Monday, March 01, 2010

I Might As Well Go Home Now.


Psychiatry's getting blasted this week: we don't know what we're doing, our diagnoses are not valid or reliable, our treatments no better than placebo and we maxed out in the 1960's with imipramine. Yesterday's NYTimes Magazine article on The Upside of Depression (see my post) implies that we're derailing evolution by treating what may be an adaptive condition, and The Wall Street Journal says Psychiatry Needs Therapy ! Edwarder Shorter writes:
Psychiatry seems to have lost its way in a forest of poorly verified diagnoses and ineffectual medications. Patients who seek psychiatric help today for mood disorders stand a good chance of being diagnosed with a disease that doesn't exist and treated with a medication little more effective than a placebo.

What's a shrink to do with this? Perhaps the diagnoses we make are wrong and the meds we use are ineffective, but at the end of the day, the patients seem to get better. Maybe it's my charm (hmmm, there's a thought) or the concurrent psychotherapy, or some other non-specific factor...maybe the cognitive dissonance that you have to believe that anything you're paying a small fortune for has to be working.

So do read Shorter's article and tell us what you think.

15 comments:

moviedoc said...

Here's what I think:

http://behavenetopinion.blogspot.com/2010/02/psychiatric-diagnosis-shorter-version.html

Keep in mind Shorter is not a physician. He has a PhD. In history maybe? That may explain a lot.

Sherri Nichols said...

He's unhappy with the diagnoses of major depression and schizophrenia, "the scientific status of which make insiders uneasy," but thinks that "nerves" was a reasonably accurate diagnosis?

It's a little tiresome hearing that what I suffer from doesn't exist, and that the drugs I take don't work. Funny, two independent psychiatrist, two independent therapist, my family, and friends in two different cities have all observed the same things: I suffer from depression, and when I take drugs, I'm better. I wish it weren't so, but it is.

Anonymous said...

Perhaps I'm just having a bad day after a lousy therapy session combined with drugs that aren't working very well, but I'm inclined to agree with Shorter - more specific, yet broader, criteria do not lead to better diagnoses or treatments. Call it melancholia or nerves or something under the DSM, treat it with benzos or SSRIs or MAOIs or some other class of drug, but at the end of the day, it's still a guessing game - sometimes it works, sometimes it doesn't.

stevebMD said...

Like all op-ed pieces, Shorter's summary is polemical and mildly divisive. Obviously meds aren't entirely "ineffective" and diseases DO exist.

However, what he's pointing out is something I would agree with in my psychiatric practice. The majority of patients I see do not have a clear diagnosis, or have a diagnosis that two psychiatrists might disagree on, or would not even be called "ill" by a layperson or at another time in history (e.g., around DSM-III). And this is supposed to be medicine?

The majority of new diagnoses given by my peers (and by me, I confess) are constructs, labels by which we categorize a collection of maladaptive behaviors. While that might not be so damning in and of itself, the medical-industrial complex and pharmaceutical companies have capitalized on it: If patient A has diagnosis B, then he'll get better with drug C... even though the "diagnosis" is simply a collection of symptoms (B1, B2, B3, etc) and drug C might only prove beneficial for one of them, or for symptoms that exceed some threshold that patient A has not yet met.

I do enjoy helping patients get better, but the poor efficacy of current medications, and the ambiguity of our diagnoses, makes me frustrated and wonder whether (as with Dinah) simply my "being there" for the patient is the most effective part of treatment.

And if that's the case, the last thing you want to do is go home!

Sunny CA said...

I read it, and tend to agree with him in a broad sense anyway. I think the driving force is the drug companies due to the money involved, and they are aided by MD's who hawk drugs for the drug companies using articles written by drug companies, and talks written by drug companies. Then there is all the research paid for by the drug companies and the studies thrown out if they show negative side effects or lack of effectiveness, and the exaggeration of minimal results. I appreciate those of you who use drugs conservatively and who don't slap on diagnoses with the admonition to never go off the drugs or serious consequences will occur.

From Depression To Happiness said...

Patient, my friends, is a virtue. I time will break the depression code, don't worry and don't feel frustrated :)

Anonymous said...

If, as you say, at the end of the day, your patients are getting better, then you're ahead of the curve. Unfortunately, with most psychiatrists that's just not the case. Throughout many years of treatment, I got steadily worse. This whole push to use antipsychotics for anything and everything is a disaster, and there are a lot of people who are very justly angry at having been put onto medications that didn't help them just because their psychiatrist was listening to the door-to-door salesman that had shown up right before their appointment.
From what I've seen, getting better is just not what usually happens. If your patients really do get better, don't you dare give up and go home! Psychiatrists who produce positive results are way too rare already!

Anonymous said...

I don't understand Shorter's comments about "manic depression" vs. unipolar depression. He does know that manic depression IS bipolar disorder and that they are indeed two different illnesses, doesn't he? I have bipolar type I and it is not just major depression with some hypomania thrown in. In my case, I almost always experince the manic side of the mood episodes and the one depression I had 25 years ago (prodrome or onset) could be considered mild. So "major depression" would be a very poor dignosis for me and not simply because the lithium helped. That makes no sense. Shorter obviously knows only a little about psychiatry.

It's odd that he champions the tranquilizers of the '60s. All I can think of is an overly-sedated Marilyn Monroe popping Librium or Milltowns for her "psychoneurosis."

I'd almost go so far as to say that Mr. Shorter is ignorant. At work, I came across a fellow attorney's notes regarding an applicant for SSDI that he agreed to represent. He wrote that, "she was diagnosed with bipolar disorder but says that it's more like a manic depression." I went home, took down my copy of the DSM-III that I used in college, turned to the back pages where the name change to bipolar disorder was discussed, saw that 1980 was the year of the official change, and made a footnote to the client's file that the two terms referred to the same disease. Unlike Shorter, I do research before I write stuff.

Retriever said...

I decided he was an idiot when I read this "Despite an undeserved reputation for addictiveness, the benzos remain today one of the most useful drug classes in the history of psychiatry." Yes, they can be very useful (not least, for temporarily calming some manic patients in denial or people who are terrified and anxious) in the short term, but they are incredibly addictive...

The DSM is getting like one of those dream dictionaries: fun to read and get ideas from, but sometimes absurd when it medicalizes moral failings (sexual addiction is just one example) or normal negative emotional reactions to difficult life circumstances. But it is still useful at times.

To dismiss psychiatry because it is not easy to quantify or predict, because people are made up of body, soul, mind and mystery, is just dumb. LIkewise, just because the meds are as yet inadequate, does not make it a pointless discipline.

I have a tongue in check post up on people's fantasy shrinks that might make you smile instead of worrying what journalists are saying about your profession. http://artemisretriever.blogspot.com/2010/03/fantasy-shrinks-real-shrinks.html

Anonymous said...

Whatever provides HOPE is what helps people get better...

Anonymous said...

The chair of the DSM IV taskforce wrote an interesting article in the LA Times, recently.

"It's not too late to save 'normal'
Psychiatry's latest DSM goes too far in creating new mental disorders."

http://articles.latimes.com/2010/mar/01/opinion/la-oe-frances1-2010mar01

LivePsychiatry said...

There is a lot to be learned about the many existing psychiatric disorders...

tracy said...

Exactly, Dr.Steveb!!! Your being there and my psychiatrist "....being there"... IS "...the most effective part of treatment".

Thank you!!!!

tracy said...
This comment has been removed by the author.
Anonymous said...

I wonder if 'depression' itself is being misdiagnosed - how can we be sure we're not all just feeling the weight of all the horrible, 'insane' things going on around us? Global warming, animal cruelty, corrupt politicians etc etc etc - how are we supposed to NOT feel powerless and hopless when everything around us is going down the toilet? And people in power insist on ignoring it all - how are we supposed to 'fight' for what's right? Maybe the rest of the world is insane and we with 'untreatable' depression are the only ones seeing the world as it really is. It's untreatable because the cause(s) cannot be removed!