PicoBlog

Last month, I began my one-year term as the new president of the Massachusetts Psychiatric Society. In that role, I’ll be writing a column every month for the MPS newsletter. I’ll share those columns, edited, here. Here is the first one, which was the basis for my presidential address:

A friend of mine, a professor of mathematics with personal experience in psychiatry, once wrote me: “Nassir, stop defending psychiatry.  All professions are corrupt, even mathematics  is corrupt!” We usually think of corruption as coming from the outside, so critics of psychiatry often point to pecuniary motivations, as in the pharmaceutical industry. But my friend was making the point that the main source of corruption comes from inside: it resides in human nature. We human beings tend to accept the status quo, we tend to be conformist, and we want to like and be liked. There’s nothing wrong with that in many ways, but there are some disadvantages here and there. It was the main defense made in Nuremberg.

Every profession is corrupt, if you want to put it negatively, because it’s always defending it’s own turf. But since all humans do that, any criticism would have to be directed at everyone.  One can put it positively: All professions have problems, and they deserve self-criticism and rectification.

I assume the presidency of the Massachusetts Psychiatric Society in that spirit.  I wish to uphold what our profession does well, and to correct what it does less well.  My country right or wrong, the old German Marxist-turned-Civil War general Carl Schurz said: when right to be kept right; when wrong to be set right.

With that advice in mind, in this first column, I would like to discuss briefly how MPS can best represent this profession, and in general how our profession represents itself. MPS constantly finds itself engaged with lawmakers and the public on issues of advocacy and legislation where, no matter what the specific topic (like outpatient commitment, cannabis, psychedelics), the psychiatric profession becomes a target of attack. At the recent State House hearing on psychedelics, described more separately in this newsletter,  one of the themes of the many people who testified for psychedelic medical legalization was that the medical establishment could not be trusted with appropriate and sufficient access to such treatments. After the trauma of the COVID-19 pandemic, this general critique of the medical establishment these days is greater than it used to be.  But where our infectious disease colleagues were caught off-guard, we psychiatrists weren’t surprised. We’re used to this. For over half a century or more, psychiatry has been in the cross-hairs of active interest groups who see the profession as inept at best and destructive at worst. These criticisms have not decreased with time.

We can just circle the wagons, ignore the criticisms, and chalk it up to stigma.  It does partly reflect stigma, but not totally, as the broader critique of Covid vaccines shows.  There is a general distrust in much of the public - a distrust of doctors, traditional medicine, drug companies, and psychiatrists. We try to blame the drug companies sometimes so that we might receive less blame, but it’s not that simple.

This distrust may be exaggerated; it may be misplaced at times; it may be wrong overall; but it’s not completely false. There are more than a few kernels of truth there, and I believe we should accept those truths, painful as it might be for us, not only because truth is its own reward, but because it will improve the profession and meet the legitimate demands of our critics.

The only assumption I ask at this point in this essay is the important proviso of If.  If what is claimed here is true or partly true, then some of the consequences would follow. I’m not addressing the If in this column; for that, we can either have other discussions in a public forum, or we can read scientific articles where the evidence is laid out in more detail.

So what are some of the deeper problems in psychiatry, if I’m correct?

One problem is that our diagnoses are not as valid scientifically as many of us believe, or as we often are prone to claim in public.

A second problem is that our drugs are not as effective as many of us believe, or as we often are prone to claim in public.

These are two major problems, if true, that get at the heart of the profession: diagnosis and treatment.

If true, they produce at least once central corollary problem: We engage in unnecessary self-censorship, refusing to comment on public matters when we often have relevant expertise, because of how our socially constructed, and hence scientifically wobbly, diagnostic constructs can be misused. This self-censorship leaves us outside of the public square on important topics that relate to our profession and to our patients.

The first problem is the DSM problem. This is central to the identity of our national organization, the APA. It is the third rail of American psychiatric politics. A few facts though: A good chunk of the APA budget is dependent on DSM royalties, which tend to run to millions of dollars yearly. Whatever one thinks of its content and the science behind it, DSM is the economic engine of our professional society. The original core third revision in 1980 was based on an initial set of 14 Research Diagnostic Criteria (RDC) diagnoses which had some scientific evidence of validity. Within a few years, DSM-III produced 292 diagnoses; there was no or little evidence of scientific validity for the 95% of diagnoses that were added.  Since then another hundred or so have been added, with the original structure largely unchanged. There is little claim that can be made, based on that history, that there is strong scientific validity to most DSM diagnoses.  Reliability can be claimed – we can agree on definitions – but not validity – those definitions are not proven correct.  There’s much more to say, and more pros and cons, but our profession needs to start to acknowledge some of these limitations if we want to engage more fully and effectively with the public in addressing the criticisms and concerns about us.

The second problem is the miracle drug problem. Everyone’s waiting for a miracle: First it was Prozac, then Zyprexa, then lamictal, then ketamine, now psilocybin, next who knows?  The field is flitting from wish to wish without much grounding in reality.  The second point relates to the first. As my old MGH teacher Ned Cassem used to teach: Your treatment is as effective as your diagnosis.  The first problem takes it further: your treatment is ineffective if your diagnostic system is wrong: your diagnoses aren’t wrong because you made a mistake in identifying or applying them; the diagnoses themselves may be invalid. Another aspect to the limitations of our treatments is that they tend to be symptomatic, like aspirin or Tylenol or ibuprofen or steroids: they address immediate acute symptoms problems, which is good. But they are not long-term solutions in many cases: they don’t improve the long-term course of the underlying disease, for instance. Sometimes they do, like lithium for manic-depressive illness, but often they don’t, like benzodiazepines for anxiety symptoms. By making these claims, I refer to absence of proof, as in randomized trials, for such long-term disease-modifying benefits.

The third problem relates to the infamous Goldwater Rule. The APA Ethics Committee’s restriction on psychiatrists commenting on public figures can only be defended if diagnostic judgments are idiosyncratically used, like “narcissism,” or scientifically unproven. But if there are some diagnoses that are scientifically true and biologically valid, such as manic-depressive illness, and they actually occur not infrequently in public figures, then the Goldwater rule would seem overly restrictive. The issue is really not one of ethics, but rather of the consequences of commitment to diagnostic system that is a social construction, and thus prone to manipulative uses.

All these issues come into play in the central role of MPS in public education and legislative advocacy.  As described in the accompanying report, a good example is the debate that will be central this year regarding legalization of psychedelic agents. It is hard to defend the profession against the criticism that our drugs are less effective than many have claimed. It’s a weak defense to simply state otherwise.  It’s also hard to promote restriction of new and potentially harmful treatments like psychedelics to certain diagnoses, and excluding others, when some diagnoses, like “major depressive disorder” or “generalized anxiety disorder”,  or even “adjustment disorder”, are not well-based in scientific validity, and thus can be claimed or loosely used by those who wish to do so. Also, when we are so absent from the public discussion, it is harder for us to have influence when we only enter it in reaction to the concerted actions of others, such as the political action committees promoting psychedelic agents.

Let’s come back to how we are viewed by the larger public and how we should promote our profession. My mathematician friend had a good point that should get us thinking. Let’s defend without being defensive; let’s not criticize if we aren’t self-critical; let’s make better use of the intelligence and good-heartedness of our many members, and speak to the public more openly. Let’s stop reacting to our critics, and start acting to better ourselves.

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