1 Boring Old Man

DOES AMERICAN PSYCHIATRY MATTER?
Healthcare Renewal
by Bernard Carroll
November 03, 2012

In his latest posting he compared the domain of American psychiatry to Yugoslavia. Cast Melvin Sabshin as Marshal Tito. Sabshin was the medical director of the American Psychiatric Association in the late 1970s, the period leading up to DSM-III. Tito and Sabshin each strong-armed a confederation of sorts but failed to deal with the conflicts beneath the surface. Both leaders were faced with the prospect of their domains disintegrating – Tito’s at the hands of Moscow and Sabshin’s at the hands of insurance companies. Both persuaded wary stakeholders to sign on to a compromise, for want of anything better and fearing a worse outcome.

The domain of psychiatry hasn’t yet reached the stage of ethnic cleansing and genocide that we saw in Yugoslavia after Tito’s death, but it is well on the way. One only has to look at the vicious response of the American Psychiatric Association leaders to Allen Frances and other critics of DSM-5. The APA president in 2009, Alan Schatzberg from Stanford, went out of his way to smear Dr. Frances and Robert Spitzer, the architects of DSM-IV and DSM-III because he had no credible scientific response to their criticisms of the directions DSM-5 is taking. He was joined in this low act by David Kupfer and Darrel Regier, who are directing the DSM-5 effort. Where is the comity, Comrades? Where are the shared values? Why is the APA holed up in a bunker?

Then we have the unsavory sight of the APA lawyers threatening a blogfrauchen in the U.K. with a SLAPP lawsuit for alleged infringement on the APA’s intellectual property – as though the APA owns psychiatric classification! Talk about chutzpah. So now the confederation Sabshin cobbled together is breaking up and the stakeholders are starting to go their separate ways – psychologists, counselors, social workers, patient advocacy groups, even many psychiatrists. Christopher Lane in Psychology Today has said American psychiatry is facing “Civil War” over its diagnostic manual. Even an international psychiatric journal like British Journal of Psychiatry is distancing itself from DSM-5 and there is talk of abandoning DSM-5 for the next ICD classification.

Why is American psychiatry self destructing? Because the grand bargain forged in 1980 with DSM-III was a sham from the get-go and the promised benefits of diagnostic reliability have not materialized. They knew all along that reliability was a poor substitute for validity, but they settled for half a loaf. That compromise led us into the epistemologic quagmire of today, where there is no solid ground for clinical decisions or clinical research progress or drug development. A stunning absence from the DSMs to date is any statement about treatment. That compromise also led us to diagnostic inflation, which Pharma embraced. Pharma quickly filled the vacuum with experimercials that pretended to be real clinical science, and in the process diverted precious clinical research infrastructure away from genuinely important questions. Just look at the clinical trials er, experimercials, mill operating out of Massachusetts General Hospital at Harvard University…

Mel Sabshin Was Truly a Man for All Seasons
Clinical Psychiatry News
by Allen Frances M.D.
June 28, 2011

For the first two-thirds of the 20th century, Sigmund Freud and Adolph Meyer were the most influential figures in American psychiatry. Then Mel Sabshin picked up the mantle and became the person most responsible for shaping psychiatry into its current form… Mel was appointed medical director of the American Psychiatric Association in 1974. He inherited a mess. Psychiatry was in a confused funk – torn by internal dissension, widely attacked from without, and rapidly becoming irrelevant to the rest of medicine. The smart money would have bet against us. But Mel turned it around. With brilliant [but always unobtrusive] diplomacy and leadership, he was able to integrate the warring elements within the association, pacify the critics from without, and help our profession regain both medical credibility and scientific distinction…

Mel also ensured that psychiatry would remain a member in good standing in the medical community. He did everything possible to advance the accuracy of its diagnoses, the efficacy of its treatments, and the strength of its foundation in basic and clinical science. He felt that it was essential that we develop a strong base of knowledge on the epidemiology of psychopathology [and normality], without which our diagnostic system could not achieve credibility. Benefiting from his effective advocacy, psychiatric research funding grew exponentially, so that now, across all medical schools, it is the No. 2 department in terms of National Institutes of Health research funding.

From without, psychiatry was variously attacked for being unscientific, ineffective, stigmatizing, and acting as a tool of the state. Mel soothed the troubled waters by always treating opponents with respect and understanding – often finding unexpected common ground whenever this was possible and being unfailingly cordial when he had to pursue a different agenda. His remarkable diplomatic skills were applied, almost always behind the scenes, across an astounding range of national, international, and professional stages – from Soviet misuse of psychiatry to revolutionizing psychiatric diagnosis to ensuring that effective leaders were successfully recruited and placed in major policy and academic positions. Mel could accomplish so much because he had an almost unique combination of two traits that rarely sort together – he was usually simultaneously both the smartest and yet also the humblest person in the room. Mel was always playing three-dimensional chess while the rest of us were playing Chinese checkers…

The Illusions of Psychiatry
The New York Review of Books
by Marcia Angell
July 14, 2011

When psychoactive drugs were first introduced, there was a brief period of optimism in the psychiatric profession, but by the 1970s, optimism gave way to a sense of threat. Serious side effects of the drugs were becoming apparent, and an antipsychiatry movement had taken root, as exemplified by the writings of Thomas Szasz and the movie One Flew Over the Cuckoo’s Nest. There was also growing competition for patients from psychologists and social workers. In addition, psychiatrists were plagued by internal divisions: some embraced the new biological model, some still clung to the Freudian model, and a few saw mental illness as an essentially sane response to an insane world. Moreover, within the larger medical profession, psychiatrists were regarded as something like poor relations; even with their new drugs, they were seen as less scientific than other specialists, and their income was generally lower.

In the late 1970s, the psychiatric profession struck back—hard. As Robert Whitaker tells it in Anatomy of an Epidemic, the medical director of the American Psychiatric Association [APA], Melvin Sabshin, declared in 1977 that “a vigorous effort to remedicalize psychiatry should be strongly supported,” and he launched an all-out media and public relations campaign to do exactly that. Psychiatry had a powerful weapon that its competitors lacked. Since psychiatrists must qualify as MDs, they have the legal authority to write prescriptions. By fully embracing the biological model of mental illness and the use of psychoactive drugs to treat it, psychiatry was able to relegate other mental health care providers to ancillary positions and also to identify itself as a scientific discipline along with the rest of the medical profession. Most important, by emphasizing drug treatment, psychiatry became the darling of the pharmaceutical industry, which soon made its gratitude tangible…

^{For the next decade the greatest need, in my opinion, involves the collection of empirical data regarding multiple populations studied by multiple techniques. Offer describes one such study, which illustrates what I hope will become a new period of empiricism. Many more populations must be reviewed by methods including interviewing in depth over a significant time dimension. Out of this process should emerge new hypotheses and more sophisticated deductions, as well as new theory building. The science of normal human behavior will have been launched when our current period of deductions and generalizations is seriously challenged by the new empirical evidence.}

Here’s the hard lesson of a career as a psychotherapist. There really aren’t that many Angels and Demons walking our streets. Most of us are creatures of our times, schlepping along the best we can – awash in our biographies, our culture, and our piece of history. They have to go out and locate those black and white reality television characters, because they only live in the crevices. I say it’s a hard lesson because it’s so much easier to see people in black and white, or at least in primary colors. That’s why we’re drawn to the simpler characters in our media and fiction – they’re easier to understand, to love, to hate, or to discount. Mel Sabshin had an enormous impact on psychiatry, on psychiatrists, and on our patients. And while I’m mogrified by the current state of psychiatry and a lot of what happened during his tenure, reading parts of his book, I think I would’ve liked him. He was not made of cardboard. I certainly came upon thoughts he had along the way that I’ve had myself. Peeking ahead in the book, Dr. Sabshin responds to many of the criticisms I might level at what transpired, but that’s for another day. I think he felt good about Changing American Psychiatry when the book was published in 2008. But 2008 just happens to be the year of Senator Grassley’s and Paul Thacker’s investigations, and the year I personally mark as the final bursting of a large bubble. Dr. Carroll’s post above ends with:

^{What lies ahead? Stakeholders are going to vote with their feet. DSM-5 is likely to be a footnote in the history of psychiatric classification. The APA will become even less relevant than it is today, much like the American Medical Association, which now commands the loyalty of maybe 30% of U.S. physicians. Mel Sabshin will turn in his grave, the APA will lose revenue, ICD-11 will become the dominant classification of psychiatric disorders, and the quagmire will continue until a new synthesis arises from the ashes. If Yugoslavia is any kind of model, don’t hold your breath.}