How much do we really know about the causes of mental illness and how it should be treated? As Antony Funnell reports, there’s a growing rift within the field of psychiatry over the effectiveness of traditional mental health treatment, with some practitioners declaring it’s time to throw out the diagnostic handbook and start again from scratch.
There has long been a contradiction at the heart of psychiatry.
While the profession is staffed with doctors (a medical degree being the very basic prerequisite), psychiatrists have, over the past century or so, shown very little interest in the discipline of biology. Although they dispense medications, their system of diagnosis is unlike any other in the field of medicine.
To understand the difference is to understand why psychiatry is currently experiencing a global schism.
Led by the powerful US National Institute of Mental Health, practitioners across the world are in open revolt, demanding that the practice be brought into the modern world and be anchored not in conjecture but in contemporary science.
‘There are many practitioners, including psychiatrists, who wonder about the sanity and the soundness of the enterprise in general,’ says Dr Gary Greenberg, a practicing psychotherapist and trenchant critic.
The essential problem with traditional psychiatric practice, according to its detractors, is its over reliance on ‘symptom-based’ diagnosis. That is, the diagnosis of psychiatric conditions based almost exclusively on clinical observations.
Under the current system, a standard consultation goes something like this: the psychiatrist talks with a patient about his or her problems and then uses the substance of that verbal exchange to identify the underlying cause of the patient’s mental illness.
Then, in order to prescribe treatment, the symptoms exhibited by the patient are matched to a set of pre-determined psychiatric labels, for example depression or ADHD—attention deficit hyperactivity disorder—and medication is dispensed accordingly.
Those labels—or ‘disorders’, as they’re known—are listed in a book called the DSM, The Diagnostic and Statistical Manual of Mental Illness, which is published by the American Psychiatric Association, and is often referred to as the ‘psychiatrist’s Bible’. Though it’s an American publication, it heavily influences the practice of psychiatry and affiliated mental health professions around the world.
However, critics charge that treating people according to their mental health symptoms makes as much sense as a physician prescribing the same medication to everyone with chest pain, regardless of whether that pain is the result of heartburn, a simple muscle spasm or the beginnings of a massive myocardial infarction.
In other words, it makes no sense at all. The symptom doesn’t necessarily tell you anything about the specifics of the underlying cause.
‘The problem here is the problem of the map and the terrain,’ says Dr Greenberg, author of several books on psychiatric practice including Manufacturing Depression and The Book of Woe: The Making of the DSM and the Unmaking of Psychiatry.
‘The DSM is a map. The question is, is it mapping anything real? Or are the people who are using it engaging in a kind of self-contained exercise, not unlike, to be a little bit provocative about it, going down the rabbit hole with Alice into an alternate reality.’
Dr Greenberg and other critics are demanding a re-emphasis in psychiatry in favour of a more biologically-based assessment procedure, having long accused the authors of the DSM of failing to appreciate developments in neuroscience and medical technology.
While he says an increasing number of psychiatrists personally view the manual with disdain—or even outright contempt—he says it continues to have an ongoing influence over the profession and, crucially, over mental health research.
‘In the US and around the world, who gets treatment and who gets special services in schools and who gets special treatment in the courts, and all sorts of really important policy decisions and distributions of funds are made based on the DSM,’ says Dr Greenberg.
‘So there’s a disconnect between the extent to which the DSM truly represents the reality of mental suffering on the one hand and the power that it has on the other.’
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In April 2013, Dr Greenberg and other detractors were given a decisive boost to their reform campaign when the head of the National Institute of Mental Health in the United States came out publicly against the DSM and its symptom-based diagnostic approach.
‘Patients with mental disorders deserve better,’ declared Thomas Insel, whose organisation is the world’s largest funder of psychiatric research. He then announced that the NIMH would begin redirecting its money toward projects that involved a greater understanding of genetics and the use of modern medical technologies.
‘All of the [current] diagnoses are done according to presenting symptoms, but we increasingly know a lot about genetics and neural circuits and we know that the symptoms don’t map very well onto those genetics and neural circuits,’ says Professor Bruce Cuthbert, the director of the NIMH’s Division of Adult Translational Research and Treatment Development. ‘So we are finding that for research purposes, the DSM is not serving us very well,’
‘As some people have said, the brain has not read the text. So we really need to try to find alternative ways of conducting research to take advantage of the explosion of knowledge that we’re getting about how the brain works.’
The reason the current debate about the primacy of the DSM is important is that for all the good psychiatry has done over the years, it’s also been responsible for incredible harm.
Oxford psychiatric professor Tom Burns acknowledges as much in his newly released book Our Necessary Shadow: The Nature and Meaning of Psychiatry, taking readers back to some of the questionable, and arguably unscientific, psychiatric practices of the recent past. Practices like ‘recovered memory’ and lobotomy.
It’s a desire to be more specific about the cause of mental problems and thereby avoid mistreatments that appears to be driving the current push against the DSM.
Dr Greenberg argues that a failure to anchor psychiatric disorders in evidence-based research has led to the manipulation of diagnoses over time in order to suit funding priorities, the demands of the big pharmaceutical companies and social fashion. The most prominent example of the latter being the psychiatric profession’s attitude toward homosexuality.
‘Homosexuality is a special case in the sense that the disorder pathologised what we now think of as a political problem,’ he says. ‘It turned it into a medical problem. I don’t know that there are too many of those. There are a few of them still in the DSM that may in subsequent years look like they were just an attempt to diagnose dissent. But the larger question, whether or not we are going to look back in 50 or 100 years and say, “Oh my God, what were those people thinking”, I think they are going to think that about every disorder in the DSM, frankly.’
Another less political, but still controversial disorder, Asperger syndrome, has also come and gone from the DSM in recent decades as the fluid and open nature of psychiatric diagnosis has changed. According to Professor Cuthbert, even prescribed disorders that once looked more solid and promising are now beginning to fail their purpose.
‘If you have depression, for instance, you can have Anhedonia, which means you fail to find pleasure in your usual things, you may have sleeping problems, eating problems, social withdrawal. You may feel tense and jittery. All of these different things may have different ways of expressing themselves in the brain. So trying to come up with a treatment for depression is very difficult,’ he says. ‘It’s like saying, “well, we are going to fix your car without specifying exactly which part of the car you’re going to fix.”’
At Stanford University in California, Assistant Professor Amit Etkin has been at the forefront of efforts to begin building a more scientific basis for psychiatric diagnoses.
Using what’s called fMRI, or functional magnetic resonance imagining, Dr Etkin has been working to measure the activity of the brain and link it to particular behaviour.
‘Any time when you think about somebody who has a mental illness, you have to think about what is it that we are trying to do, what organ are we trying to effect when we talk with them, when we give them medications. Fundamentally, that organ is the brain,’ says Dr Etkin. ‘The MRI machine takes pictures of the brain every two seconds or so, and from that you can see what brain activity did at different points.’
While Etkin is convinced that modern medical technology is the key to better psychiatric practice, he says he understands why the profession has taken so long to adapt. Because the brain, he points out, is an extremely complicated organ and unlike any other in the human body. He also acknowledges that even his own neuroscientific work is really only at the beginning of a very long process of discovery.
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However, according to Dr Etkin, the future of psychiatry has no option but to pursue a more evidence-based diagnostic approach, because the traditional approach, he says, has clearly run its course.
‘We are no further along now than we were several decades ago. We don’t have any new treatments that dramatically decrease the morbidity and mortality associated with psychiatric disorders. Medications have not been created for any new targets in the past several decades. In fact, those that we have created have really only been discovered by chance. That is, serendipity revealed itself and somebody said, “well, maybe this is useful for depression or schizophrenia.”’
‘So it has been a gradual process of realising that there has to be another way. Any ability we’re going to have for new treatments is going to have to come out of neuroscience.’
It seems some of that message is getting through.
In 2007, in an attempt to deal with already growing unrest within the psychiatric community, the American Psychiatric Association announced an extensive review of the Diagnostic and Statistical Manual of Mental Disorders. It set up a review taskforce under the chairmanship of Professor David Kupfer from the University of Pittsburgh.
That taskforce led to the publication last May of the DSM-5, the first major revision of the manual in 20 years.
‘Many of us were in a sense picked, and I certainly was involved in picking many people who were both clinicians and also, if you will, neuroscientists,’ says Professor Kupfer, who uses the word ‘iterative’ to describe his new version. He says the manual will be modified in future on a much more frequent and regular basis.
‘We’ve talked about this as a living document, but it’s living in the sense that we believe that we would change parts of it where there is new science and new clinical evidence to change it,’ he says. ‘What we want to do is to set up a process by which perhaps every five years we might make appropriate changes to improve the criteria so that diagnoses might be more easily made. This is also an opportunity for us to include any of the neuroscience findings that reach a level of reliability and replication that they can help clinicians to make a more appropriate diagnosis.’
However, he cautions against presuming that the DSM will change dramatically any time soon.
‘What we’ve done is prepared DSM-5 in a much more flexible framework than was available previously. Even in the one year since the DSM-5 has been published, there have been a number of scientific advances in autism and some of the other major disorders which I think are signals to us that in a few years, as these advances get really tested clinically, we will be able to make that first iteration of DSM-5.1—something that incorporates more neuroscience than what we have now.’
So are the critics convinced?
‘In my mind DSM-5 is really not much different than DSM-4, in practice very few things have changed in the DSM,’ replies Dr Etkin, while acknowledging that the manual is moving in what he believes is the right direction. ‘It’s probably not of no use, but it’s probably not the ultimate answer.’
Dr Greenberg, however, still has significant doubts. Claims that this new version of the DSM is helping to move psychiatry toward a more rigorous scientific approach are dubious, he says.
‘Without wanting to impugn the integrity of the people who make that claim, it is a circumscribed claim about science, especially medical science. It may be wrong for us laypeople to expect that scientists really know what they’re talking about, that they can point to the data. But I think we do expect that, and there are many fields in which they can.’
‘In psychiatry, the problem is that there is no external reference. No psychiatrist will tell you that he or she thinks that the disorders listed in the DSM are valid. They will not claim that because they know it’s not true. Now, if you accept that you can create a document full of disorders that are just convenient labels and you define them well enough, then you can do science with that. There’s no question about that. You can do rigorous inquiry using statistics. But that doesn’t necessarily mean that at the end of the day you’ve proved anything. You may have simply made an argument about something that doesn’t exist.’
‘So the problem isn’t that they are sloppy or that it’s unscientific in that sense. The problem is that it isn’t what we expect science to do, which is to expose, reveal and understand the bedrock reality of the world in which we live.’
This article first appeared on ABC Radio National on 19 August 2014.