WSJ: Incompetent Ranting

At first, I was going to title this post WSJ: Incompetent Ranting. Then
I decided that was too strong.  Then I read the article again, and
went back to the original title.  Mind you, this is not intended
to be an ad hominem attack.  The author, href="http://www.chass.utoronto.ca/history/faculty/facultyprofiles/shorter.html">Edward
Shorter,
has been the Hannah Professor in the History of Medicine since 1991,
and in 1996 was cross-appointed as Professor of Psychiatry (at the
University of Toronto).  He has written some good books, including
A History of Psychiatry: From the Era of the Asylum to the Age of
Prozac.  The book was href="http://psychservices.psychiatryonline.org/cgi/content/full/49/9/1241">reviewed
favorably in an APA journal.



The WSJ article is so fraught with problems, that I thought it must
have
been written by a Scientologist, or someone like that.  No, Dr.
Shorter is a serious academician.  Perhaps his perspective has
been
distorted by some unstated agenda.  I don't know.



(Note: the WSJ has a dorky semi-permeable paywall, so the link below
might not work.  If it does not, perhaps the href="http://74.125.95.132/search?q=cache:1XLrEucYxaEJ:online.wsj.com/article/SB10001424052748704188104575083700227601116.html+Psychopharmacology,+or+the+treatment+of+the+mind+and+brain+with+drugs,+has+come+to+dominate+the+field.&cd=2&hl=en&ct=clnk&gl=us&client=firefox-a">Google
cache version will, or href="http://www.google.com/url?sa=t&source=web&ct=res&cd=2&ved=0CAoQFjAB&url=http%3A%2F%2Fonline.wsj.com%2Farticle%2FSB10001424052748704188104575083700227601116.html&ei=nwSLS5WILY6INpSxpd4H&usg=AFQjCNHqIV4pNU9Trx6fZ0aoC0Ht0UmVYw&sig2=OHZaB3vIwRqQfg66uUnWNw">a
link taken from a Google search.)

href="http://online.wsj.com/article/SB10001424052748704188104575083700227601116.html#articleTabs%3Dcomments">Why
Psychiatry Needs Therapy

A manual's draft reflects how diagnoses have grown foggier, drugs more
ineffective

By EDWARD SHORTER

LIFE & STYLE

FEBRUARY 27, 2010



To flip through the latest draft of the American Psychiatric
Association's Diagnostic and Statistical Manual, in the works for seven
years now, is to see the discipline's floundering writ large.
Psychiatry seems to have lost its way in a forest of poorly verified
diagnoses and ineffectual medications. Patients who seek psychiatric
help today for mood disorders stand a good chance of being diagnosed
with a disease that doesn't exist and treated with a medication little
more effective than a placebo...

To put this in context, the DSM is in the final stages of revision,
from DSM-IV-TR, to DSM-V.  The draft to which he is referring is
online, at www.dsm5.org. 
Shorter begins with a rookie mistake.  You see, in order to have
any hope of understanding the DSM (whatever version), you cannot merely
read the lists of criteria; you have to read the text.  I know he
has not read the text, because the text hasn't been written yet. 
Only the draft criteria are out.  It is not a sign of academic
rigor to pass judgment on a draft, much less a draft of the framework
of the work itself.  It is like looking at the pictures in a
chemistry textbook, and thinking you can discern something about the
textbook itself.  Well, perhaps you can discern something, but not
enough to write an article for a newspaper...even if it is a Rupert
Murdoch paper. 



(OK, maybe I am wrong, maybe there is a draft of the entire text, that
has not been announced or put online.  But I don't think so. 
The APA has been making an effort to be publicly transparent in their
process, and the website only mentions a draft of the criteria sets.)



The next error is more subtle, but still significant: "...stand a good
chance of being diagnosed with a disease that doesn't exist..." 
It is my impression that few psychiatrists think of the criterion sets
as definitions of diseases.  They are lists of symptoms and items
in a patient's history.  These define syndromes, not
diseases.  He must know that.  Perhaps he is dumbing the
article down, to make it appropriate for a mass audience.  But if
that is the case, what point is he trying to make?



Then it gets worse:

In the 1950s and '60s, when psychiatry was still under the
influence of the European scientific tradition, reasonably accurate
diagnoses still sat at center stage. If you felt blue, uneasy and
generally jumpy, "nerves" was a common diagnosis. For the
psychotherapeutically oriented psychiatrists of the day,
"psychoneurosis" was the equivalent of nerves. There was no point in
breaking these terms down: clinicians and patients alike understood "a
case of nerves," or a "nervous breakdown."

Sure, if you leave everything vague, then no one can prove anything to
be incorrect, and you can say anything you want.  In would be very
difficult to disprove a diagnosis of "nerves," for example. 



It is hard to know what to make of the statement that "there was no
point in breaking these terms down."  He is a historian, he must
have read works such as Fenichels' href="http://books.google.com/books?id=r1zmhbjEAn0C&printsec=frontcover&dq=otto+fenichel&source=bl&ots=guXBr-6Tvq&sig=J33kDhA46ziNuSYMqLtU9ZehntA&hl=en&ei=NGWLS7bsLY7YM9DbsaYB&sa=X&oi=book_result&ct=result&resnum=13&ved=0CDYQ6AEwDA#v=onepage&q=&f=false">Psychoanalytic
Theory of Neurosis
(OK, it's from the 40's, but the point stands).  The psychiatrists
of that era broke things down into excruciating detail.  
(The problem was, that the way they broke things down did not help them
come up with diangoses that were sufficiently specific as to be useful.)



Then it gets worse:

Our
psychopathological lingo today offers little improvement on these
sturdy terms. A patient with the same symptoms today might be told he
has "social anxiety disorder" or "seasonal affective disorder." The
increased specificity is spurious. There is little risk of
misdiagnosis, because the new disorders all respond to the same drugs,
so in terms of treatment, the differentiation is meaningless and of
benefit mainly to pharmaceutical companies that market drugs for these
niches.

See that?  Can you believe it?  In his opening paragraph, he
states that the drugs do not work.  Now, he is telling us
that they do
work.  As for his point about there being no reason to
differentiate between two conditions, if they both respond to the same
drug, this is ridiculous.  It is like saying that there is no
point in differentiating between two bacteria, if they both are killed
by the same antibiotic.  You can't do research by throwing out
data.  Social phobia is very different from seasonal affective
disorder.  Sure, persons with these conditions might respond to
the same drugs (SSRIs), but I've never seen anyone seriously propose
that we
treat social phobia with bright-light therapy in the AM.  They
respond to the same drugs, but their responses to other therapies are
different.  Cripes,
what was he thinking???



What more can he muddle?

The
first of the "tricyclic antidepressants" (because of their chemical
structure) was launched in the U.S. in 1959, called imipramine
generically and Tofranil by brand name. It remains today the single
most effective antidepressant on the market for the immediate treatment
of serious depression.

Imipramine is a great drug.  Nothing has been shown, convincingly,
to be more effective, on a population basis (individual results vary,
of course).  But to say it is the single most effective, implies
that it -- alone -- is better than the rest.  This simply is not
true. 



Dr. Shorter than goes on to imply that that the changes in diagnostic
criteria, and the emergence of new classified syndromes, is all a plot
to market drugs.  This is illustrated in the following, although
he goes on at some length to make his point:

New
drugs appeared to match the new diseases. In the late 1980s, the
Prozac-type agents began to hit the market, the "SSRIs," or selective
serotonin reuptake inhibitors, such as Zoloft, Paxil, Celexa and
Lexapro.

The implication is that psychiatrists created a new diagnostic
category, so that drug companies could sell their drugs.  Now, I
am very much aware of the fact that there are many shady practices in
the marketing of these products.  But this is not one of
them.  You see, in order for a drug company to sell a drug in the
USA, it has to have what the FDA calls an "indication."  That is,
it has to be show to be safe and effective for a particular
condition.  Thus, ALL drugs marketed in the USA will have an
indication.  The indication will be drawn from whatever the
standard diagnostic scheme is, pertaining to the condition at
hand.  As it happens, oncologists reclassify tumors from time to
time.  Is he going to argue that oncologists are defining new
cancers, just so the drug companies can sell their drugs?  Is he
going to argue that Pfizer would not have had a market for Zoloft, if
Major Depression had not been defined?  This simply does not make
any sense. I am reasonably confident that pharmaceutical companies
would do just fine, if
not better, if we still used his favored terms. 



Examples: Mellaril (an antipsychotic) once was marketed for the
treatment of " href="http://www.psychosomaticmedicine.org/cgi/issue_pdf/backmatter_pdf/27/4.pdf">anxiety,
tension, and agitation." 
Taractan, another antipsychotic, was indicated for "moderate to severe
emotional disorders, especially agitated states associated with
neuroses, depression, or schizophrenia."  (Those are quotes from
the FDA-approved product labeling, as published in the July-August
1965 issue of href="http://www.psychosomaticmedicine.org/content/vol27/issue4/">Psychosomatic
Medicine.) 
Is he seriously saying that this way of describing drug indications was
superior?  That it led to more precisely-targeted drug
prescribing?  He is a historian.  He should take a look at
some old documents to see if they support the points he is trying to
make.  Unfortunately, they do not.



Because Dr. Shorter is a serious scholar, and obviously quite
knowledgeable, I was curious as to how he could make such a fundamental
error.  As it happens, he recently published a paper in the
Canadian Journal of Psychiatry that sheds some light on this.  The
paper is in a debate format, structured as a debate with another
scholar.  (The link opens a PDF of the paper.)

Disease
Versus Dimension in Diagnosis

Edward Shorter, PhD, FRSC; Herman M van Praag, MD, PhD

Can J Psychiatry. 2010;55(2):59-64.

Dr. Shorter mentions five disease states that match his
conceptualization of a real, definable disease: melancholia, catatonia,
atypical depression, panic, and ADHD.

And that is it. Those are the disease entities in
psychiatry that, to date, have been relatively well characterized.
Others will doubtless follow as the concept of biological markers again
gains traction (after the premature discarding of the DST).

Ah, the DST ( href="http://en.wikipedia.org/wiki/Dexamethasone_suppression_test">dexamethasone
suppression test) reals its lochnessian head again!  I'm not
sure why he says it was discarded prematurely.  It was studied
exhaustively as for its potential to provide a reliable diagnosis of
major depression.  Nobody could figure out how to make it
clinically useful.  Although I cannot prove that nobody ever will,
I must say that it seems exceedingly doubtful.



Anyway, the impression I get from Dr. Shorter's part of the article, is
that he seems to feel that diagnoses need to correspond to his
conceptualization of a disease, in order to be useful.  He adapts
these criteria to form his idea of a disease:

If we are to regard psychiatric diagnoses as medical
diagnoses, how might they be constructed? Building on Guze, Max Fink
and Michael Alan Taylor have proposed a 3-fold basis for carving out
discrete psychiatric illnesses: describing an illness entity in
well-circumscribed psychopathologic terms; verifying its existence with
laboratory measures; and, validating it with a distinctive response to
treatment.

To be fair, I should say that it would be nice if it were so. 
That is, it would be nice if all psychiatric diagnoses had
corresponding biological markers, differential response to specific
treatments, and statistically cohesive symptom sets.  Alas, this
is not the case; moreover, it is not clear whether it ever will
be.  So we have choice to make.  We can sit around and do
nothing, while awaiting scientific advances that may never come, or we
can work with the existing -- albeit inadequate -- models that we
already have. 



Let's put this in perspective.  The human brain is the most
complex organ that we know.  Indeed, it is the most complex entity
that we know of, in the entire Universe.  Sometimes it does not
work right.  This is no surprise.  Often, we have difficultly
coming up with a good model to describe these dysfunctions.  This
also is no surprise.  The models are false.  We know this,
because we know that all models are false, even if they are modeling
something relatively simple.  In my view, the question is not
whether the model is true, but: is it useful? 



There are many uses for a diagnosis.  The most important one, is
to provide a link between research and treatment.  Evidence-based
medicine is practices by gathering up a bunch of studies that seem to
relate to the condition that a specific patient has.  Then, the
practitioner assesses how likely it is that the outcomes described in
the studies reflect the outcome that is likely to occur if a specific
treatment is applied to that patient.  In order to do that, we
need to have some way to link the research to the patient.  The
diagnosis is that link. 



If the diagnostic scheme fulfills that purpose, then it is
useful.  This usefulness transcends any quaint notions about
reality.  We all would feel better if we knew that the diagnosis
represented something real.  However, the point is not for us to
feel better, the point is to find effective ways of linking research to
specific patients.  Whether the diagnosis represents something
real, is actually beside the point. 



So when Dr. Shorter rants about "a disease that doesn't exist," he is
talking about something that we know is true (it is true that the model
is false), but which is immaterial (what we care about is whether the
model works).