Tag Archives: psychiatric diagnosis

06/28/22

Time for a Fresh Look at Diagnosis

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Allen Frances, chair of the DSM-IV Task Force, has been a vocal critic of modern psychiatry and diagnosis. He was selected by fellow psychiatrist Awais Aftab to do the first interview for Conversations in Critical Psychiatry, a series for Psychiatric Times that aimed to engage prominent individuals who have made important and constructive critiques of psychiatry. Dr. Frances said while he considered psychiatry to be one of the noblest of professions, it had drifted away from best practice. Too many psychiatrists, he said, are reduced to pill pushing with too little time to really know their patients well. And psychiatrists have not done enough to educate primary care physicians, who prescribe 80% of psychiatric meds, on “the principles of cautious prescribing, proper indications, full consideration of risks, and the value of watchful waiting and the tincture of time.”

I despair the diagnostic inflation that results from a too loose diagnostic system, aggressive drug company marketing, careless assessment, and insurance company pressure to rush to judgement. Diagnoses should be written in pencil, and under-diagnosis is almost always safer and more accurate than over-diagnosis.

With regard to the philosophy of diagnosis, he saw three approaches that he likened metaphorically to three kinds of baseball umpires. The first kind called balls and strikes as they are. The second called them as he saw them. The third said there were no balls or strikes until he called them. Frances likened Robert Spitzer, the architect of the modern DSM, to Umpire 1, along with most biological psychiatrists (See “The Quest for Psychiatric Dragons” Part 1 and Part 2 and “Where There’s Smoke …” for more on Robert Spitzer).  “The credibility of this model has been destroyed as we have learned more about the unfathomable complexity of the human brain and the complete failure of genetics and neuroscience to provide useful answers about what causes psychiatric problems.” He thought most psychiatrists aspired to be like Umpire 2, doing their best to define mental disorders in useful ways without any pretention that it is the only way or that current constructs would withstand the test of time.

Dr. Frances expressed concern with the risks of over-diagnosis and advocated for a narrower system with higher diagnostic thresholds. He thought experts in each diagnostic area sought to expand their pet diagnoses and worried too much about missing patients (false negatives) rather than mislabeling patients (false positives). These experts were given a free rein in DSM-5, allowing mislabeling to dominate the field. This led to a checklist approach to diagnosis, which was not intended by the creators of the DSM.

The diagnostic exuberance of DSM 5 confuses mental disorder with the everyday sadness, anxiety, grief, disappointments, and stress responses that are an inescapable part of the human condition. DSM 5 ambitiously mislabels normal diversity and childhood immaturity as disorder, creating stigma and promoting the excess use of medications.

Frances thought if anything in DSM could be misused, it would be misused. “Data drawn from research studies on highly selected patients in the hothouse environment of a university research clinic generalize very poorly to the hustle and bustle of primary care.” On Twitter he pointed to a study he said “blows to bits any hope that statistical modeling” could eliminate the many inherent limitations of “Evidence Based Medicine.” This study, “Many Analysts, One Data Set” concluded that uncertainty in interpreting research results was not just a function of statistical power or the use of questionable research practices. It was also a function of the many reasonable decisions made by researchers as they conducted their research. This did not mean that analyzing data and drawing research conclusions from the data was subjective. Rather, it meant “that many subjective decisions are part of the research process and can affect the outcomes.”

Frances said “Evidence Based Medicine” often generalized poorly to everyday practice because: 1) patients in controlled studies aren’t like unselected patients; 2) research settings differ from real life; 3) biases influence data analyses. “EBM provides a necessary guide, but shouldn’t be worshipped.”

Returning to the interview for Conversations in Critical Psychiatry, he noted how there was an inherent financial, intellectual and emotional conflict of interest that leads every medical specialty to recommend over-diagnosis. He recommended that specialty groups like the APA, the American Psychiatric Association, should never be permitted sole power to determine the diagnostic guidelines for that specialty. Contributions from primary care, public health, health economics and consumers are important. With regard to psychiatric diagnosis, he thought the APA had a special conflict of interest because the DSMs were such a valuable publishing property. The income is crucial for meeting its budget. “This makes frequent revision too tempting and results in an unseemingly hyping of the product.”

Soon after the publication of the DSM-5 in 2013, Allen Frances published an article in World Psychiatry, “The past, present and future of psychiatric diagnosis.” He said psychiatric diagnosis is facing a serious crisis caused by diagnostic inflation. “The elastic boundaries of psychiatry have been steadily expanding, because there is no bright line separating the worried well from the mildly mentally disordered.” Drug companies have used their marketing muscle to sell psychiatric diagnoses by convincing potential patients and prescribers that life problems were really mental disorders caused by chemical imbalances and curable by pills.

We are now in the midst of several market-driven diagnostic fads: attention-deficit/hyperactivity disorder (ADHD) has tripled in rates in the past twenty years; bipolar disorder has doubled overall, with childhood diagnosis increasing forty-fold; and rates of autistic disorder have increased by more than twenty-fold. In the US, the yearly prevalence of a mental disorder is reported at 20–25%, with a 50% lifetime rate, and Europe is not far behind. A prospective study of young adults in New Zealand has reported much higher rates and another of teenagers in the US found an astounding cumulative 83% rate of mental disorders by age 21.

He said the DSM-5 was prepared without adequate consideration of clinical risk/benefit ratios and did not calculate the large economic cost of expanding the reach of psychiatry. It has been unresponsive to widespread professional, public and media opposition “based on the opinion that its changes lacked sufficient scientific support and often defied clinical common sense.”  A petition endorsed by fifty mental health associations, that called for an independent review, “using methods of evidence-based medicine, was ignored.” It was time for a fresh look at diagnosis.

On the podcast The Recommended Dose with Ray Moynihan, Frances said the tendency over the last forty years has been to turn the stuff of life into mental disorder. “The best customer for a drug, is someone who is basically well.” We get advertisements for drugs as frequently as we get advertisements for cars or brands of beer. When it comes to most psychiatric problems, people get better on their own in a few weeks. “My concern is that we’re way overmedicating the problems of everyday life and that parallel to that, we are terrifically neglecting people who are really sick.”

One of the areas he gave as an example of transforming ordinary life into mental illness is with mild forms of depression, that really aren’t depression, but are being diagnosed as major depressive disorder. “The drug companies have convinced the world that major depressive disorder is one entity, and that it is always a chemical imbalance, and that it always requires a chemical solution in the form of a pill.” Eleven percent of Americans are taking an antidepressant. Grief in particular is often over diagnosed and over treated with medication. Then there is anxiety; children who have temper tantrums; and so on. “In general, we have taken every day experiences, that are part of the human condition, and we’re over diagnosing them as mental disorders, and we’re way too often providing a pill, when there’s not really a pill solution for every problem in life.”

Children have been over medicalized with Attention Deficit Disorder, which should be properly diagnosed at around 2 or 3 percent of the U.S. population. In the U.S., by the time a child is 18, they have a 15 percent chance of getting the diagnosis. “This is absolutely ridiculous. We are turning immaturity into a disease.” There are also unwarranted increases in diagnosing childhood Bipolar Disorder. And there is a terrific overuse of antipsychotics in children with behavior problems. “I think we are doing a massive, worldwide experiment on immature brains, bombarding them with very powerful chemicals, with no knowledge whatever about what the long-term outcome will be; and without informed consent.”

He thinks the DSM-5 set off on in the wrong direction. Psychiatrists were worrying about underdiagnosis, when they should have been concerned with overdiagnosis. He said we have gone overboard in the developed world in giving too much treatment to people who can afford it, while neglecting people who can’t.

Then he was asked to comment on the role of good evidence that comes from systematic reviews, from summaries of evidence. Frances said evidence is absolutely crucial in making medical decisions, even though you can’t trust all of it. It takes time to gather enough reliable evidence to be confident. “But without evidence it’s a crapshoot that will be governed by commercial, for profit elements that so determine how people are treated.

I think the biggest role for change will come from the evidence-based guidelines and from a press that is educated to advertise to the people reading the article, not just the possible miracle medical benefit, which is always exaggerated, but also the possible realistic risks of side effects.

The biggest problem for the doctor is too little time. The more time you have to get to know the patient, the less likely you’ll be inaccurate in your diagnosis. “It’s the easiest thing in the world to give a diagnosis and to write a pill prescription. It’s the hardest thing in the world, often, to get rid of a diagnosis once it’s been established. . . A wrong diagnosis made in ten minutes can haunt for life.” Medication, given casually, can do great harm and you should be as careful in taking medication as you would be for a major life decision.

 

Originally posted on 5/19/2020

11/10/20

Does ‘Medical’ Mental Illness Exist?

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A recent article in Vice, “The Movement Against Psychiatry,” wrestled with the ongoing debate between mainstream, institutional psychiatry and what has been called “anti-psychiatry” or critical psychiatry. The subtitle to the article was “The contentious debate of whether to fix—or completely overthrow—the way we treat mental illness.” Around the same time Mad in America highlighted an article published in the American Journal of Physical Anthropology, “Mental health is biological health.” The authors noted that while the biomedical sciences have rapidly reduced the global burden of infectious disease, mental disorders are emerging as major contributors to the global burden of disease. However, “the causes of most mental disorders … remain a mystery, and there has been little progress in reducing the prevalence of any of them.”

You get a condensed, but ultimately biased, picture of the debate, and are introduced to several of the individuals and institutions associated with anti-psychiatry in “The Movement Against Psychiatry,” whose author said anti-psychiatry should not be dismissed as a fringe movement. Issues like over-medication, and problems tapering off of meds are being seriously discussed within mainstream psychiatry. An interview series published in Psychiatric Times called “Conversations in Critical Psychiatry” seeks to engage “prominent individuals who have made meaningful criticisms of psychiatry and have offered constructive alternatives.” Awais Aftab, the author and interviewer for “Conversations in Critical Psychiatry”has interviewed several of the same individuals quoted and referred to in “The Movement Against Psychiatry”: Allen Frances, Sandra Steingard, Lisa Cosgrove, and Lucy Johnstone. Other individuals interviewed for “Conversations in Critical Psychiatry” include Joanna Moncrieff, Giovanni Fava, and Ronald Pies—names I recognized from my own journey and reading articles for and against “anti-psychiatry.”

In “Mental health is biological health,” you find a persuasive argument for a “re-thinking” of psychiatry from the ground up, including psychopharmacology and diagnosis. The authors said scientists understand little about the etiology of mental disorders and noted popular treatments like antidepressants and antipsychotics “have only moderate-to-weak efficacy in treating symptoms” and do not target biological systems that correspond to discrete psychiatric syndromes. The track record of biological psychiatry was said to be poor. “So far, there are no diagnostic tests, and treatments have limited efficacy.” Many critics believe this is due to fundamental flaws in the DSM classification system and that it is impeding research.

Unlike the natural classifications of plants, animals, infectious diseases, and inorganic substances, which all played key roles in the discovery of underlying causal principles, such as the theory of evolution, the atomic theory of matter, and the germ theory of disease, the various classifications of mental disorders have failed, so far, to uncover their underlying causes. The current system has little claim to be a “natural” classification, and is instead deeply contingent on the specific history of psychiatry.

Both articles are long, but worth reading and digesting, if you are interested in the topic. But first let’s push through some of the rhetoric. “The Movement Against Psychiatry” made a distinction between “anti-psychiatry” and “critical psychiatry” seeing anti-psychiatry as having more of an abolitionist sense—a movement of people who feel psychiatry is harmful and needs to be eradicated. Critical psychiatry may be a good lens to see how a biological paradigm has captured our cultural and medical understanding of mental distress. Lucy Johnstone said she agrees with many of the points made by critical psychiatry and opposes what she sees as the medical model of mental illness. She added the term anti-psychiatry is used in the U.K. as an insult.

Challenging the medical model of mental illness seems to be at the heart of the current debate over “anti-psychiatry.” Psychiatrists see their position as a medical specialty being attacked by so-called “anti-psychiatrists.” Aftab, who is a psychiatrist, warned that anti-psychiatry positions run the risk of encouraging distrust of the medical system and available treatment options. This leads people to be wary of seeking help. “For individuals who are on psychiatric medications, they can abruptly discontinue their medications with very serious consequences.”

On the other hand, “Critical psychiatry is more of a reformist movement, attempting to address psychiatry’s issues while maintaining some semblance of its infrastructure.” Lisa Cosgrove, a clinical psychologist and professor at the University of Massachusetts Boston, has a more nuanced view of psychiatry as a medical discipline. She said the fact that we don’t have biomarkers does not make psychiatry irrelevant as a medical discipline. “It just makes it different from other subspecialties in medicine.”

The failure to identify biomarkers for psychiatric illnesses under the auspicious of the medical model of mental illness, despite decades of research and millions of research dollars, stands in direct contrast to the progress with other medical specialties over the past 150 years. Psychiatry seems to feel uncomfortable or self-conscious of this difference.

In her article “Does ‘Mental Illness’ Exist?”, Lucy Johnstone said it obviously does exist, but the idea that the experiences subsumed under the term ‘mental illness’ are best explained as medical disorders “has never had any evidence to support it.” She said that despite decades of research, no so-called symptoms have been causally linked to established patterns of chemical imbalances, genetic flaws or other bodily malfunctions. “Any science – in this case medicine – needs to be able to demonstrate that it is based on a reliable and valid classification system, in order to develop testable hypotheses and hence the general laws that constitute a body of scientific knowledge.” If this cannot be established, she said the whole model breaks down and all psychiatry’s functions are fundamentally undermined. “In the words of Peter Breggin, psychiatry would then become ‘something that is very hard to justify or defend – a medical specialty that does not treat medical illnesses.’”

Johnstone said a psychiatric diagnosis turns ‘people with problems’ into ‘patients with illnesses.’ Psychiatry itself is a failed paradigm. While we have made extraordinary advances in what she called legitimate branches of medicine, “we have made no comparable progress in the illegitimate branch of medicine that calls itself psychiatry.” Her suggested starting point for understanding  these problems was ‘formulation,’ the process in psychology of making sense of a person’s difficulties in the context of their social circumstances and life events. “The professional contributes their clinical experience and their knowledge of the evidence—for example, about the impact of trauma. The client or service user brings their personal experience and the sense they have made of it.”

In “Moving Beyond Psychiatric Diagnosis,” Awais Aftab interviewed Lucy Johnstone for his series, “Conversations in Critical Psychiatry.” He said he was intrigued by her envisioning formulation as an alternative to psychiatric diagnosis. He thought most people in psychiatry and psychology don’t see diagnosis and formulation as mutually exclusive, but rather as complementary and synergistic. “In fact, many would argue good diagnostic practice requires diagnosis to be made in the context of a formulation. Why should we see diagnosis and formulation as competitors rather than allies?” Johnstone replied:

The argument for psychological formulation—or formulation as an alternative to diagnosis—is simple. A formulation is a hypothesis, drawing on the best evidence, and tailored for the particular client. If you have a reasonably complete hypothesis, based on someone’s life experiences and the sense they have made of them, about why they are having mood swings or feeling suicidal or self-injuring, then you don’t need another, competing hypothesis that says, “And it is also because you have bipolar disorder/clinical depression/borderline personality disorder.” Even if we think these are valid categories, the diagnosis is now redundant. 

Aftab disagreed that a diagnosis could be conceived as a causal hypothesis. He later asked her if she advocated for the abolition of psychiatric diagnosis. Johnstone said she did not think “abolition” was the right word. She believed they should use concepts that were evidence-based and jettison those that weren’t. Aftab responded by saying he thought it was disingenuous to argue that psychiatric diagnoses were not valid with respect to a certain scientific standard and then not apply the same standard to psychological formulations. But Johnstone was not distracted from her point.

She replied that in science, it was understood that constructs routinely had to be revised and then abandoned in favor of more accurate ones. She noted that in Biblical times, people believed madness was caused by evil spirits. No one could see them, but everyone was certain they existed. Diagnoses like schizophrenia were based on the same logic. “There are no bodily signs to confirm or disconfirm their presence, but we are convinced we’ll find them someday. This is purely a matter of faith, and it flies in the face of the mountain of evidence for psychosocial causal factors in all forms of mental distress.”

We may be able to come up with all kinds of cleverly nuanced perspectives on how we, as professionals and philosophers, understand psychiatric diagnosis, but the fact remains that people are being told they have mental illnesses and disorders, with all the usual connotations of those terms in Western societies. Moreover, they are heavily encouraged to take on the particular narrow understanding that you refer to—we are all bombarded with messages about “mental illness” being “as real as a broken arm”, and needing to be managed by drugs “just like diabetes.” Even the dubious compromise that is the “biopsychosocial” model—a way of acknowledging some role for psychosocial factors while at the same time instantly relegating them to “triggers” of a disease process—is not much in evidence on the ground. And furthermore, the biomedical message is reinforced by the fact that these labels are applied by doctors and nurses, working in hospitals and clinics, who use not just the labels themselves but the whole medicalized discourse of symptom, patient, prognosis, treatment, relapse, and so. The “stereotypical biomedical understanding of diagnosis” as you put it, is absolutely everywhere.

Aftab said clearly there was a lot wrong with the popular perception of what a diagnosis entails and he thought they needed tremendous effort to counter that. But he thought she was engaging in a certain sense with a strawman—a widespread stereotype of psychiatric diagnosis. If she was only trying to convince the public or professionals who did not have a nuanced understanding, her arguments worked well. But if her goal was to engage with thoughtful psychiatrists and psychologists, they were not sufficient.

Johnstone replied that her primary goal was to work towards a non-medical understanding of emotional suffering, which was what “mental illness” actually meant. She and her colleagues decided this was necessary because “there is not and never has been” any hard evidence that experiences that are now called “mental illness/disorder” were best understood in that way. There is an overwhelming amount of evidence that they arise from within the person and can be understood as a response to psychosocial adversities. “The dominance of the diagnostic viewpoint blinds us to the extent to which non-medical alternatives are already flourishing.”

In summary, it doesn’t matter whether you think I am putting forward a caricature of diagnosis. Diagnosis—however we choose to understand it—has no place in this field, and nor does the diagnostic thinking that it supports and perpetuates. All human experience has biological aspects, but not all forms of suffering are medical illnesses. We are dealing with people with problems, not patients with illnesses, and the whole paradigm—the “DSM mindset” as clinical psychologist Mary Boyle puts it—needs to change.

Notice another piece of rhetoric here: diagnosis itself is a medical term. So, the critique of psychiatric diagnosis has a medical nuance from the start.

Returning to “The Movement Against Psychiatry,” I agree that whether we are pro-psychiatry or anti-psychiatry resolving disagreements over the medicalization of ‘problems in living’ is complicated. After millions of dollars in research funding, biological psychiatry still finds the human brain to be an enigma. As Allen Frances said, “The human brain is the most complicated thing in the known universe and keeps its secrets well hidden.” Yet he thought the next right thing in care for the severely mentally ill was simple: decent housing; easily accessible treatment; social clubs; vocational rehab. The top priority was to get people out of prison and off the streets; and provide them with proper community housing and care. “How can it be that the richest country in the world is most neglectful of its most vulnerable citizens?”

It’s nearly as useless to be steadfastly pro-psychiatry as it is to be anti-psychiatry. Psychiatry is not a monolith, but an entire field and history, with some practices that are more helpful than others, and a huge range of diversity in terms of the kinds of people it treats.

Can’t we start with a critical psychiatry approach and see where it leads us? Calling for the abolition of psychiatry or diagnosis only results in the further entrenchment of psychiatry and supporters of the medical model with no real change to the existing system. Attempts at dialogue, as with Dr. Aftab’s interviews for “Conversations in Critical Psychiatry” and the formation of groups like CEP, Council for Evidence-Based Psychiatry, and the Critical Psychiatry Network are a good start.

04/28/17

Huffing and Puffing at Anti-Psychiatry

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For awhile now I’ve been aware of the ongoing dispute between mainline psychiatry and what is disparagingly referred to as the “anti-psychiatry” movement instead of the critical psychiatry movement.  Over time I have come to identify with the “anti-psychiatric” types. The term sets up a false dichotomy, implying you can only be “for” or “against” psychiatry. Critiques of psychiatric diagnosis or the use of psychiatric medications are regularly dismissed out-of-hand by mainline psychiatry. One of the ongoing dialogues of dispute occurs between the author and journalist Robert Whitaker and the eminent psychiatrist Ronald Pies.

Robert Whitaker is the author of three books that relentlessly drive their readers to question the narrative for mental illness and psychiatry verbalized by mainline psychiatrists like Ronald Pies. These books are: Mad in America, Anatomy of an Epidemic and Psychiatry Under the Influence.  His articles on the mentally ill and the drug industry have won several awards. A series he wrote for The Boston Globe was a finalist for the Pulitzer in 1998. Anatomy was the 2010 winner for best investigative journalism by Investigative Reporters and Editors, Inc. Mad in America is also the name of a nonprofit organization and webzine, madinamerica.com, whose mission is “to serve as a catalyst for rethinking psychiatric care in the United States (and abroad).”

Ronald Pies is a noted psychiatrist, a Clinical Professor of Psychiatry at Tufts University and SUNY Upstate Medical University, Syracuse NY. He is also Editor in Chief Emeritus of Psychiatric Times. A bit of a Renaissance man, he’s published poetry: The Heart Broken Open, a novel: The Director of the Minor Tragedies, nonfiction: Becoming a Mensch: Timeless Talmudic Ethics for Everyone, as well as psychiatry: Psychiatry on the Edge, Handbook of Essential Psychopharmacology and psychotherapy: The Judaic Foundations of Cognitive-Behavioral Therapy.  He has authored or coauthored several other books as well.

Whitaker and Mad in America authors have disagreed with Pies on several issues. For example, they disagreed on whether psychiatrists widely promoted the chemical imbalance theory (see “Psychiatry DID Promote the Chemical Imbalance Theory” and “My Response to Dr. Pies” on madinamerica.com); or whether the long-term use of antipsychotics is helpful (see “Dr. Pies and Dr. Frances Make a Compelling Case that Their Profession is Doing Great Harm on madinamerica.com).

Into this mix Pies has written three articles for Psychiatric Times: “Is There Really an ‘Epidemic’ of Psychiatric Illness in the US?,” “The Bogus ‘Epidemic’ of Mental Illness in the US” and “The Astonishing Non-Epidemic of Mental Illness.” He’s clearly playing off of Whitaker’s book: Anatomy of an Epidemic. In his third article, “The Astonishing Non-Epidemic of Mental Illness,” Pies said that the epidemic of mental illness narrative is (with a few qualifications) “mostly fear-mongering drivel.” It sells books and makes for good online chatter, but “The so-called epidemic of mental illness among adults in the US proves largely illusory.”

He did some rhetorical sleight-of-hand, stating that by pulling out the bottom card of the epidemic narrative, the entire house of cards of the anti-psychiatry movement would collapse. In order to do this, he first quoted what he said was the CDC definition of epidemic: “ . . . an increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area . . .” Pies then said the CDC definition of epidemic applied to actual cases of disease; not to changing rates of diagnosis, which are subject to many socio-cultural variables. The distinction was critical,

Since psychiatry’s critics do not claim merely that there is more diagnosis of schizophrenia or major depression; rather, they claim there are actually more people sick with these illnesses, owing to misguided or harmful psychiatric treatment.

Remember that in psychiatric diagnosis, there are relatively few diagnoses that can be confirmed by medical tests. The vast majority of psychiatric disorders are assessed by a diagnostic process alone. If you demonstrate to a clinician that you meet the diagnostic criteria for a psychiatric disorder, you are treated as if you actually have the disorder. So Pies seems to be splitting hairs with his distinction between actual cases and diagnoses. And I don’t think he has made as telling a point as he thought.

It would seem he is suggesting that psychiatric diagnostic rates for a disorder are overstated from the actual cases because of the influence of socio-cultural variables.  Yet how can you distinguish the actual cases from the false positives due to socio-culturally influenced diagnosis? The same diagnostic criteria are used. Is there an unstated assumption that diagnostic inflation is due to factors beyond psychiatry? Namely, that if a trained psychiatrist follows the structured clinical interview process, only actual cases of a psychiatric disorder will be identified?

Pies also said the “epidemic” claim was largely based on the increasing US rates of psychiatric disability over the past 50 years. Here he cited an article by Whitaker without mentioning Whitaker’s name. He dismissed the validity of using disability determinations, saying they cannot be used as “a legitimate index of disease incidence or prevalence.” He then shifts the focus to affirm there is a growing population of “persons with serious psychiatric illness who are not receiving adequate treatment.” Here he named two well-known psychiatrists who have written of their concerns with the “epidemic” of neglect with our most severely impaired citizens. But one of the persons he mentioned, Dr. Fuller Torrey, wrote The Invisible Plague about the rise of mental illness from 1750 to the present!

In the Introduction to The Invisible Plague Torrey described what he saw as “the epidemic of insanity.”  He said a major impediment to understanding the epidemic of insanity was that its onset occurred over so many years. Few people fully appreciated what was happening. “Those who did raise an alarm were largely ignored.” He said the suggestion today that we are living in the midst of an epidemic of insanity strikes most people as unbelievable.

Insanity is an invisible plague. There are no body counts with which one can compare the present with the past. In most countries, there are remarkably few statistics that can be used to assess insanity’s prevalence over time. Professional textbooks assume that insanity has always been present in approximately the same numbers as now.

Fuller Torrey is a believer in insanity as an epidemic of brain dysfunction. And he blames the likes of Michel Foucault, Thomas Szasz, Ronald Laing and others for emptying the insane asylums that have been “the mainstay for containing the epidemic for a century and a half,” without insuring these individuals received the treatment needed to control the symptoms of their illness.

When looking at the costs of this epidemic, Torrey said the combined costs in 1991 for the US were $110 billion. “And this included the single largest disease category for federal payments under the Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) programs.” So in quantifying the cost of the epidemic of insanity, Torrey used the same statistic to make his point that Whitaker did. Pies either didn’t realize this, or ignored it in his critique of Whitaker. I wonder if Pies sees what Torrey said as fear-mongering drivel or one of the few qualifications?

Pies dismissively cited two articles written by Marcia Angell for The New York Review of Books in 2011 (“The Epidemic of Mental Illness: Why?” and “The Illusions of Psychiatry”) in all three of his articles as an example of the promotion of the false narrative of “the raging epidemic of mental illness.” Her articles discussed three books and their implications for psychiatry: The Emperor’s New Drugs, Anatomy of an Epidemic, and Unhinged: The Trouble with Psychiatry. Angell’s review of Whitaker’s book drew it to the attention of a wide audience; so it seems this may be at least partly why Pies is dismissive of it.

However, read her articles. They will give you a thumbnail sketch of issues Pies goes to great lengths to deny and minimize. Then read the books she discusses. Remember that Marcia Angell is a Senior Lecturer at Harvard Medical School and was the first woman to serve as editor-in-chief of the New England Journal of Medicine. Don’t be dismissive of what she has to say; she has great credibility.

There is one final point to be made with regard to Pies’ third article. In the conclusion, he references Thomas Kuhn’s idea of “paradigm,” saying it is misleading and unfair to suggest that psychiatry is laboring under a “failed paradigm.” This was, he said, because “there is no one paradigm the defines all of psychiatry or that dictates practice on the part of all psychiatrists.” But I wonder if he truly understood the implications to his comment. If you apply Kuhn’s notion of paradigm (“a paradigm is what members of a scientific community share”) with Pies’ application of the term to psychiatry, then you would have to conclude that psychiatry as it’s practiced, is NOT a science. Rather, it would either be what Kuhn called a “pseudoscience” or pre-scientific. He also seems to be oblivious to the possibility of an implicit paradigm generated in psychiatric practice with DSM diagnosis—that it classifies a real “illness” or “disease” of the brain.

I’m reminded of what Robert Whitaker pointed out in his review of Jeffrey Lieberman’s book Shrinks, “The Untold Story of Psychiatry.” Whitaker noted how speeches given by the presidents of the American Psychiatric Association at their annual meetings regularly sounded the same theme: “Psychiatrists are true heroes.” He said it struck him that Shrinks served as an institutional self-portrait of psychiatry. “What you hear in this book [Shrinks] is the story that the APA and its leaders have been telling to themselves for some time.” Similarly, it seems Pies is preaching to the psychiatric choir—a message that there really isn’t an epidemic increase in mental illness; the argument that the anti-psychiatry movement is just a house of cards. Yet it seems to me that house is still standing despite the huffing and puffing of Pies and others.