caseworker,
you could be sent off to be exploited in a factory farm,
because who’s gonna stop you? (Wright, 1997)
we’re not perfect now,
maybe we’re not even very good now,
and perhaps one of the biggest issues we have
is the neglect and abandonment of people with mental illness (Morris, 1977).
Then again, if you weren’t burned, incarcerated, or exploited for your labor,
maybe the best thing you had to look forward to was being abandoned by your family.
Let’s stick with living today.
So, who do we have to thank?
How about the good people that recognized that mental illness was in fact an illness,
a medical disease,
just like heart disease or cancer or influenza?
How about psychiatry, aren’t they the reason we are where we are?
“The weakness is its lack of validity.” (Insel, 2013)
from Thomas Insel, ex-director of the National Institute of Mental Health.
Wait, we don’t actually know that psychiatric diseases have biological realities?
“Only 50% of social workers would use DSM if not required” (Frazer, 2009)
Many therapists don’t think they benefit from using the psychiatric diagnostic manual, the DSM?
“Critics have argued that removal of the bereavement exclusion will “medicalize” ordinary grief
and encourage over-prescription of antidepressants” (Pies, 2014)
My spouse died three weeks ago, I’m still devastated, and the medical community considers me diseased?
Psychiatry is not perfect,
when the DSM5, the newest edition of the diagnostic manual, was released in 2017,
It was met with an torrent of psychiatric skepticism and anger in the popular media and scientific literature,
which was met by an equally adamant defense of the societal value of psychiatry.
and people should probably be understood as both a victim of
and a lifetime of bad choices.
To reject psychiatry is not to reject suffering,
it’s not to lack sympathy for people with mental illness,
and it’s not to blame people with psychiatric illness for bringing it on themselves.
But the diagnoses are wrong, I mean, at least they’re not quite right.
They’re placeholders until science advances to the point where we really understand the neurobiology.
Even the people who write the diagnostic manual will admit this much,
but we still need psychiatry for now, because, well, we need something, right?
On the other hand,
millions of people receive treatment from psychiatrists,
and lots of those people owe a lot to their treatment.
The brain is an incredibly complicated thing,
is psychiatry really as flawed and useless as some people think,
or is psychiatry the best we've got
in the struggle against the profound mystery of human suffering?
long before that, there was this
Brainbows aside, there are a lot of things people don’t like about psychiatry,
But most importantly,
Shouldn’t we care about whether or not the “diseases” are actually real?
If psychiatry is claiming to be a branch of medicine,
is it medicine?
Let's take an example of something that seems very real
Like this thing
This is premised on a big IF, which is,
IF clinicians are actually referring to the same thing.
If they aren’t,
valuable perspectives might be lost as they’re swallowed up into the mainstream interpretation.
The DSM is more than medicine,
it advances a political and cultural agenda,
in a good way.
One of the original goals of creating diagnoses was
to facilitate the collection of public health statistics,
because knowing the number of people who suffer
from a disease can help determine national priorities.
But the DSM occupies a political role broader
than just as a reference for data collection.
which according to Empedocles were the unchanging elements of the universe,
that combined to form the things of the world through the process of love,
and disassemble back to their elemental forms through strife (Campbell).
Apparently, this way of thinking had an impact on ancient medicine (Kee-Aaek, 2013),
but it didn’t exactly give ancient Greece
a space program or antibiotics or unexplainably resilient french fries.
It seems to go without saying that without the categorization of atoms on the basis of proton number,
and the recognition of periodicity in atomic behavior,
science wouldn’t be a fraction of what it is today.
But the same question emerges, is the periodic table true?
Is Hydrogen real?
Turns out absolute truth is a kind of complicated question.
So, can’t we just say for now that,
whether or not you think the elements are real things,
our way of thinking about the elements has stimulated the advancement of medicine and technology,
and is an enormous achievement for humanity
because it made the world a more predictable place?
Back to psychiatry
The “Diagnostic and Statistical Manual of Mental Disorders”,
the bane of some people’s, and the reason for others, existence.
Start with this,
why does the American Psychiatric Association (APA),
the organization responsible for the DSM, think their jobs are useful?
The DSM provides a common language for
clinicians and researchers across disciplines.
If clinicians are describing the same thing using different terms,
a common language will facilitate the efficiency of communication.
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If mental health weren’t “health”,
there’s a chance a “psychological services” insurance market wouldn’t develop,
and there wouldn’t be enough of an appetite for a government program.
So, if you’re the type that thinks society should help provide for mental health services,
then the existence of a credible scientific body
advocating for the medical reality of “mental health” is probably a good thing.
The DSM is a useful guide for clinical practice.
Although the manual itself doesn’t provide treatment recommendations,
it does serve as a common reference that researchers can use,
and clinicians can then refer to.
So if a patient comes into a clinician's office
and presents a certain set of symptoms,
that clinician can look up research on how people with these symptoms
generally respond to particular treatments.
and then they can give their patient an SSRI or an antipsychotic,
and if that doesn’t work, another SSRI or another antipsychotic,
and if that doesn’t work, another SSRI or another antipsychotic...
The validity of DSM diagnoses have not been established.
Psychiatric diagnoses are based on subjective patient evaluations,
rather than biological markers.
In other areas of medicine,
signs and symptoms are clues about disease,
the basis for hypothesis about the true nature of the ailment,
which is then confirmed through biological tests.
Influenza is “valid” because we’ve seen the virus,
we know the genome,
and now, you’ve seen it too.
To be fair,
influenza and other infectious diseases are a particular success of modern medicine.
There are probably instances in which we can’t confirm the validity of a thing,
but nonetheless we can make some accurate predictions, right?
Psychiatric diagnosis are not useful
Yes, SSRIs work better than placebo in alleviating the symptoms of depression (Cipriani, 2018),
and so does cognitive behavioral therapy (Butler, 2006),
and antipsychotics effectively reduce symptoms of schizophrenia (Stroup, 2009).
In light of this,
to say that diagnoses don’t indicate appropriate treatments sounds like an crazy statement,
but not everyone thinks so (Timimi, 2014).
what if the diagnostic categories didn’t exist?
Would we not have discovered that SSRI’s improve mood?
Or that antipsychotics tamp down delusional thinking?
Isn’t it possible that researchers would have recognized the key symptoms
and that would have been enough?
none of the treatments are perfect,
most or all of them aren’t even that great.
On the physicist Richard Feynman’s blackboard at the time of his death was the quote:
“What I cannot create, I do not understand”.
Applied to psychiatry, you might say that
if you can’t effectively treat people with mental illness,
you don’t understand it.
looking at what scientists are researching as an indication of the state of our knowledge,
You would see several studies attempting to discover “subtypes” of psychiatric diseases
that might be more responsive to particular treatments (Ozomaro, 2013).
Why would we need “subtypes” if the diagnosis itself was predictive enough?
The most cynical interpretation of events
in an attempt to retain credibility as a medical profession,
created superficially objective diagnoses that were reliable between clinicians (Spitzer, 2001).
These objective and reliable definitions became easier to do research on,
and since science has historically been based on promoting positive findings (Easterbrook, 1991),
while neglecting negative ones (Rosenthal, 1979),
structural and cultural incentives in science
reaffirmed the existence of the current disease framework.
There also wasn’t a ton of objections in the psychiatric literature,
because most of the real scientists that cared about improving mental health
did things like discover neuroplasticity (Kandel, 2001)
and invent optogenetics (Boyden, 2005),
while anyone who knew anything about human existence
retreated to the humanities.
In the meantime,
people built their professional lives around the existence of DSM categories,
both clinicians and researchers.
to give up on the DSM is to discredit decades of research and clinical practice,
and force them to grapple with world-view challenging perspectives,
people tend not to like doing.
And while people have always disregarded the American Psychiatric Association’s work in the past (Kawa, 2012),
and people have never stopped complaining,
in a time of Trumpian anti-establishment anger,
are political forces beginning to gain enough power to change things (Insel, 2010).
PS no offense meant to Dr Insel.
So, what went wrong?
Was psychiatry built off bad intentions?
Are we tragically living in an age where career climbing bureaucrats
worked their way into positions of authority
and changed the way we conceive of mental illness,
neglecting scientific realities
while they promoted the advancement of their own reputation obsessed agendas?
is the brain an impossibly complex system,
one that hundreds of thousands of people
have been working centuries to understand,
yet are still coming up short.
So no matter how good intentioned,
and science-based psychiatry wanted to be,
there’s just a lack of science,
and psychiatry’s doing the best it can.
The former sounds better doesn’t it?
Whichever explanation is more accurate,
we still have to grapple with the scientific question of
what, if anything, about the old system,
prevented us from finding more effective treatments.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub, 2013.
Barton, Russell. "Abandoning the mentally ill." Australian & New Zealand Journal of Psychiatry9.4 (1975): 215-219.
Butler, Andrew C., et al. "The empirical status of cognitive-behavioral therapy: a review of meta-analyses." Clinical psychology review 26.1 (2006): 17-31.
Campbell. Empedocles (c. 492—432 B.C.E.) Internet Encyclopedia of Philosophy.
Cipriani, Andrea, et al. "Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis." The Lancet (2018).
Frazer, Paul, et al. "How clinical social workers are using the DSM-IV: A national study." Social Work in Mental Health 7.4 (2009): 325-339.
Insel, T. "Post by former NIMH director Thomas Insel: Transforming diagnosis." Accessed November 18 (2013): 2016.
Kawa, Shadia, and James Giordano. "A brief historicity of the Diagnostic and Statistical Manual of Mental Disorders: issues and implications for the future of psychiatric canon and practice." (2012): 2.
Kee-Baek, R. H. E. E. "Empedocles' influence on hippocratic medicine: the problem of hypothesis and human nature." Korean Journal of Medical History 22.3 (2013).
Morris, Robert. "Integration of therapeutic and community services: Cure plus care for the mentally disabled." International Journal of Mental Health 6.4 (1977): 9-26.
Ozomaro, Uzoezi, Claes Wahlestedt, and Charles B. Nemeroff. "Personalized medicine in psychiatry: problems and promises." BMC medicine 11.1 (2013): 132.
Pies, Ronald. "The bereavement exclusion and DSM-5: an update and commentary." Innovations in clinical neuroscience 11.7-8 (2014): 19.
Schoeneman, Thomas J. "The role of mental illness in the European witch hunts of the sixteenth and seventeenth centuries: an assessment." Journal of the History of the Behavioral Sciences13.4 (1977): 337-351.
Stroup, T. Scott, et al. "Results of phase 3 of the CATIE schizophrenia trial." Schizophrenia research 107.1 (2009): 1-12.
Timimi, Sami. "No more psychiatric labels: Why formal psychiatric diagnostic systems should be abolished." International Journal of Clinical and Health Psychology 14.3 (2014): 208-215.
Wright, David. "Getting out of the asylum: understanding the confinement of the insane in the nineteenth century." Social history of medicine10.1 (1997): 137-155.
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