“Shortcomings of a Psychiatric Bible”: A Revealing New York Times Editorial?: author: Jeremy D. Safran

The May 12 New York Times editorial titled: “Shortcomings of a Psychiatric Bible” is both revealing and distressing.  After briefly discussing the recent National Institute of Mental Health (NIMH) decision to replace DSM-5 with their new Research and Diagnostic Criteria as a guiding framework for funding future research, the editors conclude with the following assertion: “The underlying problem is that research on mental disorders and treatment has stalled in the face of the incredible complexity of the brain. That is why major pharmaceutical companies have scaled back their programs to develop new psychiatric drugs; they cannot find new biological targets to shoot for. And that is why President Obama has started a long-term brain research initiative to develop new tools and techniques to study how billions of brain cells and neural circuits interact; the findings could lead to better ways to diagnose and treat psychiatric illnesses, though probably not for many years.”

http://www.nytimes.com/2013/05/12/opinion/sunday/shortcomings-of-a-psychiatric-bible.html

This conclusion reflects an unquestioning acceptance of what has become the received wisdom that further advancement of our understanding of both the etiology and treatment of mental health problems is completely dependent on our ability to accurately map out the associated brain chemistry and neural circuitry. This belief is in keeping with the disease model of psychiatry which holds that psychological problems are no different in kind than diseases such as cancer or tuberculosis, and that both the underlying causes and relevant targets for treatment are biological in nature.  This assumption was also one of the important factors that led to the major revision of the Diagnostic and Statistical Manual for Metal Disorders (DSM-3) by the American Psychiatric Association in 1980 that laid the groundwork for the forthcoming fifth edition of the DSM that the NIMH is now abandoning because its lack of validity. NIMH is assuming that the failure to find relevant biological targets for psychiatry to focus on is the byproduct of a diagnostic system such as the DSM which cannot be assumed to reflect the way in which “nature is carved at the joints.” What they are failing to consider is the possibility that  a  more fundamental problem is the assumption that the underlying causes and relevant targets for treatment are exclusively biological.

It is one thing to  hypothesize  that psychological and emotional problems are associated with changes at the biological level (e.g., specific patterns of  brain activity or levels of neurotransmitters) or that  symptom remission is  associated with biological changes   It is another, to assume that the underlying causes of psychological problems are always or exclusively biological in nature. While it may be the case that biological factors play a more significant causal role in some psychological problems (e.g., schizophrenia) than others, the assumption that the major causal factor (and thus the appropriate target for and level of intervention) for mental health problems is always biological is a form of simplistic reductionism. Nevertheless, it appears that the disease model of mental illness has become the dominant narrative in our culture – a narrative that the editors of the New York Times apparently accept in an unquestioning fashion. Some readers may assume that an article such as “Shortcomings of a Psychiatric Bible,” which is signed by the editorial board of the New York Time reflects the newspaper’s official position on the topic. If they do I hope they are mistaken.

Shortcomings of a Psychiatric Bible

A version of this editorial appeared in print on May 12, 2013, on page SR10 of the New York edition with the headline: Shortcomings of a Psychiatric Bible.

http://www.nytimes.com/2013/05/12/opinion/sunday/shortcomings-of-a-psychiatric-bible.html

Patients and parents concerned about mental illness have every right to be confused. The head of the federal agency that finances mental health research has just declared that the most important diagnostic manual for psychiatric diseases lacks scientific validity and needs to be bolstered by a new classification system based on biology, not just psychiatric opinion. The hitch is that such a biology-based system will not be available for a decade or more.
Dr. Thomas Insel, director of the National Institute of Mental Health, posted his critique of the manual in a “Director’s Blog”on April 29 and expanded on his reasoning in a recent interview with The New York Times. He was critiquing a forthcoming revision of the American Psychiatric Association ’s Diagnostic and Statistical Manual of Mental Disorders, the first major reissue since 1994. Although there have been controversies over particular changes in diagnostic descriptions, he said, the new revision involves “mostly modest alterations” from its predecessor.
The psychiatric association’s diagnoses are mostly based on a professional consensus about what clusters of symptoms are associated with a disease, like depression, and not on any objective laboratory measure, like blood counts or other biological markers. The mental health institute says scientists have not produced the data needed to design a system based on biomarkers or cognitive measures. To fill the gap, the agency started a program two years ago to finance research in biology, genetics, neuroscience, cognitive science and other disciplines with the ultimate goal of helping scientists define disorders by their causes, rather than their symptoms.
The underlying problem is that research on mental disorders and treatment has stalled in the face of the incredible complexity of the brain. That is why major pharmaceutical companies have scaled back their programs to develop new psychiatric drugs; they cannot find new biological targets to shoot for. And that is why President Obama has started a long-term brain research initiative to develop new tools and techniques to study how billions of brain cells and neural circuits interact; the findings could lead to better ways to diagnose and treat psychiatric illnesses, though probably not for many years.
Meanwhile, the diagnostic manual remains the best tool to guide clinicians on how to diagnose disorders and treat patients. Consensus among mental health professionals will have to suffice until we can augment it with something better.

A version of this editorial appeared in print on May 12, 2013, on page SR10 of the New York edition with the headline: Shortcomings of a Psychiatric Bible.

Fix Event Spreads New Hope on Opioids

Presenters from Physicians for Responsible Opioid Prescribing and CASAColumbia engage doctors on the drug epidemic of our time.

By Ben Feuerherd, 02/26/13 Posted at http://www.thefix.com/content/the-fix-opioid-conference91331

Addiction to prescribed opioids has become an epidemic in the US, as The Fix has frequently reported. Who’s to blame? It’s the addicts who “doctor shop” and misuse their prescriptions, right? Not quite—after all, if you're a doctor shopper, you're probably addicted already. The doctors who prescribe drugs like Oxycontin to chronic pain patients, and the pharma companies that falsely billed such drugs as “non-addictive” for chronic use, have had large parts to play.

In an effort to spread awareness of the problem and the possible solutions, The Fix sponsored a lunch presentation for physicians at the Yale Club in New York last Saturday, co-hosted by the National Center on Substance Abuse at Columbia University (CASAColumbia) and Physicians for Responsible Opioid Prescribing (PROP). “There is no objective national effort...[to address the epidemic]...this leads us to conclude it’s up to the medical professionals,” said Susan Foster, CASAColumbia’s director of policy and research analysis, during her opening talk on the prevalence of the problem.  

Leading psychiatrist Dr. Andrew Kolodny, chief of psychiatry at Maimonides Medical Center in New York and president of PROP, then gave a riveting presentation on the root causes of America's opioid epidemic, and the vital need for change in prescribing practices. Every US state has seen an alarming rise since the late '90s in fatal opioid overdoses, Kolodny showed us, and most who die were introduced to the drugs by a prescription. With doctors having to rely on self-reported information about patients' pain levels, we've actually arrived, said Kolodny, at the point of "de facto legalization of heroin." But most doctors haven't been prescribing opioids for chronic pain maliciously, he stressed; the drugs' manufacturers successfully presented them as "non-addictive" for such use, and doctors began prescribing them out of compassion. Now we know better.

In the final talk, Fix contributor Dr. Andrew Tatarsky, director of the Center for Integrative Psychotherapy for Substance Misuse, founder of the Center for Optimal Living and a founding member of the Division on Addiction of New York State Psychological Association, stressed the importance of the doctor-patient relationship in dealing with the problem, and the value of a holistic approach. And he urged the audience of primary care physicians to address the stigma associated with addiction. Various stereotypes about addicts can contribute to over-prescribing, he said, but"Everyone is vulnerable to substance misuse." Tatarsky also noted various possible alternative treatments for chronic pain, including relaxation techniques, yoga, exercise and diet. 

The event—in which Dr. Richard Juman, the former president of the New York State Psychological Association and the coordinator of The Fix's Professional Voices strand, played a major role—was designed to “engage primary care physicians to address addiction,” as Susan Foster summarized. It appeared to be working: The doctors stayed on long after the end to ask follow-up questions on how they should apply what they'd learned about opioid addiction to their practice. Attending GPs like Dr. Vincent Esposity and Dr. Jeff Trilling, for example, told us that the chance to meet "like-minded people" within their community was valuable to them, "because the resources just aren’t there.”  

Full article at http://www.thefix.com/content/the-fix-opioid-conference91331

The Politics of Care

By:  Catherine Boutwell, MA

B. is a quiet and seemingly gentle man, with a soft spoken voice that is difficult to understand. He walks, like a lot patients do, around the inpatient unit with a distant gaze but when you call his name he responds and on good days, he smiles. B. was admitted to a psychiatric inpatient unit in September 2011 because his brother lowered his medication dosage. B's chronic illness and poor economic and social support complicate
matters.

Ketamine for Depression

By:  Alexandra Shaker, MA

Antidepressant medications have been criticized for a number of reasons, including unwanted side effects, a high placebo response rate, and the fact that they tend to take weeks to kick in.  In an effort to reduce the time between first dose and reduction of depressive symptoms, scientists are exploring the effects of Ketamine on individuals suffering from depression, for whom other antidepressants have been ineffective.