Saturday, November 03, 2012



The blogmeister of has done it again. A semi-retired psychiatrist in rural Georgia, he has done more than anyone to document the follies and the ethical challenges of contemporary American psychiatry. His site is required reading for all who care about behavioral health issues.

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.

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.


InformaticsMD said...

I have a teenage relative who's suffered from this charade in the form of psych med polypharmacy in the extreme, to the point of actual toxicity at various points.

Now, the question is - how to get the relative off the polypharmacy when everyone involved in her treatment either profits from or buys into it thanks to the "experts" you write of?

-- SS

Anonymous said...

Great post.

Steve Lucas

Anonymous said...


Carl Jung is turning in his grave.

Afraid said...

Of course it matters, but in a negative way. Perhaps medicine is finally becoming like all the rest, falling prey to the law of opposites. That intended to help hurts.

Any operation with the mission to help is easier to use to scam folks. There is naturally more cover for bad behavior under the guise of a pious mission.

We see it everywhere, in all aspects, private and public institutions. From religions to environmental groups, all sides of the aisle, in every walk of life.

Institutions with a mission to help provide a weapon to the unscrupulous. With smiles that look more like sneers they boldly practice self-interest while making pronouncements of compassion that are transparently incredible.

So often the rest of us just watch in wonder. We can't speak the truth for fear of being targeted as being callous and uncaring, or worse.

Call it what you will, unintended consequences whatever, but what is underneath is a well meaning mission and policy being used as a cover for deception, not by the many but instead by the few.

It's not impersonal either. Real people twist the purpose of an institution with a mission to help. Despicable acts by individuals that often go unpunished. This attracts more people capable of despicable acts and the problem infests everything.

I'd like to think the problem is not getting worse, that this has always been with us. But I suspect that it really is getting worse.

Joel Hassman, MD said...

Amen to this post. And this said by a practicing psychiatrist!

Don Klein said...

The situation in the 1970s seems forgotten. DSM-III did settle for half a loaf because that was better than no loaf at all. The job of DSM-III was to reduce gross psychiatric unreliability by spelling out inclusion and exclusion criteria for a given syndrome. Validity was not given up because it did not exist. Previously, when a clinician said that a patient had schizophrenia you had literally no idea except that they were in bad shape. Unless of course they were pseudo-neurotic.

That the syndrome definitions were due to the argumentation of clinical experts is certainly true. Unfortunately, that was the best available. It is arguable whether the various definitional changes since then have improved reliability, and the promises of genetics and molecular biology for diagnostic validity remain unfulfilled. The serendipitous discovery of new classes of psychiatric drugs ceased back in 1975. What to do about that is certainly worth discussing.

As the recent RDoC indicate, a useful data- manipulative statistical method, factor analysis , can become a madness when indiscriminately required (dimensional domains ) from a top-down, monopoly source of money.