It wouldn’t be the American Psychiatric Association’s annual meeting without them: the protestors. Every year for as long as I can remember, they line up with their signs and chant. In more recent years, there have been megaphones, speaker systems, and a Jumbotron.
It takes dedication.
It’s easy to ignore those who have beefs with psychiatry. We’re in demand, and I believe that because our practices remain busy with long waits to access psychiatrists in the public mental health system, it’s been to easy to ignore a small, but growing, group of individuals we may have once written off as being zealots or “kooks.” With time, their numbers and voice have gotten stronger, and their constituents more mainstream.
In the last few weeks, the New York Times published an article about the financial benefits of mandated (also called “assisted” or “forced”) outpatient programs. A letter in response was written by three professors of social work and social welfare who have authored a book called “Mad Science” (Livingston, N.J.: Transaction Publishers, 2013). It joins a number of books by Robert Whitaker that denounce our profession. This year, the National Alliance on Mental Illness invited Mr. Whitaker to speak at its annual convention – a controversial choice by any standard.
How should we, as a profession, deal with those who denounce the benefits of psychiatric care? It’s a difficult question, because they are often intent on using sensational examples, and their tone is offensive and not open to conflicting ideas. “Mad Science” uses for its first clinical example of psychiatric mistreatment a vignette about a young man with symptoms of depression who is brought to the hospital by his parents. There, with no evaluation, he is strapped to a gurney and taken immediately for brain surgery, and he is left with permanent brain damage. We have to read for several pages before the authors mention that this happened in China, even though their book is about American psychiatry.
For starters, I believe we need to acknowledge that some of the points the protesters make are valid. Our diagnostic criteria are arrived at by consensus and not by biological markers. This is a major point that those against pharmacologic treatments want to make. They seem unaware that the values for defining diabetes and hypertension were also arrived at by consensus, and in June, the American Medical Association decided that obesity was a disease. We have loosened the criteria for diagnosis of bipolar disorder and attention-deficit disorder to the point that we should use caution before recommending lifetime treatment, and should probably not do so at the initial interview with outpatients, especially if the patients are teenagers. Few psychiatrists do this anymore, but those examples circulate.
The hopes we’ve had for finding the biological basis to psychiatric disorders have, so far, been disappointing. The pharmaceutical companies have skewed the publication of data to show only the positive results, and there are individual research psychiatrists who have been corrupt in manipulating data for their own financial gain (for this, our own profession should join the opposition in being angry). And our treatments don’t help everyone, which is not news to any psychiatrist.
Other antipsychiatry voices go on to talk about how treatments are not only not helpful, but also harmful. They present cases such that perfectly well individuals were given medications that caused them to become psychiatrically ill, physically ill, occupationally disabled, suicidal, and even homicidal. We might point out that perfectly well people don’t generally seek psychiatric care, and be more open about the fact that people have a variety of responses to our medications, such that the bad sometimes outweighs the good. We need to respond to studies showing fault with psychiatry that have been overly touted by the media and are simply wrong. For example, a widely publicized and often quoted study showed that an initial trial of antidepressants is comparable in efficacy to placebo. But this is not reflective of psychiatric practice, where we often need trials of several medications, sometimes with augmenting agents, to yield much higher improvement rates. That fact is left out, and the message the public sees is that antidepressants don’t work. Only with my patients, they do work.
I often wonder why there isn’t a loud and growing anti-oncology movement. Oncologists offer toxic treatments with horrible side effects to dying patients. Our protesters would point out that treatments for cancer are never forced, and perhaps we should look more carefully at the impact of civil commitment and forced medications on patient satisfaction and outcomes.