Robert M Kaplan is a forensic psychiatrist and historian of psychiatry. He has written biographies of the Melbourne psychiatrist Reg Ellery and New Zealand psychiatrist Mary Barkas
For those who care deeply about the profession and its goal to treat genuinely debilitating conditions, the state of the profession is cause for deep dismay. Needed is nothing less than a thorough review of the framework in which psychiatry operates, plus a clear plan for its future.
Psychiatry, it must be said, is at an all-time low, the culmination of a steady slide since the Eighties. Its practitioners have little to be excited about, and that hardly does much for patients. If we look back on history – something about which psychiatry is notoriously lax – the closest analogy would be the Thirties, when there were a number of biological treatments but, in truth, they were hardly successful cures (ECT was a notable exception). Cynicism ruled supreme until the Fifties, when a golden age of psychopharmacology started.
Several issues can be indicted for the current desuetude. The first is the Diagnostic & Statistical Manual of the American Psychiatric Association (DSM) which, in the eyes of some critics, has become the Mein Kampf of the discipline. Started, like so many things that go wrong, with the best of intentions, it has given the world an American-based classification of ‘disorders’ (no one is allowed to have a disease or illness now) derived from in-house committees subject to intense political, social and personality processes. The result has not been pretty.
Conditions that were determined by 150 years of careful psychiatric observation have been put through a bureaucratic grinder that killed off paraphrenia and Asperger’s syndrome, seriously messed up depression and inflicted such etymological nightmares as Late Luteal Phase Dysphoria Disorder (aka premenstrual syndrome). By putting everything in a neat pocket manual and providing a tick-box list for every disorder, the DSM made instant diagnosis a reality for professionals, if not the less skilled who wanted to get in on the mental health business. So much for the lengthy and careful psychiatric examination! Add to all this the appetite of a voracious legal profession for new “conditions” that might provide pretexts to sue and, with one thing and another, we are where we are today.
Then there are the drugs. It seems, a new product is launched on the market every day, judging by the journal ads, the glossy flyers in the mail and the bevvies of pert and perky sales reps who come calling with their latest brochures. The problem is that the new drugs are all variations on a theme. Antidepressants, antipsychotics and sedatives have not changed for decades; the only real difference is in the side effects.
A particularly egregious practice is the use of the so-called “atypical antipsychotics” as a kind of psychiatric penicillin. They are prescribed now for just about any disorder, regardless what other drugs are used. Their effect is to produce an emotional flattening. This can be considered something of an improvement, but hardly a cure. Add to this the most spectacular side effect is weight gain, turning skeletal figures into Michelin men and women in a few weeks. Journals are full of articles about the metabolic syndrome produced by these drugs.
It cannot be said that the public image of psychiatry is in the ascent. The disclosure that some prominent researchers have their hands deeply in the drug companies’ pockets is less than a good look. Add to this that psychiatry’s mandate – its exclusive control of the designated illnesses – is fragmenting to an unprecedented degree. There have always been turf wars with neurology and psychology, but they were but kindergarten squabbles compared with the present situation. Witness the disparate agencies which have not just a foot, but an arm and a leg, in invading (and, in the process, facilitating) the raging epidemics of autism and attention deficit/hyperactivity disorder ADHD (another user-friendly acronym that says as much as its hides). The best example is the widespread use of stimulant drugs to control behaviour in children. Add to that all the adult cases and you get some idea of the mess. Future generations will not thank us for this unwanted legacy.