1 Boring Old Man

• Precipitated depressions that were severe and/or associated with psychosis
• Severe depression that had no precipitant without psychosis
• Psychotic depressions without "causes"
• First episides of Manic-Depressive Illness

• "Existential Depressions" occurring in people with character pathology

Also common clinically.

I recall thinking that it might be nice to have a category like "Depression Other" that had required coded add-ons: Severity; with or without Psychosis; with or without a precipitant; with or without significant Personality Disorder. Run it for a few years, then do the statistics and see how it came out. I think I had that thought in an on-call room as a second year resident after seeing a profoundly depressed man with a first episode who had no apparent precipitant and was not psychotic. There was no place for him in the book. That would’ve been in 1975 or 1976. Little did I know that there were lots of Psychiatrists at that time scurrying around revising the DSM who were thinking about a whole lot more things than I was.

There is little question that psychoanalysts had been a dominant force in American Psychiatry from the late 1940s through the 1960s. And the psychoanalytic view of mental illness was a dominant paradigm for the non-psychotic illnesses. I expect that the general stance of psychoanalysis towards a unique formulation for patients was a force in the loosely constructed diagnostic structure of Psychiatry. But the dominant problem was the insurance companies balking at paying for long term therapy, a perfectly legitimate complaint. Their point was that the criteria for embarking on such a therapy were more in the range of choice or interest rather than necessity, and that outcome was not measurable in any objective way – also legitimate complaints. I have no idea how insurance got involved with long term therapy in the first place, but if I were an actuary, I think I would’ve pulled my hair out too. There were other forces operating that had to do with insurance for mental health – psychiatric hospitalization, disability, fringy therapies, the subjective nature of mental illness itself, and the coming of DRG’s correlating coverage with specific diagnosis in the rest of medicine. Whatever the explanation, a large force in the development of the DSM III was the relationship of Psychiatry to third party payments.

^{Psychiatrists faced a major professional dilemma. With psychotherapy growing in popularity, psychiatrists had to collectively decide if they were going to try to restrict talk therapy to themselves behind the guise of medicine or if they were going to surrender most of this type of practice to the psychologists, social workers, and lay counselors who could consistently undercut them in price. The more nonmedical psychotherapy became in the eyes of insurance companies and the government, the more professionally vulnerable psychiatrists became. If psychiatrists could not sufficiently demonstrate that their practice produced superior results to those of their competitors, they would have to define psychiatry’s exclusive contributions and jurisdiction in other ways.}
^{In conclusion, many issues converged to force psychiatrists to consider changing definitions of mental disorders and what constituted optimal treatment for them: psychiatry’s marginal status within the medical profession, the increasing reluctance of insurance companies and the government to reimburse long-term talk therapy, the need to treat formerly institutionalized seriously mentally ill persons in the community, the growing influence of medication treatments, and the growing professional threat from nonphysicians such as clinical psychologists, counselors, and social workers. The confluence of these pressures led to a new DSM that fundamentally redefined what mental disorders were and how they should be identified, diagnosed, and treated. “By intent and careful plan,” according to Kirk and Kutchins, “the developers of DSM-III sought to bring about a revolution in how mental health professionals thought about and practiced psychiatric diagnosis. On many levels, the revolution succeeded remarkably well”. What is of particular interest to social scientists is the extent to which politics and the underlying economics of psychiatric practice permeated the DSM-III’s creation.}

In 1980 when the DSM III arrived, I was a "newbie" – a few years out of training and hadn’t yet reached the stage of worrying about the profession’s future. I was still trying to master what was known [or not known]. What I recall as the central issue of psychiatry in those days was the unfunding of the community mental health movement. The "deinstitutionalization" of the severely mentally ill had been accomplished by liberal psychopharmacology and the creation of a strong community support system. By 1980, the limits and the negative effects of the antipsychotics were more than apparent, the hospitals were disappearing [almost gone], but so was the system designed to replace it. I was directing a residency where the residents were working in systems under siege – overwhelmed with very ill patients but severely lacking in resources to do much for them. Administrators were still spouting the lofty slogans of deinstitutionalization and One Flew Over the Cuckoo’s Nest, but the reality was the opposite – the severely ill were now filling the jails as they had several centuries before or living marginally under urban bridges. So I was only a passive observer of the arrival of the DSM III which didn’t address the issues of my daily life.

But I can report what happened. Within a few years, we got a new Chairman. All he talked about was research – and by that he meant "drug research." I wasn’t so much bothered by that at the time. What got to me was that all he wanted to talk about was the future of psychiatry, the department, and I was embroiled in the problems of the present [which we never discussed]. It took me a while to figure out the two most obvious things in the world. The first was that both things that I was focused on – the plight of the severely mentally ill and learning and teaching psychotherapy weren’t even on his radar. The second was that from both of our perspectives, I needed to move on and did. I could see that working in the public sector was a dead end – those forces came from way up in the clouds. And I quickly learned that whatever was happening at Emory in Academic Medicine was happening everywhere so I declined offers to move [plus, we loved being in Atlanta]. So the currents drifted towards an outpatient private practice which, for me, turned out to be a fine place to be. I continued to teach in our psychoanalytic institute and some in the college [and lived happily ever after]. Not long after I left, Charlie Nemeroff came to Emory, and whatever connections I had with the psychiatry department ended. Our institute is at Emory, but the town/gown split was strictly maintained by amicable consent.

From my perspective, the changes in Psychiatry were abrupt. At first, I thought that it was a local thing, and it only slowly dawned on me that it was something of a revolution. I also thought it was ironic at the time. From where I sat, psychiatry was struggling with the failed promises of the introduction of the antipsychotic medications. It seemed odd that it was becoming the age of neuroscience and psychopharmacology. To me, it was an age of overvaluing a pharmacologic intervention and abandoning the severely mentally ill to the streets. I guess, looking back, it was both. I remain embarrassed about how long it took me to realize how much of all the change swirling around us had to do with the pharmaceutical industry. I knew what was happening made little sense, but I was late to realize the mega-force that was a major driver of the show, even though one of the epicenters was only a mile or two from my office on a campus where I was on the faculty. I guess I was more wounded than I knew by the change in direction in my own career and had become something of a turtle, or as I said earlier, a Rip Van Winkle.