Sunday, August 18, 2019

Comments by Vivek Datta, MD, MPH

Showing 71 of 71 comments.

  • you seem to have missed “but we hope to follow people up for longer in the future”. it’s pretty standard for initially funding of a study to be for a limited period of time. Typically additional funding would have to be secured through another grant application at a later date. There are a number of reasons for this. One is that it would obviously cost a lot more to do a long-term study and thus an application is more likely to be sucessful if the initial request is for a shorter period. The second is that this study will be contingent on being able to recruit enough participants and retain them over 2 years, which is challenging enough given the population we are talking about. Only after successful recruitment and retention over 2 years is known would you be able to do a meaningful long-term follow up. And sadly, 2 years is actually considered a long time in medicine because of the challenges and disincentives to conducting longer term studies.

  • I am not quite sure how you arrived at this conclusion. Of course there is a physiological basis to subjective experience, but it is neither necessary, nor most of the time relevant, to understand this level in order to intervene. Since we understand the physical basis of fear better than depression let me use this is an example. We respond to stimuli picked up in the prefrontal cortex, sensory cortex and hippocampus and that is interpreted by the amygdala, the emotional center of the brain. The amygdala has projections to the hypothalamus which stimulates release of hormones from the pituitary that send a flood of hormones releasing from the adrenal glands to activate us, as well as activating the locus caeruleus increasing heart rate and blood pressure, and the periaqueductal grey area which activates are flight, flight, freeze response etc. However we do not need to understand or think about any of this to help some overcome a phobia for example. And drugs like benzodiazepines which reduce the subjective experience of anxiety and fear do not target the fear circuits specifically, but have a general dampening effect diffusely on the brain by potentiating the major inhibitory neurotransmitter in the brain (GABA). In a similar way, whether one uses antidepressants or not is not contingent on the physical basis of “depression”. These drugs act in non-specific ways and had been used for many years before there was any claim about “chemical imbalances” or any real understanding of the emotional brain at all.

    In fact, the first antidepressant iproniazid was an antitubercular drug that had a number of psychiatric side-effects including being a mild euphoriant, that led to its use as a “psychic energizer” which is what “antidepressant drugs” were called before the 1960s when the idea that they might have some specific action on depression took hold. Even at that time, American psychiatrists could not be convinced to prescribe these drugs by marketing claiming they reversed some physical processes. Instead, these drugs were marketed as a way to gift a “lift” to patients and make them better able to engage in psychotherapy or life changes. In my view it is not necessary to think about the physiological basis of depression in order to help people and is often harmful.

    As an aside, most people prescribed pain killers or who experience pain (i.e. most of us) don’t have any disease to speak of. Headaches, lower back pain, and various other musculoskeletal pains are most often not related to any underlying disease process at all. Even 40% of abdominal pain or chest pain presenting to an emergency department has no pathological process found to explain it. So again, we approach pain as a subjective experience “pain is what the patient says it is” rather than from a physical perspective.

    thanks

    v

  • thanks for your comment though I am not sure how I fall short on alternative therapies given this is not discussed or the focus of the above. Gabapentin btw is widely prescribed for anxiety, alcohol withdrawal and so on. It is no longer used for “mood stabilization” as it doesn’t work. Diagnosis in medicine is typically based on history and examination, laboratory and imaging are used to support diagnoses and there are many conditions where the diagnosis is made clinically – for example migraines, Parkinson’s disease, essential tremor, even epilepsy – no investigations are required to make the diagnosis though they may be used to support or exclude other diagnoses. It would, in my view be odd to use laboratory or imaging markers to confirm that someone is “depressed” given this is a subjective experience, in the same way we don’t use biomarkers to tell whether someone is in pain.

    As a neuropsychiatrist, I treat patients with problems like traumatic brain injury, Alzheimer’s, fronto-temporal degeneration, Lewy Body dementia, or emotional and behavioral changes due to neurological diseases (such as multiple sclerosis, Parkinson’s disease, limbic encephalitis) and frequently use laboratory investigations (for example paraneoplastic and autoimmune panels, Alzheimer’s markers, 14-3-3 protein, heavy metals, hormones etc), neurophysiological tests (e.g. EEGs) and imaging (MRI, MRA, FDG-PET) to support diagnoses or identify the cause of problems.

    thanks

    v

  • this seizure risk you’re describing is specific to tramadol and not a feature of opioids in concerts with other drugs you mention in general. Tramadol is a fairly weak opioid agonist and is a “dirty drug” blocking multiple different receptors which leads to it having a seizure risk. The risk of overdose when combined with other sedating drugs such as benzodiazepines and neuroleptics is seen across the class of opiates however.

  • thanks for your comments but they do appear to be a digression from the article above and seems to make assumptions about my beliefs which I am not sure where you get this from. I am sure you will agree, as is the focus of this article, that feeling good with narcotics does not mean one has a dysregulation in endogenous endorphins as has been claimed. The notion of “chemical imbalances” in depression or other states is an article of blind faith. I believe it is damaging to tell people they have a chemical imbalance or other neurochemical defect when this has not been shown to be the case. However as a psychiatrist, I do see people, who are suffering and desperate for relief. Sometimes I do use drugs, including MAOIs. I am not anti-drug, but I am opposed to pseudoscience and deceiving people by telling them that they have some flaw in their neurochemistry when this is no more based in science than the idea that depression and mania are caused by imbalances in black bile and yellow bile.

    I agree with you that it is important to consider the risks and balances and consider whether there might be circumstances where people are experience such acute suffering that using opiates may be appropriate as we do already use for pain. However, the study I have discussed, was adding buprenorphine to people after 1 or 2 antidepressant trials, not as a last resort, and not for people with the psychic pain that was driving them to become seriously suicidal. Interesting, a different study has looked at very low dose buprenorphine for people who are suicidal and suggested its possible use as an acute intervention for those who are risk of taking there lives due to mental anguish. I am not necessarily opposed to this idea, but the idea that this somehow means the problem is simply an abberation of the endogenous opioid system is disempowering, reductionistic, and false.

  • Well screening is problematic in general because it leads to false positives, and can generate unnecessary intervention, misdiagnosis, and cause anxiety and actual harm. Some cancer screening programs such as breast cancer and prostate cancer have been shown to do more harm than good. If you can’t provide care to people, or interpret the results of a positive screen for depression, that is in my view, unethical. That is also the position of the World Health Organization. I do not screen for depression in my practice, but I’m not a primary care doc, but a specialist, so if someone is coming to see me it is because they already have a neuropsychiatric problem like memory loss etc. And I am able to provide a comprehensive assessment of problems unlike the average PCP office because I see patients for 2-3hrs at a time, not 10 minutes.

  • I would disagree with this. Screening in itself is inherently fraught once you begin screening “everyone” as you are more likely to have false positives and false negatives which has its own inherent risks. Also screening is not necessary as benign or helpful as you may think. For example, as I discussed in a previous post mammography screening for breast cancer led 1.3 million women over 30 years to be overdiagnosed with breast cancer – often leading to unnecessary mastectomy, whereas the PSA screening for prostate cancer leads to overdiagnosis of prostate cancer in 50% of cases and you had to unnecessarily treat 48 men to save one life. This leads to complications like impotence, incontinence and radiation proctitis. The perfect screening tool would identify 100% of cases of the problem at hand, and would have no false positives. But no such screening exists. This is why screening should be targeted to those most at risk of a particular outcome regardless of what you are screening for.

  • thank you for your comments. I think we mostly agree but for the sake of simplicity and parsimony I have avoided going into these important though thornier issues in this post. As for the “depressive illness” – this is mainly a semantic disagreement. I do use the term illness to describe morbid mental states not to imply disease or a medical problem, but to underscore the subjective experience of being unwell. Clearly larger social, political, and economic factors can make people feel unwell- this does not of course mean the solutions is medical, and I don’t think it necessarily pathologizes those feelings as individual ones, but rather emphasizes the larger toxic influences that may affect how we feel.

  • hi sandy

    the problem is just that procedures are more highly valued than relationships it is that procedures fraudently are rated at higher RVUs for time than they should be. So a standard screening colonoscopy which takes all of 10 minutes is billed on the assumption it takes 75 minutes! The problem for psychiatry is we are essentially paid on how much time we actually spend with the patient (not to mention that psychotherapy is valued as less than E&M). So we are talking about here is that you get $115.88 for an hour or so of network meetings – this would be like being able to do 6 of these in an hour and getting paid the same which would be $695.28.

    No one is going to argue that procedures are costlier for all sorts of reasons. But what people don’t realize is how the value of a medical visit or procedure is determined. Relative Value Units (RVUs) are the units of cost each is determined (as you know) and broken down into work, practice expense and professional liability. Obviously the practice expense and professional liability is much greater for a screening colonoscopy than psychotherapy or a 99213 15 minute visit but the work RVU is significantly higher too. The RVUs for medical visits and procedures is set by a group of the AMA and this group is made largely out of subspecialists which is why dermatologists, cardiologists, Gastroenterologists etc make such vast sums of money. It is not just because they do procedures (which would be hard to argue with except that clearly the cost of these procedures is grossly overrated) but they get paid on the assumption said procedures takes 6-7 times as long as they do and the higher the volume you do the more you can earn. In psychiatry you can’t really do that. So not only are primary care specialties undervalued, specialists are vastly overpaid in what is tantamount to fraud on the part of the AMA.

    Congress has tried and failed to claw back setting physician remuneration from the AMA. The fact is patients are being screwed and it is a lot dirtier that the actual mechanics of procedures costing more, but not adjusting the work RVU to take into account that a colonoscopy no longer takes 75 minutes and hasnt for many many years.

    I would of course argue that getting into this discussion of what is valued misses the point. Which is that fee for service just doesn’t work. It costs too much, incentivizes unnecessary visits, investigations and care and leads to many people being vastly overpaid. And ultimately everyone ends up paying more with little evidence this is good for our health.

    v

  • Psychoanalysts would not necessarily regard splitting as pathological, in fact we probably engage in splitting at some time or other. Although pervasive splitting behaviors are associatedwith borderline personality organization, I did not make that implication – if that were my intention, I would have spelt it out! I used the term because it seems the best description for the critiques of psychiatry which deride it all whilst idealizing medicine when all the problems with psychiatry can be traced to it being part of medicine.

    v

  • you make some interesting assumptions which is not really correct. I actually do not have any power to detain anyone involuntarily (nor do any psychiatrists where I am) and I have no more power than any other physician to compel drugs involuntarily. Psychiatry still continues to exist in those US states where this is the case. It is also not correct that psychiatric power would allow surgeons to operate on people involuntarily, in the cases where psychiatry is involved it is to clarify that no such powers exist and that whether the law allows it (which varies), it never allows it under any mental health law.

    I would also add that most of those hundreds of diagnoses in the DSM are not used by most psychiatrists. They simply don’t see or diagnose patients with most of the diagnoses in the DSM. I myself, do not use the DSM unless there is some specific reason (and I can’t even think of a reason to do so).

    v

  • you seem to have missed my point about conflating disease and illness. most people with illness (‘mental’ or otherwise) do not have disease. many people with disease are not ill. I have no qualms gently confronting people who see themselves as sick or as victim where this is unwarranted. but people are often made unwell by their circumstances and I think it is important therapeutically to recognize that, while at the same clearly locating the source of illness or distress within the context that is generated it rather than medicalizing it.

    psychiatry is a broad field and many psychiatrists do see people with problems that they have no greater expertise in than anyone else or some other kind of mental health professional. but I think it is a step too far to argue that problems like delirium, dementia, traumatic brain injury, drug-induced altered states (like steroid induced psychosis etc) are not within the province of medicine or that psychiatrists don’t have a role in managing. especially when my colleagues in medicine and neurology often want nothing to do with anyone with any kind of emotional , reasoning or behavioral difficulties regardless of whether it is due to some clearly identifiable medical condition (such as cerebral lupus), trauma, or something else.

    v

  • thank you for your response. I do not wish to absolve psychiatry of responsibility to get its own house in order, mainly to contexualize the problems within medicine as a whole as I believe these issues cannot be resolved unless we look at the whole system, rather than a narrow part of it.

    One problem is people seem to have a pretty skewed view of psychiatry. while the use of coercion is one of the most troubling aspects of the field and should not be minimized, the fact remains once they leave training the vast majority of psychiatrists are not involved in civil commitment or forcibly drugging their patients, and the overwhelming majority of mental health encounters do not involve involuntary detention or “treatment”. Similarly, while you may have not experienced coercion in other aspects of medical care, surgeons routinely operate of people without informed consent, and though it is exceedingly rare for someone to be operated on against their will, this is mainly because you are not going to drag someone kicking and screaming to the OR – I routinely get calls for surgeons who want to operate on patients who are refusing surgery, and in medical wards confused agitated patients are routinely drugged with haldol and/or placed in restraints. to claim this is not the case is to miss the point.

    I also think it is to miss the point to think that “doctor-work” has a basis in biology (which I will address in my next blog) as most medical consultations are the result of social or behavioral factors, and there is of course a biological basis to everything. the question is not whether there is a basis in biology, but whether this is the appropriate level to conceptualize and tackle the problem. And some psychiatrists, such as myself deal with problems that inarguably have a basis in “biology” such as neuropsychiatric complications of HIV/AIDS, delirium, dementia, traumatic brain syndrome, autoimmune disease and so on. This is a small part of of the field, but it a part of psychiatry nonetheless.

    v

  • The Dutch are the ones who have looked at this. NEMESIS (The Netherlands Mental Health Survey and Incidence Studies) was a population based study that suggested psychotic symptoms in LBG individuals was twice that found in heterosexuals. They suggested most of this was mediated by childhood trauma, bullying and experience of discrimination in the main. The problem with these sorts of surveys is they use lay interviewers to try and tease out psychotic experiences which vastly overinflates the number of cases identified as psychotic. So they are not looking a psychosis (i.e. people who might seek help or find themselves in the mental health system as a result of these experiences) but people who are endorsing unusual experiences or who didn’t understand the question. If you ask people “do you hear voices?” A lot of people say “yes” because they don’t understand what you’re asking. To my knowledge no one has actually looked at differences in the incidences of cases diagnosed with psychotic disorders between LGB and heterosexual individuals.

    In my experience clinically (50% of my patients are MSM) I have not seen twice the rate of “psychosis”, not that couldn’t be explained by meth or other substance use. Difficulties with attachment, trusting other, re-experiencing trauma, anxiety, self-loathing, phobic behavior, maladaptive behaviors used to regulate powerful emotions are however much more common.

    v

  • Pedophilia is not a sexual orientation anymore than klismaphilia (enema fetish) is. Pedophiles typically engage in sexual activity and have sexual attraction to adults. I really am not quite sure what you are getting at. Children do not have the ability to consent to sex, and this is why sexual activity with children is legislated against and quite rightly so. Pedophilia is also not a mental disorder and does not meet even the DSM requirements for being so despite being included.

    I do think there is a difference between those individuals who have sexual phantasies through no choice of their own involving in children and those who willfully act on these phantasies. I sympathize with the former, but certainly not with the latter who are quite rightly criminalized.

    v

  • I don’t think psychiatry is intended to divide and conquer though it has certainly been used in this way, especially in the US. This coincides with the professionalization of medicine in general, and the rise of psychiatry in particular in the early 20th century in the era of late capitalism where governments saw the potential for psychiatry and psychoanalysis to oppress and repress and displace the causes of misery onto the individual rather than the structure of society itself. In contrast to the US in some countries such as France and Italy psychiatric thinking in the 20th century was often more subversive and many within the profession had the goals of liberation rather than oppression.

    v

  • I am sorry to hear you have not had a positive experience from psychotherapy. I am not sure if that is because you want psychotherapy to be something that it is not (it is not friendship for example) or because you have had bad luck. It really depends on the kind of therapy and the therapist what kind of frame their is. In more psychodynamic or analytic therapy, there will be little in the way of self-disclosure, and no gifts are typically accepted. However I do accept gifts from patients in other therapeutic settings, especially where the cultural background of the patient is such that this is how they pay their doctor and/or show gratitude. I also self-disclose all the time in order the facilitate the therapeutic relationship but there has to be a balance and there have to be boundaries. Depending on the kind of therapy, the boundaries may be different.

    Befriending by non-professional volunteers may be more the kind of thing that you are thinking of as helpful. There is good evidence that befriending is a useful intervention for women suffering from chronic depression and in fact the evidence is better than for non-directive counseling interventions!

    In 1621, Robert Burton in The Anatomy of Melancholy noted:

    “It is the best thing in the world…to get a trusted friend, to whom we may freely and sincerely pour out our secrets; nothing so delighteth and pleaseth the mind, as when we have a prepared bosom to which our secrets may descend, of whose conscience we assured as our own, whose speech may ease our succourless estate, counsel relief, mirth expel our mourning, and whose very sight may be acceptable unto us.”

    v

  • it seems those days are a distant memory. resident physicians are not students, they are employees of the institutions they work at and spend most of their time in patient care. in many ways they are are lot less powerful than students in that their positions are more precarious, they have a lot more to lose, and they quickly find it is in their interests to put up or shut up. Most keep their opinions to themselves. I have often been told that I am foolish for contributing to this site by peers no less as they worry about the possible negative repercussions for me. As a result residents and faculty alike often privately confess they share my sentiments but do not feel able to express them openly.

    v

  • thank you for your comment. you raise an important point of how large organizations have corrupted the research and educational agendas of institutions. i have been awarded a number of fellowships over the years, and they have not always had anything to do with psychiatry or medicine. the money has come from philanthropy typically. I have not been awarded any fellowships where the funding has come from industry.

    v

  • absolutely. i always try and work with families and help them best support their loved ones as it’s families who provide the most support and best chance of recovery. this is sadly not always possible but thankfully it is quite uncommon for as toxic family systems as described above to be present. i don’t think it is helpful to blame parents for their children’s mental illness, nor do I think it is helpful to locate mental illness completely within the brain or genome as this can be very disempowering for individuals, lead the therapeutic hopelessness, abdication of responsibility, and cultivate a sense of self as somehow “broken” or “damaged” which is then internalized. my point is both of these different approaches are problematic but one is a reaction to the other.

    i also agree that there are many causes of mental distress far beyond abuse, and my own interests are in the wider social sphere. Often people over-emphasize the role of abuse and early trauma in mental illness precisely because it has often been ignored or overlooked. Again, neither approach is helpful and it is a shame much of the literature on this topic is not based on good data but poorly substantiated assertion.

    autism is a different beast altogether, and in syndromic cases is clearly related to identifiable genetic syndromes.

    v

  • I think that the role of early experiences never diminished much in relevance for things like depression, anxiety, personality disorder and addiction. But when talking of extreme mental states we call psychosis or schizophrenia, in the US there seems to a complete lack of interest or denial amongst psychiatrists of how things like childhood trauma might play role. I think this goes back to a wish not to “blame” families, which is a legitimate aim that went too far. In Europe there has been more research into these factors in recent years, though much of the research is quite poor. Helen Fisher in the UK has done some of the best quality research in this. Personally, I think there is increasing evidence that the structure of some societies themselves may be “schizophrenogenic” for certain people but most psychiatrists are completely unaware of the burgeoning evidence that social factors seem to very important in the development of psychosis.

    v

  • hi don – to clarify i didn’t mean things like CBT, DBT or permutations of that (MBCT) but those psychotherapies which had NOT been systematically studied or have evidence supporting their efficacy, but engage in claimsmaking regarding their effectiveness in relieving mental distress.

    I am very familiar with cognitive behavior therapy and technically, all psychiatrists in training are expected to become competent in this modality (along with psychodynamic and supportive psychotherapy). In practice, many training programs pay lip service to these requirements, however there is a strong emphasis on CBT and DBT here. In general, psychiatrists tend to be more familiar with psychodynamically-oriented therapies and there are many places where, although psychiatrists receive required CBT training, this is often denigrated in the hidden curriculum. I will also mention that there is definitely more of an emphasis on psychodynamic theory and therapy than cognitive theory and therapy during psychiatric training for historical reasons.

    sorry for any confusion, and hope that explains my position. I often using a cognitive-behavioral approach in treating patients.

    v

  • thank you, maria, for your comments. you make an important albeit not directly related point about considering a broad differential diagnosis of causes of altered mental states, including oft overlooked exposures to environmental toxins. I do my best to do a thorough neurological examination and assessment of the cognitive state in my evaluations that would point towards a toxic-metabolic encephalopathy or secondary cause of the person’s mental state, and where indicated various laboratory and radiological investigations. Unfortunately today, many psychiatrists have very little postgraduate medical and neurological training, and are only expected to know when another medical condition may be contributing to a patient’s mental state rather than to look for the cause. This is in my view a tragedy, as the value of a good psychiatrist, is the medical training and the ability to be able to recognize the wide range of conditions (endocrine, metabolic, nutritional, neoplastic, autoimmune, systemic etc) that can cause neuropsychiatric disturbances and present as “depression”, “mania”, “psychosis”, “confusion” and so on. It begs the question of what use is a psychiatrist if she cannot use this supposed medical expertise.

    Unfortunately, this situation is compounded as there is no real mental health parity in the US. As a result, unlike in almost any other hospital service, psychiatry is unable to bill for blood tests, brains scans, lumbar punctures etc, in the inpatient setting. The result is there is a financial disincentive to NOT look for other causes contributing to the mental state. In fact, management often breathes down our necks if we DO investigate and treat medical conditions that are either comorbid or contributory! Until this changes, I do not see the culture shifting.

    v

  • hi pat. i think most doctors today know that inderal (propranolol) can cause depression, which occassionally can be profound. reserpine is another drugs that in the past was often used for hypertension and caused people to become suicidal. i am assuming your experience was many years ago as Inderal is no longer used in the treatment of heart disease in the US today (or if it is, I have not seen or heard of it still used like this.)

    v

  • that is unfortunate. there are many great interns and residents out there. unfortunate there are also many who, having spent 4 years at medical school seem to no longer be able to talk to their patients as people and form meaningful connections. being thrust into the role of physician and psychiatrist means the intern often feel she has to ‘do’ something, and master the knowledge base in order to be of value. the knowledge base that seems most practical is psychopharm.

    v

  • you have to remember, whatever people think of psychiatry, the doctors that enter the field more often than not do so out of a genuine desire to help people. where and why things go awry I discuss elsewhere, but we mostly tend to start out idealistic. most of us are aware that the vast majority of what constitutes the practice of psychiatry in the US is quite frankly an embarrassment, and are spurred on by a wish to do better. there are all sorts of constraints that unfortunately means that does not happen very often. it does not help that medical training mostly consists of memorizing and regurgitating vast quantities of knowledge that actively seeks to discourage critical thinking and separates us from the person as an individual.

    v

  • well i am referring to a number of different patients who i have had in similar situations, and the aim where it is clear that there is no benefit and only harm for being on these complex cocktails is to stop everything. unfortunately, as i am not doing outpatient work, i have no control over what happens when these individuals when they leave the hospital other than speaking with their providers and coming up with a plan to do some. more often that you would expect the outpatient doc had wanted to get them off various drugs but did not know when to start, or did not ‘want to rock the boat’.

    v

  • hmmm this is a problem. psychiatrists tend to see people when they are not doing well having stopped their medication. people who do well off them tend not to see psychiatrists. we know from the records of kraepelin and other psychiatrists in the pre-pharmacology era, that many people were well for long periods of time, even whole lifetimes, but today these people will be told ‘it is the medication’ which it may not be! if you are representative of others, this could be skewering things further. perhaps there will be a time when you can tell your psychiatrist that it has in fact been years since you have taken any medication at all!

    v

  • who said it wasn’t?! this is a more complicated question that first appears. it is possible for someone not to believe diagnosis is relevant but the label may apply and be submitted for billing purposes. it is also the case often the person receiving the diagnosis stands to benefit from that diagnosis, such they want a diagnosis and are thus not going to complain if it is suspect. a further issue is the moral authority of the physician is almost absolute such the diagnosis is what i say it is even if it isn’t!

    v

  • thank you for your comments! i think we need to distinguish between psychiatrists in clinical practice, to whom the DSM matters little and psychiatry as an organization to whom the DSM matters a lot. Since DSM-III each revision has been a veritable cash cow for the American Psychiatric Association which fills its coffers not only with the profits of the DSM but the associated paraphernalia which include case books, study guides, tapes, videos, training courses. DSM-III was supposed to help American Psychiatry reclaim respectability and also to reassert psychiatry’s moral authority over mental life in an era when other professions were competing to minster to the soul. but only psychiatrists were doctors, and only psychiatrists could make diagnoses. The landscape has changed but the sentiment is the same. note i have not placed a value on whether it is good or bad that most psychiatrists don’t use the DSM. That doesn’t mean it isn’t learned or examined just that it is ultimately forgotten. The other point is the DSM was never meant to be the final word, but beyond psychiatry in the popular imagination that it is exactly what it has become.

    v

  • thank you for your kind words. it is a conclusion i only came to when writing about this topic. much has been written about the sociopolitical nature of the diagnosis of PTSD and what this diagnosis offered, but little has discussed the wider implications for the rest of psychiatry of this diagnosis which so uniquely marries symptoms of psychological distress to trauma.

    as for what constitutes real ‘science’ – psychiatric research is scientific, rather than pseudoscientific as some have claimed. the question is not how ‘sciencey’ an approach is or not, but rather whether it is useful to have a wholly scientific approach to the problem of human suffering.
    vivek

  • thank you for your comments. the exportation of the western concept of PTSD was beyond the scope of my article though one i touch upon elsewhere. our responses to trauma and the rituals we use to treat them are certainly constrained by culture, and other cultures have much better ways of dealing with trauma, not least because the response is a collective and not an individual one.

  • hi stephen,

    When I am on the inpatient psychiatry services I spend 8-10 hours a week doing intensive psychotherapy with select patients. The system is not geared for this and I feel that people (the non-psychiatrists) feel upset or threatened that I should spend my time like this. I feel like I am expected to provide a medical opinion and pharmacological management and nothing else. I also require my students to gain some experience in supportive psychotherapy and they also find this difficult because of the systemic barriers in place. It is a sad state of affairs.

    vivek

  • There are certainly problems with selection into medical school, especially in the US where the system is designed to privilege those in higher socioeconomic classes and whose own parents are physicians, and exclude minorities. There is a big push to change entry requirements into medical school and soon ethics and social/behavioral sciences will be required in addition to the usual fare. However, the process of becoming a doctor is one in which the former self disappears. We use metonyms (“the appendix”) and even locations (“room 8”) to forget about the person and we use humor to forget that gravity of what we do.

    I am no sure how long one can last in clinical medicine without losing a bit of empathy.

    Yes, palliative care is different a wonderful model of care. Unfortunately the social, geographic, cultural and psychological barriers that exist limit the availability of end of life care.

  • Thank you for your thoughtful post. The Transmission of Affect sounds like an interesting book. Certainly our attempts of classification take the positivisic view that emotions and mental states have their own existence in external reality, as tangible, measurable ‘things’. But as anyone who has experienced extreme emotional states realizes, “what is the reality of any feeling?” as Virgina Woolf noted.

    Vivek

  • Well the categorical vs dimensional debate is an interesting one, but there are major problems with a wholly dimensional approach to classification as well. The dynamic approach to psychopathology that preceded our current approach was more fluid and the problem there was that because there was no clear boundary between mental health and illness, everyone could be viewed as mentally ill. The corrolary of discrete categories (at its extreme) was the unitary concept of madness, popularized by Karl Menninger which saw different aberrant mental states as varying only in degree and not in type.

    Some people are entirely anti-positivism and thus reject the notion of classification. I don’t. I think for purposes in research there can be utility in having a positivistic way of seeing. I also think it is important to acknowledge what is lost by doing so, and the inherent loss of essence that goes with it.

    The main problem with the DSM except for what I have already mentioned, is not really about its categorical nature. It is that the categories are not valid. They were never meant to be. DSM-III was wholly driven by the concept of reliability, and for the most common inclusions it was successful. The problem is the validity of these concepts was sacrificed and has never been addressed since. We also have the problem of reification.

    I don’t know much about the NIMH RDoC – I will look into it, thanks!

  • Thanks Daniel, you make a lot of interesting points. I don’t psychiatric drugs were designed to suppress individuals, but they have been used in that way. The same is true for psychoanalytic therapies, and CBT of course as I have written elsewhere. Psychiatric and psychological interventions are too often focused at the level of the individual rather than looking at the individual in the social world. It was with psychoanalytic ideas, not psychiatric diagnoses or drugs that American Psychiatry came to first to suppress discontent, the drugs revolution was the logical extension and allowed many more individuals with seditious murmuring to be dampened.

    I am also interested in the therapeutic potential of psychedelics. I do think it is misguided to see psychedelics as somehow apart from prescribed psychiatric drugs especially given that there is cross over in how they act on the brain. There is nothing inherently expanding about psychedelics, just as there is nothing inherently suppressing about neuroleptics. It is all about how these agents are used.

    vivek

  • I think that maxim has now changed to “don’t tell me about the patient. tell me the diagnosis”!

    I think the DSM-5 has received a lot of criticism (including from the hypocrites who are just sour they were excluded from the gravy train) re: conflicts of interest, being closed etc. The DSM-5 process has been the most open to scrutiny, with the tightest requirements for financial conflicts of any of the editions. I also think a lot of stock is put into how important the DSM is or isn’t in curtailing the medicalization of normal behavior. The reality is that clinicians don’t pay all that much attention to the DSM anyway, we all know how many patients who do not meet DSM criteria have somehow got a diagnosis of bipolar disorder etc.

    I do think diagnosis does have some importance of course. It is helpful to identify primary causes of psychopathology. It also has a social utility in allowing individuals protection under the ADA or to get access to benefits and special services. The over-emphasis of diagnosis-making came about in the 1970s when psychiatrists were losing ground to other mental health providers who could offer psychotherapy for less. As physicians, psychiatrists were able to carve out a new niche for themselves, not in psychoanalysis, but in making diagnoses, something only doctors could do. Now of course psychologists, PAs, NPs, even social workers can make diagnoses, the relevance of the act of diagnosis making as an inherently medical enterprise has been lost.

  • it’s probably more complicated that i made out in the post. I think the main reason for the explanation is to convince people the rationale to take the drugs. The second reason is the notion that the chemical imbalance theory implies ‘no fault’. That maybe true, but it also implies no hope and no power of doing anything except taking medication. The third is it is a dumbed down explanation of the complexity of mental experiences, which obviously have some biological basis, but this is not the same as ’cause’, nor it it in the only level of explanation. The fourth is it provides a veneer of moral authority to psychiatrists as it suggests only psychiatrists or medical doctors can legitimately treat these problems.

    Some people do benefit from taking medications, and I do prescribe medication, because they can provide some symptomatic relief, help with sleep, agitation etc. But let’s not pretend they correct some sort of defect inherent in the brain.

  • well it probably depends where you train. there has actually been a shift, and mental illnesses are no longer characterized as brain diseases so much, as to cause brain disease themselves! An idea that has been gaining popularity is that there is something neurotoxic about psychosis such that individuals end up with brain disorder, rather than brain disorder (whatever that means) being responsible for mental illness!!! The evidence for this appears rather flimsy.

    I cannot speak for everyone but I don’t recall being told/taught that most mental illnesses (with the exception of dementias) are diseases at all, though there are of course people who believe this.

  • sorry i was a bit lazy and have not posted the references but there is a clear correlation between republican government (and conservative governments in the UK) and a decline in research in the social determinants of (mental) health. This is not surprising. I did not mean to suggest that republican administrations spent more money on biological research because of course they spend far less on medical research in the first place. but compared to social research, there is a relatively more biological research representing less funding for looking at social factors, rather than more funding for biological factors.

  • I am sorry to hear that. My point is that psychiatrists of the current generation do not learn that mental disorders are caused by chemical imbalances. I cannot speak to the training of older psychiatrists. I suspect psychiatric nurses do learn this however, as they seem to be more likely to tell patients and their relatives about this. Personally I find it more helpful to elicit what it is that people believe is responsible for their problems. Whether what they say is correct or not, it provides some valuable information to work with.

  • If you mean have ever involuntarily detained anyone before, the answer is no. Psychiatrists do not have the power to involuntarily detain individuals in the state of Washington, a state appointed mental health professional (and a psychiatrist is not a mental health professional as the law defines) is the only one who can. In the UK I was only once asked to section a patient (I was not working in psychiatry) and I didn’t even know how! This however is not relevant to the current discussion, as the notion of ‘chemical imbalances’ is not typically held up as a reason for involuntary treatment. It is certainly not one that would be approved by any court I know of.

  • Sinead – whatever the problems at Harvard Medical School, the Harvard School of Public Health is rather more enlightened and teaches its students to think critically and ask challenging questions. Indeed it was at Harvard that I was required to read An Anatomy of an Epidemic and met Bob Whitaker, when he guest lectured on one of my courses.

    You will also find that in schools of public health across the country the most interesting work in mental health is being done – looking at the social factors that appear to cause mental distress, improving wellbeing on a population level, developing mental health policy, how we can give our children the best start in life, the social and determinants of dementia and so on.

  • I suggest you have another read of the article above. What I’m exploring is how did we get to the position we are in today? This is not something that started with the the DSM, nor with the pharmaceutical industry. My point is if you go back over 100 years ago you can see how psychiatry changed and how psychiatrists came to occupy the role they did. It seems no accident that psychiatry would ascend so in the US (unlike in Europe) at the beginning of the 20th century when unfettered and unadulterated capitalism was transforming America for the worse. Psychiatrists were allowed to occupy such a position because they were agents of social control; the disaffected could be managed and labelled as sick, the source of distress could be located within the individual, and not in society itself. No one could have predicted at that time just how far the concept of mental disorder would expand, just how many people could come be have a mental illness. This was before there was even interest from pharmaceutical companies in psychiatry. The mental health industry is not just psychiatrists, psychologists and therapists have something to answer for as well as they have encouraged us to believe we are in need of help to manage our emotions, and created many more disorders than are even in the DSM.

    For most of the 20th century the mental health market was controlled almost exclusively by psychiatrists. By the 1970s, this changed and psychologists, counselors, psychotherapists of various persuasions etc. found themselves vying for patients with psychiatrists. The result was the psychiatry remedicalized in order survive- what was it that psychiatrists could do that others couldn’t? They could prescribe meds, they could make medical diagnoses, they had the ‘moral authority’ of their medical training to justify their existence. In this way, psychiatry became more biomedical and drug-centered from the 1970s onwards, and more hostile to psychotherapies, treatments that were once their sustenance, could now be provided more cheaply by others.

    You appear to think it is just psychiatry that is at fault. Of course psychiatry has alot to answer for. But the most overlooked question, is why did we allow psychiatry to have so large a role in repression and managing our subjectivity in the first place? Without answering this question, you would find that even if psychiatry disappeared overnight, the role would be filled by something else. American society maintains its need to displace the source of distress in individuals, and not look too closely at the structure of society itself. Until we do this, there can be no hope of ever being free of institutions which implicitly or explicitly seek to manage our subjectivity, and convince us that our distress is not the product of a sick society, but a sick mind.

  • The figure doesn’t include NOS categories, and indeed does not even include psychotic disorders. You can click on the link provided in the article for the breakdown. The DSM is important insofar as new diagnoses mean new research dollars and studies for drugs and psychological treatments for the new disorders and “educating” physicians in the form or CME etc to recognize and treat this “previously underrecognized” and “untreated” condition. In clinical practice, it is really not that important as it is quite easy to ignore. The best psychiatrists don’t really pay any attention to it. The problem is the worst psychiatrists also don’t pay much attention to it, and loosely use the DSM to make diagnoses where actually the diagnostic criteria do not support them. I have been horrified to discover patients with no mental illness who have somehow been admitted to a psychiatric unit for as long as reimbursable (usually a few days) and then thrown out on the street with a prescription of antipsychotics when they have nothing wrong with them! This sort of thing is not the rule, but is not the exception either.

  • you are right, DSM had V codes which include things like ‘no diagnosis’ and ‘malingering’. We are all aware of this, including the attending psychiatrist mentioned in the article. But a V code is not a diagnosis. Further, DSM-IV is not used for billing (though it can be), ICD (international classification of disease) codes are used for reimubursement and the ICD does not allow you to NOT make a diagnosis!! It is a ridiculous system, because in medicine you can code for say ‘cough’ without making a diagnosis and get reimbursed. But ‘low mood’ is not recognized, nor is ‘no diagnosis’! But this does not explain the apparent epidemic (which is questionable – the best studies do not show an increase in depression and other diagnoses over the past 50 years), as the National Comorbidity Survey was a community survey not a clinic one. Most of the so called cases of mental disorder were never diagnosed by a doctor.

  • I am not aware of any psychiatrists that recommend prescribing antidepressants for common unhappiness. But it is true that organized psychiatry has played its role in encouraging general practitioners to prescribe antidepressants. For example in the 1990s the Royal College of General Practitioners and Royal College of Psychiatrists had the pharma-sponsored “defeat depression campaign” that was designed to get GPs diagnosing depression and prescribing more antidepressants. And a success it was. However I don’t think anyone was really recommending prescribing antidepressants for those who weren’t depressed, even if that was the logical end-point we have got to today.

    As an aside, I more often take people off antidepressants than start them. They do seem to do something of benefit in limited cases, but in the vast majority of patients who do not know they are on them (and thus cannot have a placebo effect), I have not found it made a bit of difference to their emotional state, and was not surprised, since they had very good reasons to be depressed (even if it was more ‘severe’) that had not disappeared.

  • in my experience, it is not psychiatrists who are trigger happy with prescribing antidepressants to patients with minor misery and self-diagnosed ‘depression’ as these patients rarely see a psychiatrist. instead it is family physicians and internists who have little time and little interest in exploring their patients’ problems and who find it difficult to rebuff demands for antidepressants from patients who have been convinced by direct to consumer advertising that there is a pill for every ill. by the time they realize the side-effects of the medications, or the withdrawal syndrome is far worse than difficulties that made them seek antidepressants in the first place it is too late.