Psychiatry is on the couch and must look at issues such as its relationship with 'Big Pharma', writes PAUL O'DONOGHUE
FOR ANY FORM of therapeutic intervention to work to its maximum potential it is crucial that there is a high degree of trust and confidence on the part of the client or patient. This is particularly true in the case of psychiatry, psychology and the various forms of psychotherapy. Psychiatry is now facing a significant struggle in this arena.
Historically, psychiatry has experienced many challenges and is often seen as playing second fiddle to the rest of medicine. US psychiatrist Daniel Carlat of Tufts University in Boston says: “There is no question that among the medical professions, psychiatry is the most scientifically primitive. We have no more than a rudimentary understanding of the pathophysiology of mental illness and we have resorted to tenuous and ever-shifting theories of how our treatments work.”
The latest criticism was precipitated by the impending publication in May 2013, of the fifth edition of the Diagnostic and Statistical Manual (DSM-5) of the American Psychiatric Association(APA). There has been much criticism of the proposed content and of the processes and personnel involved.
The DSMprovides standard criteria for the classification of mental disorders and is used extensively in clinical and research settings and by health insurance companies and the pharmaceutical industry. The first edition in 1952 had 130 pages and described 106 disorders. By 1994, the fourth edition had expanded to 886 pages and 297 disorders.
In June the British Psychological Society wrote to the APA with criticisms of the proposed content of the DSM-5. Its comments are scathing and express deep concern that normal experiences and responses to external stressors are pathologised and may result in overtreatment with powerful and unnecessary drugs. There is much evidence to support this viewpoint. It also emphasises the need to see mental distress on a spectrum with "normal" experience and that psycho-social factors such as poverty, unemployment and trauma are the most strongly evidenced causal factors. Another category of concern is psychosis risk – a troubling concept from a conceptual and treatment perspective. This has caused a furore with many clinicians and researchers opposed to its inclusion.
The comment by Carlat came within his response to a two-part review by Marcia Angell published in the June and July 2011 New York Review of Booksin which she considered the DSMand three new books critical of the current state of psychiatry. Among her concerns is the extensive and often insidious relationship between psychiatry and the major drug companies. Conflicts of interest abound and a worrying aspect of this questionable alliance is the influence the companies may have on how psychiatric conditions are constructed and defined. Their influence on clinical practice is also worrying.
One particularly questionable tool is the use of “seeding studies” in which a pharmaceutical company will source a large number of doctors to take part in a research study. Often payment per patient recruited is provided. Doctors become familiar and comfortable with the drug involved and so prescribe more, resulting in increased profits for the companies. These studies are merely marketing ploys and, while not technically illegal they are ethically abhorrent.
The DSMhas been criticised as reflecting the opinions of its writers and being devoid of theoretical and scientific rigour. Angell quotes Harvard psychiatrist George Vaillant, saying that the DSMis just a bold series of choices based on guess, taste, prejudice and hope. It is also concerning that of the 170 contributors to the current version of the DSM, 95 had financial ties to drug companies, including all contributors to the sections on mood disorders and schizophrenia.
While there is certainly a place for drugs in the treatment of a range of conditions, there is extensive overuse of medication in circumstances where less intrusive psychosocial supports would prove more effective and more humane. The negative long-term effects of psychotropic drug use is worrying and the increasing use of these medicines in the case of young children is of particular concern.
Psychiatry is again under the microscope and would do well to pay careful attention to the many criticisms it faces and to modify its practices and distance itself from the cloying tentacles of the pharmaceutical companies who are driven by a different ethic.
Paul O’Donoghue is a clinical psychologist and founder member of the Irish Skeptics Society, contact@irishskeptics.org.