Marcia Angell on 'The Illusions of Psychiatry' (Part II)

The second half of Marcia Angell's New York Review of Books essay on psychiatry is up, and I was wrong: She does mention Thomas Szasz, but only in passing. "By the 1970s," she writes, "an antipsychiatry movement had taken root, as exemplified by the writings of Thomas Szasz and the movie One Flew Over the Cuckoo's Nest." Szasz, who has never opposed psychiatry among consenting adults, would object to that characterization. More to the point, Angell, the former editor of The New England Journal of Medicine, never grapples with his arguments about the mischief that flows from equating arbitrarily defined "mental illnesses" with bodily diseases, even though she supplies plenty of support for that critique:

Not only did the DSM [Diagnostic and Statistical Manual of Mental Disorders] become the bible of psychiatry, but like the real Bible, it depended a lot on something akin to revelation. There are no citations of scientific studies to support its decisions. That is an astonishing omission, because in all medical publications, whether journal articles or textbooks, statements of fact are supposed to be supported by citations of published scientific studies….

The DSM-III was almost certainly more "reliable" than the earlier versions, but reliability is not the same thing as validity. Reliability, as I have noted, is used to mean consistency; validity refers to correctness or soundness. If nearly all physicians agreed that freckles were a sign of cancer, the diagnosis would be "reliable," but not valid. The problem with the DSM is that in all of its editions, it has simply reflected the opinions of its writers….

[Daniel] Carlat [author of Unhinged: The Trouble With Psychiatry] asks, "Why do psychiatrists consistently lead the pack of specialties when it comes to taking money from drug companies?" His answer: "Our diagnoses are subjective and expandable, and we have few rational reasons for choosing one treatment over another." Unlike the conditions treated in most other branches of medicine, there are no objective signs or tests for mental illness—no lab data or MRI findings—and the boundaries between normal and abnormal are often unclear. That makes it possible to expand diagnostic boundaries or even create new diagnoses, in ways that would be impossible, say, in a field like cardiology. And drug companies have every interest in inducing psychiatrists to do just that.

Angell is especially alarmed by "the astonishing rise in the diagnosis and treatment of mental illness in children, sometimes as young as two years old":

These children are often treated with drugs that were never approved by the FDA for use in this age group and have serious side effects. The apparent prevalence of "juvenile bipolar disorder" jumped forty-fold between 1993 and 2004, and that of "autism" increased from one in five hundred children to one in ninety over the same decade. Ten percent of ten-year-old boys now take daily stimulants for ADHD—"attention deficit/hyperactivity disorder"—and 500,000 children take antipsychotic drugs.

For more on the "juvenile bipolar disorder" diagnostic binge, see this recent Newsweek essay by child psychiatrist Stuart Kaplan (author of  Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created the Diagnosis). This trend is the main thing Allen Frances, lead editor of the current DSM, has in mind when he says, "We made mistakes that had terrible consequences."

All of these critics, including Angell, focus on the errors and excesses of psychiatry without giving us a sense of what it would look like if it were done properly. It is fair to highlight the influence of pharmaceutical companies, which fund advocacy groups such as the National Alliance on Mental Illness as well as research and conferences. But to argue that financial considerations corrupt psychiatry suggests there is an uncorrupted form that is worth saving—one that is distinct from neurology on one hand and psychology on the other. The impression left by Angell's essay is that psychiatry is only pseudoscientific and quasi-medical, and perhaps that's the essence of the problem. If so, more tinkering with the DSM (the fifth edition of which is being prepared as we speak) is not going to solve it.