Edward Shorter of the University of Toronto keens over the bloated corpse of the latest Diagnostic and Statistical Manual.
The pharmaceutical industry, writes Shorter in the Wall Street Journal, “seeks the largest possible market for a given drug, and advertises huge diseases, such as major depression and schizophrenia, the scientific status of which makes insiders uneasy.”
The DSM provides pharma a market-expanding facade of empiricism. Its ever-broadening girth is a result of “increased specificity” of diagnosis within these immense major disease categories, but the specificity “is spurious. There is little risk of misdiagnosis, because the new disorders all respond to the same drugs, so in terms of treatment, the differentiation is meaningless and of benefit mainly to pharmaceutical companies that market drugs for these niches.” As a commenter on Shorter’s piece puts it, “We’re slicing up illnesses in small portions, we’re treating illnesses with very different names and symptoms with basically the same medications, and we’re at least partly doing this because drug companies have discovered the primary marketing mantra of differentiation. ”
Smartly tricked-out pills for your tailor-made depression; a whole other set for your very own anxiety. Yet “these indications are more marketing devices than scientific categories, because most depression entails anxiety and vice versa.”
The latest draft of the DSM fixes none of the problems with the previous DSM series, and even creates some new ones.
A new problem is the extension of “schizophrenia” to a larger population, with “psychosis risk syndrome.” Even if you aren’t floridly psychotic with hallucinations and delusions, eccentric behavior can nonetheless awaken the suspicion that you might someday become psychotic. Let’s say you have “disorganized speech.” This would apply to about half of my students. Pour on the Seroquel for “psychosis risk syndrome”!
DSM-V accelerates the trend of making variants on the spectrum of everyday behavior into diseases: turning grief into depression, apprehension into anxiety, and boyishness into hyperactivity. [One of Shorter’s commenters calls this disgusting development “psychosprawl.”]
If there were specific treatments for these various niches, you could argue this is good diagnostics. But, as with other forms of anxiety-depression, the SSRIs [a major category of pills] are thought good for everything. Yet to market a given indication, such as social-anxiety disorder, it’s necessary to spend hundreds of millions of dollars on registration trials to convince the FDA that your agent works for this disease that previously nobody had ever heard of.
See why your placebo with strong side effects costs so much?
And we haven’t yet touched on advertising and litigation budgets.
With DSM-V, American psychiatry is … defining ever-widening circles of the population as mentally ill with vague and undifferentiated diagnoses and treating them with powerful drugs.
February 28th, 2010 at 7:55PM
I’d really like to see Shorter’s evidence for all these claims that modern psychiatry is basically bunk. While there may be some truth to the argument that psychiatric disorders are overdiagnosed, he hasn’t presented very solid evidence. Readers should also know that he’s a strong proponent of electroconvulsive therapy — which may have its uses in intractable cases but has serious side effects of its own.
February 28th, 2010 at 9:02PM
Here’s one recent place to start talking about evidence.
I don’t think he says it’s all bunk. I think Shorter’s saying it’s very limited in what it can do. And the number of people it can do things for is very much smaller than pharmaceutical companies seem to believe. Or want us to believe.
I watch almost no television. But on the rare occasions when I do watch, I’m struck by the wall-to-wall, in your face, anti-depressant pill commercials. I see print ads for these pills everywhere — On the metro… big photographs of horribly miserable women, twisted in on themselves… The tag line is always something like — in big black letters — ARE YOU SAD? or HOW SAD ARE YOU? It’s just everywhere, Knitting Clio – it’s the depressant air we breathe. Shorter seems to me correct to identify the DSM as a crucial element of this toxic atmosphere.
Electroconvulsive therapy remains controversial, but plenty of responsible people continue to defend it in, as you say, very difficult circumstances. I can’t imagine how any responsible person could defend dosing 2-year-olds with three different anti-psychotics. Yet Joseph Biederman and other prominent psychiatrists continue to defend the practice.
None of this means all of modern psychiatry is bunk. It means that large segments of modern psychiatry have wandered into confusion, cynicism, and, ultimately, cruelty.
March 1st, 2010 at 7:49AM
How is the direct-to-consumer advertising for anti-depressants any different from those for other drugs?
I’m a critic of Big Pharma too — but Shorter throws out the good with the bad. I really don’t appreciate Shorter’s implication that I’m a fool for taking SSRIs. If Shorter had made this argument about treatments for arthritis or diabetes, would anyone take him seriously?
March 1st, 2010 at 8:00AM
I think it’s different because most other drugs tend to match up better with verifiable disorders and diseases, tend to have more demonstrable utility, and tend not to be promoted in terms that range from on-the-verge-of-suicide to existentially uncomfortable.
If Shorter had made a well-grounded argument that the most widely used drugs for arthritis and diabetes are little better than placebos, yes, people would take him seriously. Shorter is one of many well-regarded scientists and intellectuals making these arguments about psychotropics.
March 1st, 2010 at 8:19AM
Shorter is not a scientist: like me, he’s a historian of medicine. He has no experience treating patients with mental illness. He’s made similar claims for patients with fibromyalgia and chronic fatigue syndrome — i.e. it’s all made up and in their heads. There needs to be a middle ground between critiquing the pharmaceutical industry and acknowledging the reality of mental illness. Shorter doesn’t seem to get that.
March 1st, 2010 at 8:52AM
I too remain to be convinced that chronic fatigue syndrome exists.
You don’t have to be a doctor to make claims about the status of mental and physical disorders.
March 1st, 2010 at 8:56AM
[…] makes the same argument in The Emperor’s New Drugs). As I said in my comments over at University Diaries, I’d really like to see Shorter’s evidence for all these claims. While there may be some truth […]
March 1st, 2010 at 7:44PM
True, but if you’re going to challenge accepted scientific facts (e.g. that benzos are addictive) you should have the evidence to back it up.
re: CFS — the article you link to doesn’t say that the disease doesn’t exist, it says that earlier studies of a link between a virus and the disease turn out to not be true. Scientists don’t know the cause of MS either but that doesn’t negate the experience of those with this debilitating disease.
March 1st, 2010 at 8:47PM
I take your point about evidence.
But I don’t think the MS/CFS comparison is very good. We seem to understand the mechanisms and pathogenesis of MS pretty well, but that’s not true, as far as I can tell, for CFS.
March 6th, 2010 at 8:15AM
[…] It’s much, much, much worse now. […]
January 3rd, 2011 at 12:04PM
[…] And don’t forget. […]
February 4th, 2011 at 9:31AM
[…] Regret, his almost anguished reflection on his own implication in what another writer calls psychosprawl – the legitimation of so many behaviors as signs of mental illness that thirty percent of the […]
June 20th, 2011 at 5:00PM
[…] Related. […]