1 Boring Old Man

Sunday Dialogue: Defining Mental Illness
New York Times
March 23, 2013

To the Editor:

Controversy surrounding the soon-to-be-released fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5 — often called “psychiatry’s bible” — has cast a harsh light on psychiatric diagnosis. For psychiatry’s more radical critics, psychiatric diagnoses are merely “myths” or “socially constructed labels.” But even many who accept the reality of, say, major depression argue that current psychiatric diagnoses often “stigmatize” or “dehumanize” people struggling with ordinary grief, stress or anxiety.

We can certainly debate the legitimate boundaries of disease and “normality,” as in the controversy over “normal grief” versus major depression after a recent bereavement. But there is nothing inherently dehumanizing or “stigmatizing” about a psychiatric diagnosis. Ironically, such inflammatory charges only worsen society’s animus and prejudice toward those with mental illness, by implying that having a psychiatric disorder is grounds for shame. Diagnoses in other medical specialties rarely provoke such a reaction.

Critics typically reply that other medical specialties have “objective” criteria for diagnosis of disease, whereas psychiatrists merely apply “labels” to behaviors they (or society) find offensive. But in truth, numerous medical and neurological diagnoses, such as migraine headache, are based on the same type of data that psychiatrists use: the patient’s history, symptoms and observed behaviors. I believe that psychiatric diagnoses are castigated largely because society fears, misunderstands and often reviles mental illness.

“Diagnosis” means knowing the difference between one condition and another. For many patients, learning the name of their disorder may relieve years of anxious uncertainty. So long as diagnosis is carried out carefully and respectfully, it may be eminently humanizing. Indeed, diagnosis remains the gateway to psychiatry’s pre-eminent goal of relieving the patient’s suffering.

RONALD PIES

Readers React

It is impossible to be totally for, or totally against, psychiatric diagnosis. Done well, diagnosis is the essential prelude to an effective treatment. Done poorly, diagnosis can do more harm than good. Diagnosis and the use of psychotropic drugs have both gotten out of hand; 20 percent of the adult population qualifies for a mental disorder, and 20 percent take medicine. The boundary of psychiatry keeps expanding; the realm of normal is shrinking.

How did this happen? As chairman of the DSM-IV Task Force, I must take partial responsibility for diagnostic inflation. Decisions that seemed to make sense were exploited by drug companies in aggressive and misleading marketing campaigns. They sold the idea that problems of everyday living are really mental disorders, caused by a chemical imbalance and cured with a pill.

Meanwhile, we are neglecting the severely ill who can be accurately diagnosed and effectively treated. State budgets for mental health have been slashed, radically reducing access to care for the people who most need medicine and are likely to benefit from it.

The soon to be published DSM-5 will worsen this absurd misallocation of resources by recklessly introducing new and untested diagnoses and reducing the thresholds for existing ones. People who don’t need diagnosis and treatment will get it, while people in desperate need will be frozen out; and drug companies will laugh all the way to the bank.

We badly need a conversation about a diagnostic system that is far too loose, a drug industry that is far too unregulated and a mental health system that is badly broken. But the pages of The New York Times are not enough; it is time for a Congressional investigation.

ALLEN FRANCES

^{Dr. Pies proposes that the controversy over the DSM-5 "has cast a harsh light on psychiatric diagnosis" as stigmatizing or dehumanizing, and that "such inflammatory charges only worsen society’s animus and prejudice toward those with mental illness." But he fails to consider that the animus around the DSM-5 may well be more focused on psychiatry and psychiatrists than either our diagnoses or our mentally ill patients, particularly in an era when psychiatrists see patients briefly, and rely increasingly on medications whose efficacy and safety are often inflated. Thirty years ago, psychiatry was considered too humanistic to be medical. We seem to have moved the pendulum to its opposite pole – too medical to be humanistic. The almost universal criticism of the American Psychiatric Association’s DSM-5 Revision and current American psychiatry have been met with defensive or deflecting interpretations like this. We would be much better placed to listen to the music. It’s getting pretty loud.}