The order of things:
- the prequel…
- unanswered questions…
- the sequels
Whether you think the introduction of the DSM-III in 1980 was a necessary specialty-saving intervention, a hostile take-over, a revolution, a bloodless coup d’état, right or wrong, isn’t what this post is about. It’s about the long term ramifications of a professional organization itself orchestrating a major change in the direction of a profession. Here’s what the architect of that change had to say about how that came to be:
"How could a professional organization engineer a scientific revolution that changed its core? According to conventional wisdom, organizations respond; they do not initiate. By the 1970s psychiatry in the United States had begun to undergo massive changes. The postwar glow had been replaced by the new pressures for accountability on all of medicine. Many leaders in psychiatry deplored the ideological rifts that had divided the field, and they called for a more unified, scientifically based profession. They deplored the "demedicalization" of psychiatry and its severe loss of credibility. I was one of the young leaders who had criticized the ideological divisions within psychiatry and had been searching for ways to improve the scientific status throughout my career. The field’s ideological schisms had weakened us seriously, and psychiatrist’s bitter public disagreements were self-destructive. To cover up these differences or to act solely because of the criticism was not in and of itself sufficient; psychiatry had to adopt a genuine commitment to science rather than to ideology. It needed to change the profession fundamentally if it was to become a respected part of medicine. To accede to the pressure without radical modifications of the field would not have convinced others that the profession had changed. A new strategy was essential! Producing the DSM-III stated emmphatically that psychiatry in America chose an evidence-based practice rather than ideology."
Dr. Mel Sabshin in Changing American Psychiatry: A Personal Perspective
As one who was much younger in the profession at the time, but not in-the-know, I was oblivious to all of that. So what happened over the next several years was dramatic and unexpected, at least to me [
irony I…,
irony II…,
irony III… ]. Independent of the reasons, the correctness, or the content of what happened in those days, the changes resulted in a consolidation of power within the APA [American Psychiatric Association] that persists to the present – a "top down" power structure as described by Dr. Sabshin.
The turn of the century saw a very different psychiatry from the days that produced the DSM-III. Most practicing psychiatrists were doing medication management using a host of new drugs that had poured from the pharmaceutical industry pipeline. The journals were filled with clinical drug trials and biological research articles. What started in the DSM-III as an open question…
For most of the DSM-III disorders, however, the etiology is unknown. A variety of theories have been advanced, buttressed by evidence – not always convincing – to explain how these disorders came about. The approach taken in DSM-III is atheoretical with regard to etiology or pathophysiological process except for those disorders for which this is well established and therefore included in the definition of the disorder. Undoubtedly, with time, some of the disorders of unknown etiology will be found to have specific biological etiologies, others to have specific psychological causes, and still others to result mainly from a particular interplay of psychological, social, and biological factors.
DSM-III Introduction – page 7.
… wasn’t so open any more, at least in mainstream psychiatry, and the research thrusts were to solidify the dominant view of biological causality and treatment. An example of the continued centralization of power within the APA was the commissioning of a Task Force at the turn of the century to produce a DSM-5 that was directly keyed to the hypothesized biological substrate of the various disorders.
As mentioned in the prequel…, the 2014 landscape in psychiatry is very different from the year 1980 or even the year 2000. Exposures of scientific and commercial misconduct swept through academic psychiatry and the pharmaceutical industry; the psychopharmacology pipeline ran dry; PHARMA took "a runner" from CNS drug development altogether taking its liberal support of academic institutions and the APA with it; the DSM-5 Revision floundered in something of a public spectacle; and there was a growing backlash against the monocular biomedical directions in psychiatry in general and the efficacy and safety of the widely used medications in specific. Most psychotherapy had been handed off to other disciplines in the 1980s. These days, most medication is being prescribed by Primary Care Physicians. Most Psychiatric hospitals are closed. Many chronically mentally ill patients are in jail, prisons, or shelters. And the ACA [Affordable Care Act] looks to turn the third party system further upside down. After a frantic year or so trying to woo PHARMA back without success, the place and fate of psychiatry are again in question – endangered species? obsolete? severe shortages? train more? train less? train none? are the kind of phrases being thrown around [or hurled].
Most practicing psychiatrists have grown up in the post-1980 era – by which I mean that within the body of the APA, there’s little apparent turmoil or faction. If there’s much of a call for change or reform coming from inside the ranks, I don’t know about it. Incidentally, there are many psychiatrists who are off the grid for a multiplicity of reasons, suggesting that there’s not much room for discord, controversy, or dialog within the APA. And so to the subject: the APA’s continued assumption that it is tasked with defining, rather than representing, the body psychiatric – persistent since the the days of Sabshin and Spitzer.
In unanswered questions…, I was mentioning several articles in the PsyciatricNews where Presidents of the APA are talking about the future of psychiatry being in Integrative Care, Collaborative Care, and Population Health. I added another in which the APA is offering a course on Recovery [with a capital R] meaning Recovery as it is formulated by SAMHSA [Substance Abuse Mental Health Services Agency] or as you might read about it on many websites opposed to the current medication-heavy brief-contact psychiatric practices. That is a huge topic that I’m not going to talk about substantively in this post, not because I don’t have something to say or don’t want to say it, but for the opposite reason. It’s too big for a simple blog post [and there are too many distracting rants along the way]. Right now I want to talk about just one simple thing. There is a growing trend in what’s coming from the upper levels of the APA that the redirection of psychiatry and the redefinition of psychiatrists is what the organization is setting out to do – what it’s supposed to be doing.
That’s a bad habit that needs a great deal of reflection, because that’s what the APA did in 1980 – created a psychiatry that fit the prevailing vision of what physicians should do in the face of Managed Care’s insistence – see sick people, make a diagnosis, give them the treatment for their sickness, then send them on their way. So the APA created a dictionary to catalog those diseases in concrete terms, and industry went about coming up with a compendium of treatments keyed to the catalog. There are some mental diseases that can be classified in that way, and some treatments that can be used in that way. But being the only model in town, it inappropriately generalized to be the model for all comers. Then the medication makers jumped on board, engaged with psychiatry, and made an ill-gained fortune. We now live in a world where the system that the APA actively created, encouraged, and maintained is currently a very big problem – and psychiatrists are villified for going along with it.
Dr. Sabshin’s retrospective above makes it clear he knew that leveraging the DSM-III Revision to change to direction of psychiatric practice was highly unusual…
"According to conventional wisdom, organizations respond; they do not initiate."
My point is that the resulting consolidation of power persisted to the present along with the role of the APA in a defining psychiatry. And as to the goal of reducing discord …
"The field’s ideological schisms had weakened us seriously, and psychiatrist’s bitter public disagreements were self-destructive."
… it was achieved in spades. Many psychiatrists converted and others just left – having no place at the table. Third Party payment schedules moved psychiatrists into the medication management slot while psychotherapies and counseling went to panels of other mental health specialties, tightly controlled by Managed Care. There has been little controversy or debate among the membership of the APA since those days. Even in these later years of scandal over conflicts of interest, ghost writing, jury-rigged clinical trial publications, false advertising, speaker’s bureaus, distorted reporting of efficacy and adverse events, etc., the outcry and movements for reform have come from outside the APA, mostly outside psychiatry. And as the chronic mental patients filled up our prisons in the years after de-Institutionalization, the APA has had little to say. We could’ve used a lot more discord along the way.
The APA’s assumption of power may well have been justified in the 1970s, but holding onto it wasn’t. The APA was heavily supported by the Pharmaceutical Industry, and supportive in kind. When the ethical misbehavior, the conflicted commercial connectedness, and the invasions of our literature became crystal clear to the whole world, the APA was silent or defensive. Ironically, the revolution launched with the cry against ideology…
"Producing the DSM-III stated emphatically that psychiatry in America chose an evidence-based practice rather than ideology."
… has created a professional organization that is a bastion for a particular notion of overall causality and treatment that has all the earmarks of a fixed ideology, and in spite of a massive research effort, an ideology that operates with little in the way of a strong confirming evidence base except in limited areas.
And now the APA is making noises about another major redefinition as we move into the future, and appears to be pitching it to its membership. While there’s much to be said about what’s being pitched [next post], there’s a question that comes before that. Should the APA even be on the pitching mound at this point. The suggested changes aren’t coming from the floor of the membership. They’re not coming from some subgroup of psychiatrists intensely studying a problem, nor a subgroup of practitioners who have long-occupied the suggested roles, nor the halls of physical medicine, nor being introduced as a topic for general debate within psychiatry itself. My premise is obvious, that the centrality of the APA upper echelon in defining psychiatry has been maintained and used to keep psychiatry on a path controlled by industrial and ideological forces – a legacy from Sabshin, Spitzer, and 1980s DSM-III – whether that was their intent or not and it’s being exerted once again.
Now, the APA is pushing a major change in the directions of the profession in the face of the exhaustion of the current paradigm that will have not only an effect on practice and third party reimbursement, it does nothing to deal with the plight of the chronic patients now incarcerated; it does nothing to curb overuse of psychiatric medications particularly by primary care; it moves clinical psychiatry to a non-patient-contact role; it’s based on a theoretical role originating from outside the specialty; and it looks as if it will perpetuate the very things in need of change. These are goals that have been pushed by Managed Care and PHARMA, hardly by psychiatrists or even its opponents – more like retiring the side than reform. And it’s coming from the APA – the only negotiating force in town. Is this to be the legacy from the 1980 revolution? Is the APA representing psychiatry, our patients, or simply itself and some inappropriate assumptions of power and misguided decisions all along the way? Will practicing psychiatrists continue to leave their fate in the hands of an organization that unilaterally lead us down this path?
Undoubtedly, changes need to be made once again. But these changes? as being presented? dictated by the APA? It sounds like the decision of a group that has painted itself into a corner and further abandoned the practice of clinical psychiatry, taking charge at a time it needs to be taking stock, and operating on an anachronistic centralization of power whose utility has long passed…
I think the only specialty organization acting as mindlessly and ruthlessly self-destructive as the APA might be the American College of Physicians and ABIM and what they are doing to internal medicine.
“For most of the DSM-III disorders, however, the etiology is unknown. A variety of theories have been advanced, buttressed by evidence – not always convincing – to explain how these disorders came about. The approach taken in DSM-III is atheoretical with regard to etiology or pathophysiological process except for those disorders for which this is well established and therefore included in the definition of the disorder. Undoubtedly, with time, some of the disorders of unknown etiology will be found to have specific biological etiologies, others to have specific psychological causes, and still others to result mainly from a particular interplay of psychological, social, and biological factors.”
So what does DSM do when a specific cause is actually found? We know the answer by the exclusion of Rett’s Disorder from the latest edition. Throw it out as a mental disorder. Because we can’t have an actual bonafide taxon with an actual specific etiology and sharp definable boundaries! So if specific etiologies are found for all mental disorders, is DSM-27 going to be an empty book?
“According to conventional wisdom, organizations respond; they do not initiate. ”
Except when they get a bee in there bonnet about something, usually the president or some other administrator, and then they initiate, and usually make a pigs ear out of it.
I’ve seen it suggested that more psychiatrists— especially critical psychiatrists— join the APA and try to effect change from the inside. What say you doctors?
“I’m going to change the system from within.”
“What were once conflicts of interest are now synergies.”
Two fitting epitaphs for the Baby Boomer.
Big post, good stuff. I feel this ties well into the recent question; why do GP’s prescribe so many anti-depressants? My personal feeling is that financial pressure from the practice owner, society, family and personal need has produced a self-limiting effect that most suburban practices have embraced.
The focus of these practices is head count and upcoding patients to maximize revenue. This is all done with the assistance and encouragement of Dr. Drug Rep. Today’s suburban practice really only treats the major health issues that can be identified with a blood test as many patient never physically come in contact with, or are actually seen, as the doctor is reading the file or an EMR.
Professional courtesy has in the past kept criticism to a minimum, but a growing and glaring over use of medications outside the GP’s area of expertise, has left many specialist as primary physicians for an increasing number of patients.
An example is a friend went on vacation two years ago to France and three days in had a massive heart attack and then spent two weeks in a French cardiac care unit. Returning to the US with his medical records, all in English, his cardiologist felt he could not add anything to his care. Two months after his return my friend was very, very ill. Returning to the cardiologist test were run and concern was expressed about the rapid decline in his health. Only when ask about new medications did the cardiologist find my friend was given one medication at three times the recommended dose and two other drugs were never to be given in combination due to their known toxic interaction by his GP.
The cardiologist suggested, and my friend quickly agreed, the constant office visits, large medication load, and repeated testing were something he could easily give up in favor of the cardiologist becoming his primary care physician.
The drive to be a part of every patient’s life, even at the risk of polypharmacy and all of its negative implications appears to be the driver in every medical society. The failed model of the suburban practice has become the standard as doing what the other fellow does is the shortcut to success, or failure.
This is all set against the backdrop of shifting professional standards as MD’s try to retain their position in medicine against an influx of other medical providers who are more than capable of providing care given the self-limited practices many encounter. This is another long comment.
Steve Lucas
That, Steve, is why I think prescribing should be done or overseen by pharmacologists. Doctors rarely know much about the drugs they’re prescribing.
After this past year of working as a Locum Temp, I think psychiatry is beyond redemption. I have been following colleagues who are older and either retiring or forced to leave due to medical issues, and their level of care is pathetic in their last days as providers. Dr Nardo may want to muddle the issue with DSM 3 or just the lame agenda of more recent APA and pharma greed, but, I just want to ask this one question of Dr Nardo and his age related colleagues:
What the hell happened to most of this senior age “mentors” and elder leaders and wise providers practicing for 40 years? Did you all just freak out and sell out in the same day!? I can’t tell you readers how so many older psychiatrists have done such a disservice to the field with their reckless, irresponsible and plain clueless prescribing I have encountered in my travels the past 10 years at least. I am sure Dr Nardo is an exception to this experience per his writings at this blog at least, but, when do the more responsible and integrity based older psychiatrists finally call your age related peers on their loss of accountability and frank irresponsible prescribing?
What, when patients die in sizeable numbers!?
It is nothing less than incredible and disgusting what I have had to take on this past year in following prescribing without boundaries, and these guys think because they can leave at the drop of a hat and avoid responsibility, they have no risk or accountability. But what sickens me the most is how the administration of these sites have been silent and passive letting this crap go on for the years prior to the docs exiting.
Pontificate away about pharma, maybe someone will finally write the expose that shows that psychiatry is corrupt from the senior to resident levels pervasively, and the silence by those who claim to care is collusion.
Sorry for the rant, but, people are being harmed and discarded in increasing numbers every year. And blogs like ours really do little to significantly impact at the end of the day, and note I include myself in this sentence.
Where are the people of effective power and influence to step in and save the day, to call the incompetents and antisocials on their pervasive failures and violations of the Hippocratic Oath? They seem to be either lost or hiding.
And thus why psychiatry as a profession is really a joke today!
Back to another fun week of writing endless benzos and scripts to fix life!
Joel Hassman, MD
Whoa! It must be a blue moon. I also see much reckless prescribing by both GPs and psychiatrists, so I’d have to agree with Dr. Hassman.
(I offer this case report http://survivingantidepressants.org/index.php?/topic/5956-jshect-major-issues-with-wellbutrindeplin-and-klonopin-addiction/ ALL of his many prescribers have been psychiatrists.)
I contend that GPs follow the lead of their psychiatrist colleagues. If psychiatrists were generally very careful about prescribing, so would GPs be. But there are no brakes on either profession when it comes to mixing and matching psychiatric drugs — aside from the rare good doctor, of course.
I would take any interest the APA might have in capital-R Recovery with a grain of rhetorical salt. It wouldn’t do for psychiatry to be against it, would it? And yet where would the profession be without its drugs?
http://theconversation.com/physician-heal-thyself-may-be-impossible-task-for-a-psychiatry-profession-in-crisis-30845
Interesting article by David Pilgrim, professor of Health and Social Policy at the University of Liverpool.
I think change must come from the outside, from us outsiders, with no other bee in the bonnet than recovery, health and social justice – for all.
Does anyone know the exact figures about what percentage of psychiatrists belong to the APA?
Psychology had a schism years ago when some felt their APA had become a pseudoscientific guild.
I think this is a bit redundant to other things I have written but for what it is worth, this is a recent blog on a topic close to this one:
http://www.madinamerica.com/2014/10/rethinking-psychiatry/#comment-52882
Maybe the source of all these problems is this:
http://www.minnesotamedicine.com/Past-Issues/Past-Issues-2007/November-2007/Pulse-Bamboozled
http://jama.jamanetwork.com/article.aspx?articleid=208638
Is the real source of the problem the lack of biostatistical training in medical school and residency that allows eyes to gloss over during Powerpoint presentations? In other words, have we always been an easy mark?
And this:
http://www.psychiatrictimes.com/blogs/couch-crisis/atonement?GUID=85951552-2CF1-4C04-AE66-70F6043AEE8A&rememberme=1&ts=14102014
“For some, it may be the culture of blame and shame perpetuated for years by clinicians who explained all mental illness as being caused by trauma and evil parents”
When’s the last time someone talked like that, 1975? Now trauma and evil (maybe not evil but clueless) parents are excused and the child put on a stimulant.