Don't Take It Any More!

When I told my medical school preceptor that I intended to be a psychiatrist, he informed me that I had “a mushy, unscientific mind” and that the only advances that had been made in psychiatry were medications that had not even been developed by psychiatrists.

He was an endocrinologist. We had a difference of opinion about the approach to an inpatient with diabetes. He thought it was my job to lay out a strict regimen of diet and insulin. I thought it was my job to determine, with blood glucose levels, whether the patient's assertion that he was adept at adjusting his own insulin was accurate, and, if not, to have the evidence with which to convince him to follow a prescribed routine. After a career advising nonpsychiatric physicians, I will stand behind the approach my teacher considered “unscientific,” and I still won't stand for ill-informed attacks on our specialty.

Recently, as a participant on a Toronto television discussion program, I had to listen to the tired old accusation that psychiatric diagnoses are not as valid as other medical diagnoses made on the basis of an X-ray or a throat culture. Today I read on an antipsychiatry list serve the tired old branding of psychiatric treatments as brutal and primitive. I had to listen, and I had to read, but I did not have to let those statements go unanswered. I hope my responses will be useful for you.

We are physicians. Therefore, in these situations, I have made a habit of comparing psychiatric diagnoses and treatments with those in other areas of medicine. When people say that we never really cure psychiatric illnesses, I remind them that we are not able to cure heart failure, diabetes, or hypertension. When they say that psychiatric symptoms are simply loci on the spectrum of normal human problems, I ask them to define when dyspepsia, headache, or backache—each of which costs society millions of lost work hours, doctor visits, and dollars every year—become valid“ diseases.” How badly do I have to twist my ankle to qualify for a diagnosis and treatment, and on what scientific basis?

Carol Nadelson, M.D., a past president of APA, has recently had a surgical procedure. A Harvard professor, she consulted an orthopedist and a neurosurgeon about severe pain in her leg and got two diametrically opposed recommendations. As with a surprisingly large percentage of medical decisions, she had to depend on her common sense and the experience of a colleague. She chose the procedure recommended on the basis of her symptoms, not her MRI—and the procedure worked.

The psychiatry critic on the Canadian television show told the audience that psychiatric disorders are not as real as other disorders because we don't know exactly what causes them. I countered that ultimate causes are an elusive target throughout medicine. OK, diabetes is caused by lack of insulin—but that is caused by the failure of the pancreas—which is caused by the body's own immune responses—which might be triggered by an infectious process—in some people.... Where is the“ cause”?

Critics say that psychotropic medications turn patients into zombies and that ECT fries people's brains. But cancer chemotherapy and radiation poison and burn, all too often without curing disease. The brutality of those treatments is masked with elaborate, often unproven protocols and expensive, painful laboratory tests that produce impressive “data”—but not answers. And what about surgery? Despite the aura of sterility, heart-lung machines, microscopic procedures, lasers, and surgical robots, we are still treating diseases by cutting out pieces of people's bodies with sharp instruments and sewing or stapling or gluing them back together.

Not only, our critics say, do psychiatrists have brutal, ineffective treatments for ill-defined conditions, but also we invent those conditions to make money for pharmaceutical companies. One TV show nay-sayer stated that posttraumatic stress disorder appeared de novo in DSM a couple of decades ago. When I exclaimed, “That isn't true,” he acknowledged that something resembling PTSD had been described in World War II soldiers. There is never enough time on these programs; I didn't have a chance to mention the “shell shock” of World War I, now nearly a century ago. In fact, as fellow guest Dr. David Goldbloom noted, many of the psychiatric conditions we diagnose today were described by the ancient Greeks.

Stigma is ancient history. I don't take it any more, and neither should you. ▪