Let’s explore the myth that psychiatric conditions aren’t as well defined as other medical diseases and psychiatric treatments aren’t supported by as much scientific evidence, and don’t work as well, as other medical treatments. Even my fellow psychiatrists believe this. I’ll take broken limbs and that sort of thing out of the equation and go on from there.
Are psychiatric conditions nothing more than labels for normal behaviors? Is a person with social anxiety disorder just a shy person? Is depression just an experience we all have to live with during hard times? What makes a super-punctilious person a case of obsessive-compulsive disorder? It’s true that some psychiatric conditions exist on a continuum with normal reactions, normal states of being. Differentiating them from normal is no different than deciding what level of blood pressure is ‘hypertension,’ how many pounds add up to ‘obesity,’ or how many hours of labor it should take before a baby is born. A condition rises to the level of disease when it handicaps a person, is associated with bad outcomes, and/or can be treated — in psychiatry just as in the rest of medicine.
Do psychiatrists just sit around and vote psychiatric diagnoses in or out of the diagnostic manual? This notion assumes that medical diagnoses are handed down on tablets like the Ten Commandments. On the contrary; specialists have to look at the evidence and then make judgments about the criteria for medical diagnoses. The difference between a benign tumor and a cancer is a matter of how many sick cells appear under the microscope. Of course oncologists have to make that decision, and they presumably they have some sort of vote to make it official.
Do we know more about what causes other diseases than we do about the causes of psychiatric illnesses? Let’s take juvenile diabetes. We all know that diabetes is caused by the failure of the pancreas to secrete normal amounts of insulin. But what causes that? We say it’s an autoimmune condition — the body attacks its own insulin-secreting cells. Why does that happen? We don’t know. We do know a lot about the causes of psychiatric conditions. Several of them have a strong hereditary component — they run in families. Certain kinds of childhood experiences and later traumas have an effect. Sometimes people with certain genes can become ill only under certain circumstances.
Are psychiatric illnesses not real because there are no diagnostic tests for psychiatry? The substrate, the physical location, of thought, mood, and behavior, is the brain. That’s not a part of the body we like to biopsy without an extremely good reason. The consistency of the brain is something like Jell-O — not easy to use an x-ray to see where it’s broken. Using brain scans, however, we now can distinguish between the brain of a person with depression and a person who is not depressed — and make many, many other such observations. Those observations correlate with what we learn by interviewing a patient and observing his or her behaviors.
Do psychiatrists want to label everybody as sick so as to fill our practices? There is a shortage of psychiatrists. I don’t know any psychiatrists with time on their hands. Our incomes are at the lower end of the medical totem pole, along with family medicine and pediatrics, which makes it difficult to repay the over $100,000 in student loans we have, on average, but we make a good living.
Is there a scientific basis for psychiatric treatment? The New England Journal of Medicine some years ago published a paper demonstrating that far fewer than half the treatments used for cardiovascular diseases are supported by good scientific evidence. Psychiatric treatments work about as well as other medical treatments (1).
How can talking to someone cure a real disease? Well, it can. It can also help cancer patients to live longer; it can lessen the pain of diseases and procedures. We see the same changes on brain images whether a person’s depression is relieved by psychotherapy or medication.
Do psychiatric medications turn people into ‘zombies,’ or change their personalities? Any medication can cause ill effects in some people, especially if they take too large a dose. Are psychiatric medications ‘brain-altering’? A person who recovers from depression, post-traumatic stress disorder, or obsessive-compulsive disorder can seem to have a changed personality — a healthy one. People treated for schizophrenia can use their brains to make contributions to society and have fulfilling lives because their brains are no longer cluttered with hallucinations and delusions.
Prejudice against psychiatry, psychiatric patients, and psychiatrists goes back millennia. It’s hard enough to have a painful and possibly disabling disorder, or to treat one, without suffering from stigma as well. The brain is not only the most complicated organ of the body — it’s one of the most complicated entities in the universe. So psychiatric problems don’t have simple answers. Just like our colleagues in other branches of medicine, no more and no less, there is much more that we don’t know than that we do know. Like our medical colleagues, we’ll keep relieving the suffering of people who are ill, and we’ll keep doing research to understand and treat them ever better.
(1) Stotland NL. Presidential address. Am J Psychiatry 2009: 166:1101-1104blog comments powered by Disqus