Wednesday, January 25, 2012


What do you do when you’re a young physician, get sick at the sight of blood, and are desperately in need of psychotherapy? You become a psychiatrist.

That’s what I intended when I began in this biz. My psychiatric training in medical school had featured only two methodologies, psychoanalysis and behaviorism. The former seemed to require a three-piece suit, somberness, and lifelong constipation, and the latter, excision of all emotion. However, the “human potential” movement was just cranking up, replete with consciousness studies, body-mind concepts, and even, bless me, humor. So hoping for more humane training, I investigated psychiatric residences.

I was quickly disillusioned. A fourth approach, psychopharmacology, was rapidly showing all others the door. A class of drugs, phenothiazines, was proving so effective in treating schizophrenia that the bulk of psychiatric research had shifted to chemistry. Almost overnight, psychiatry had simplified down to spare algorithms: diagnosis A, therefore drug B. Indeed, it was evident that sometimes drugs were helpful, but the challenge of exploring the human mind had all but evaporated. Thus a psychiatrist I am not.

Fast forward a quarter-century. I’m attending a continuing medical education luncheon. Pretty good fare, actually: prawns diablo, asparagus with hollandaise, the whole works, hosted by Avarice Pharmaceuticals, which has hired a Prestigious Professor of Psychiatry to inform us simple rural docs that we grossly underdiagnose depression. Were we to perform properly, more of our patients would be taking HappyzacTM , Avarice’s best-seller.

I think you get the picture. As you read this, the editors of the psychiatric bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), are preparing its fifth edition. They will add and delete various diagnoses after some debate and a vote. Depression will maintain its place in the book. Bereavement, though, being a normal response to loss, has not been considered depression. The “bereavement exclusion,” as it’s called, is being challenged by editors making a case for bereavement being biologically identical to depression. As much as I try to calm my internal cynic, I can’t help but see Avarice Pharmaceuticals behind this push. If AP had its way, just about anything we do might be considered a drug-treatable disorder.

On the other hand, some psychiatrists are pushing back. A report issued by Columbia and New York Universities ( argues forcefully for the bereavement exclusion. If it's eliminated, says the report, “…there is the potential for considerable false-positive diagnosis and unnecessary treatment of grief-stricken persons.”

Fortunately, my inner optimist tells me maybe this is the beginning of resistance to the drug industry’s colonization of psychiatry. Maybe we’ll once again see this field as a science of wonder, not just an opportunity for profitable chemical manipulation.

Thursday, January 19, 2012


That’s a shocking statistic. The report defines “mental illness” as behavior corresponding to a specific diagnosis in the psychiatric Diagnostic and Statistical Manual of Mental Disorders. The DSM list includes psychoses, neuroses, and so-called disorders. Even though some of the latter are invented and lobbied into place by pharmaceutical firms intent on medicalizing even more behavior, one in five is nevertheless an alarming proportion.

I’m not entirely surprised, though. Reading letters to the editor in our local newspaper, it’s obvious many were written on the planet Venus. It’s hard to believe how unconnected with reality so many of our citizens are. This revelation should cause the rest of us to scratch our heads and wonder what’s happening. Genes? Recession? Regression? Heavy metals in the water supply?
I suggest it’s because we’re losing community. It’s heading the way of the dial telephone. Instead of chatting with neighbors on the front steps or attending the grange dance, we collapse onto the couch for another numbing tube dose, with its relentless reminders to consume. We’re a centrifugal society, flying out from our center into private cocoons of dark-windowed SUVs, monitor-lit rooms, and walled neighborhoods. A brilliant New Yorker cover cartoon in October, 2010 depicted parents chaperoning their trick-or-treating kids around a neighborhood, each adult face bathed in the blue light of a cell phone. Online social networks confer the illusion of community in the same way junk food pretends nutrition. Proud to have collected hundreds of “friends,” we nevertheless tweet in solitude. A popular calypso song, “Zombies,” puts it this way:

I journey to me local coffee house to sip a cup and socialize.
All of de tables are occupied by elegant gals and guys.
But nobody say a single word, dey be staring at deir laptop screens.
Wid all of dis classy company, dey prefer to talk to machines.
Dey be zombies, zombies, passing as one of us…

Loss of community means diminished reality testing. We check in—compare notions of the world—with one another less often, and with a level of skill that's shrinking from lack of practice. Civic participation has become less discussion and more non-negotiable sound bites. A popular saying is, “It takes a village to raise a child.” It also takes a village to maintain mental health. We don’t need attention from psychiatrists as much as simply hanging out with one another.