Sunday, August 15th 2010

The Problem for Psychiatry

Psychiatry has always had an image problem. And it isn’t just the stigma of mental illness or jackass Tom Cruise acting crazy and not making sense.

Having to draw the line of what qualifies as pathology is an issue for psychiatrists as it is for no other physicians. Diabetes is not “normal,” a brain tumor is not “normal,” coronary artery disease is not “normal.” Beyond that they all have comparatively well vetted treatments for things like improved long term survival and decreased major morbidity.

But beyond the psychotic disorders psychiatry has no such certainty. What qualifies as “normal” amongst our thoughts and emotions and behaviors is something not so cut and dry. Nor are the treatments particularly well proven when compared to much of what the rest of medicine might called evidence based.

True, other specialties have their share of poorly defined diseases whose pathologicization has been tied at times to the cost to treat. Anecdotally I can think of restless leg syndrome. But the rest of medicine doesn’t have to hold a vote on what to call “normal” and what to call pathology. Consider a new change to the next edition of the Diagnostic and Statistical Manual of Mental Disorders,

Suppose your spouse or child died two weeks ago and now you feel sad, take less interest and pleasure in things, have little appetite or energy, can’t sleep well and don’t feel like going to work. In the proposal for the D.S.M. 5, your condition would be diagnosed as a major depressive disorder.

This would be a wholesale medicalization of normal emotion, and it would result in the overdiagnosis and overtreatment of people who would do just fine if left alone to grieve with family and friends, as people always have.

It makes pscyhiatry, fairly I would argue, prone to questions of the validity of some of the places it dares to tread. Can psychiatry ever aspire to be a science as say, nephrology or oncology?

Depression is a good example of the problem this makes. A fever is not a disease; it’s a symptom of disease, and the disease, not the symptom, is what medicine seeks to cure. Is depression—insomnia, irritability, lack of energy, loss of libido, and so on—like a fever or like a disease? Do patients complain of these symptoms because they have contracted the neurological equivalent of an infection? Or do the accompanying mental states (thoughts that my existence is pointless, nobody loves me, etc.) have real meaning? If people feel depressed because they have a disease in their brains, then there is no reason to pay much attention to their tales of woe, and medication is the most sensible way to cure them. Peter Kramer, in “Against Depression” (2005), describes a patient who, after she recovered from depression, accused him of taking what she had said in therapy too seriously. It was the depression talking, she told him, not her.

The diagnosis and treatment of non-psychotic psychiatric disorders has sky rocketed since the 1980s. Whether that reflects legitimate outreach or the unnecessary medicalization of the “normal” or some combination of both needs to be seriously looked at by psychiatry. To be fair my experience with psychiatry is limited to my time as a medical student and I’m hardly the first or the most prominent or the last to question the validity of some mental health diagnoses. But the unique position of psychiatry as a medical specialty necessitates that organized psychiatry address questions and concerns about the medicalization of the “normal” with a more social campaign and with more self awareness about just what the future of psychiatry is.