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 (http://www.nyu.edu/socialwork/pdf/wakefield.pdf) 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.