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May was mental health awareness month. On May Day, Gallup released a survey of which we as a profession need to become very aware.
Gallup surveyed 2226 Americans regarding their perception of mental health care. That survey included a grading system, which we can read in part at least as an assessment of the mental health professions, which obviously would include psychiatry. The results were as follows: 57% of Americans gave us a grade of F or D. 27% were more generous and gave us a grade of C. Only 8% were willing to give a B and 1% an A. Let's just translate these numbers again. 99% of Americans are not willing to give us a grade of A. 91% of Americans give us a grade of C or less. Most Americans rate us as failing or near-failing: D or F.
A natural reaction could be to blame others: the insurance companies, the broken health care system, the court system, stigma. And those systemic issues certainly bear part of the blame, but not all of it. We psychiatrists and mental health professionals should be able to take some of the responsibility ourselves too. We cannot say without self-deception that we’re fine, but everything else is bad.
Indeed the Gallup poll did address these other systemic issues and found them to be relevant. Americans recognize that stigma and affordability are limiting factors for better mental health care.
These systemic issues need to be addressed, but you can make the system as good as you like, if other factors, which are more clinical and scientific, are not fixed, we will still fail our patients.
Let me give you an example:
I had a friend in Canada who had a severe depressive episode in his late 60s, the second in his life. He had a happy marriage, financial security, many friends. There was no external cause. He was given sertraline, which made him slightly hyper for a few hours, and the dose was eventually maximized, and other antidepressants were given, and other antipsychotics. Over months his episode waxed and waned, with some suicidal ideation. He went to the emergency room a few times, and was set up with an outpatient psychiatrist, and psychiatric nurses visited him in his home twice weekly. The structure of the care he was given was impeccable: he had his primary care, a specialist psychiatrist, in home nursing – and all free. His diagnosis and treatment followed DSM definitions and FDA regulations exactly. He just didn’t get better. One morning he awoke, went to the roof of his high rise, and jumped.
I knew him well. I knew that he met the definition of hyperthymic temperament (mild manic traits as part of one’s personality), which is not in DSM. I knew that his few “hyper” hours were manic symptoms; we talked about it at length, with increased libido, energy, and racing thoughts – the opposite of depression. I knew that those manic symptoms, and his baseline manic temperament represented mixed depression, not “major depression”, which ignores presence or absence of manic symptoms of less than four days duration (without any scientific evidence for that cut-off). I knew that antidepressants make mixed depression worse and increase suicidality in that condition (based on published data). I knew that lithium reduces such suicidality, but he never was given it.
In short, I can provide a strong scientific rationale for why his diagnosis and medications were wrong, but one would have to go outside the DSM box. The exclusion of mixed depression from DSM has never been based on a strong scientific rationale. The insistence of “major depression” as being legitimate when it includes mixed states with other conditions has never been proven scientifically. These are just decisions made by DSM committees by fiat. The problem is not just that they may be wrong, but that if they are wrong, they can be deadly, as in the case of my friend.
We follow the rules, but we don’t ask enough how well proven those rules are.
A skeptical reader might say that any treatment can fail, and this could just be one of those cases, and that many other people improve. The Gallup poll says otherwise: It tells us that these failures aren’t exceptional. Remember, we get an A only from 1% of the public.
What I raise in this example involves two matters I mentioned previously: first, the fact that the DSM system of diagnosis is mostly false, i.e., it has not been validated or it has been in fact invalidated; and second, that our medications are mostly symptomatic in effect, like Tylenol for pain, and not disease-modifying. These two features differentiate us from the rest of general medicine, in a bad way. Let me explain.
We speak about parity. There is no parity, partly because of stigma, but not entirely. Another reason there might not be parity may be because of our outcomes. Now that statement will be challenged by many colleagues, and there are claims against it in the scientific literature, which I could critique. But putting aside what you or I think, it matters what our patients think, what the public thinks, and there too the Gallup poll shows that most Americans think that our provision of psychiatric care doesn’t match up to our colleagues in general medicine.
To quote the poll: “Overall, 38% of U.S. adults think mental health issues are handled ‘much worse’ and 37% ‘somewhat worse’ than physical health issues, while 15% say they are dealt with ‘about the same.’ Just 4% think mental health issues are treated ‘somewhat better,’ with 1% saying ‘much better.’” Let's restate the numbers once again: 75% of Americans feel that psychiatric care is provided worse than physical health care, and only 15% say they are similar. Only 5% of Americans believe that mental health issues are handled better than physical health issues.
It doesn’t matter if we mental health professionals disagree; our patients are telling us what they experience, and we need to listen to them.
So what’s the problem? There are the systemic issues, as mentioned. But there are clinical and scientific issues, about which our profession has been in denial.
Back to my two points: DSM and our drugs.
DSM is mostly invalid. This should not be a controversial statement. It was stated by the makers of DSM-III themselves: they claimed reliability and admitted invalidity. They just hoped validity would improve over time. It has not, because the dictionary has become a Bible, and we refuse to change it. We still use definitions, like MDD, almost exactly as defined in 1980 based on limited or no legitimate scientific evidence of validity, and despite decades of research proving aspects of that diagnosis to be false.1,2
Our drugs are symptomatic. Look at all the drug trials. How much do depressive symptoms improve in 8 weeks, or psychotic symptoms in 3 months, or PTSD symptoms in a few months. The drugs are developed to reduce symptoms in the short-term. That’s it. That’s what they do. Nothing more. Compare it to general medicine: Statins are not measured for their effects on chest pain over weeks, or antihypertensives for their effect on headache over weeks, or chemotherapies for their effect on edema over weeks. All those drugs are studied for their effects in modification of the underlying disease, not based on biological measures (statins are not proven based on cholesterol levels nor antihypertensives based on blood pressure reduction), but rather based on clinical measures of long-term improvement in the course of the illness: reduction in frequency of heart attacks or stroke, and decreased mortality. These outcomes are measures over 1-5 years, not 1-5 weeks. We do not develop drugs that way in psychiatry, so the drugs we have do not function that way. They are not disease-modifying. (Exceptions are lithium and mood stabilizers, which are the only drugs proven to improve long-term course of illness in psychiatry; I know some will disagree; I have provided the research evidence for this statement elsewhere).3
It's noteworthy in the Gallup survey that the public was more satisfied with the benefits of psychotherapies than with the effects of medications.
So back to our failing grade:
The health care system is a mess – true. Stigma is a problem – true. We are not well reimbursed – true.
AND:
DSM is mostly false. And our drugs have mainly short-term symptomatic benefits.
Interestingly, the problems our profession tends to ignore are the ones we can fix most directly ourselves. We psychiatrists have the power to make things better, but we aren’t trying, on the issues over which we have the most control.
APA could decide tomorrow to drop DSM (but it won’t, for economic reasons since 2/3 of the APA budget relies on DSM income). And our profession could diagnose like every other medical specialty based on the best scientific research found in the journals, end of story, without the APA or the AMA telling us what to think. After DSM, I would predict that clinical practice would improve markedly, as clinicians were free to think more scientifically about their work, rather than simply following rote orders from afar.
Academic researchers and the FDA tomorrow could join together to demand disease-modifying clinical trials, not symptomatic ones, and the pharmaceutical industry would be forced to do so, as it does for every other medical specialty. Within a decade, we would have amazing new effective drugs.4 Instead, we have me-too psychedelic drugs that just improve symptoms more quickly and more strongly, advocates say, without any proof (meaning randomized studies) of true long-term improvement of the course of any illness.
I recently attend the American Society of Clinical Psychopharmacology annual meeting, the main congress bringing together the pharmaceutical industry, academic clinical trial researchers, and the FDA. The vast majority of presentations were on psychedelic drugs and their variations. I came away with the unhappy feeling that we are hurtling toward a dead end. The pharmaceutical industry knows it can make billions providing these me-too psychedelic drugs, and the gullible public and profession hope for a miracle from it. There will be no miracle, because super-Tylenol is still Tylenol; it won’t be transformative because it’s just doing more of the same, faster and stronger. We need something different, a new approach, treating not symptoms of diagnoses of questionable validity, like MDD or “generalized anxiety disorder” (which was completely invented with minimal scientific data in 1980 to find a phrase to replace the older concept of neurotic depression),2 but long-term clinical outcomes of changing the course of proven diseases like manic-depressive illness and schizophrenia.
We can do better, but we’re not, because we won’t admit where we’re failing.
Let’s admit that our standard of care in contemporary psychiatry is not good enough. Our graders, the public, have failed us. Let’s get to work to improve those grades.
1. Ghaemi SN. The 'pragmatic' secret of DSM revisions. Aust N Z J Psychiatry. 2014;48(2):196-197.
2. Decker HS. The making of DSM-III : a diagnostic manual's conquest of American psychiatry. New York: Oxford University Press; 2013.
3. Ghaemi SN. Symptomatic versus disease-modifying effects of psychiatric drugs. Acta Psychiatr Scand. 2022;146(3):251-257.
4. Ghaemi SN. Drug Discovery in Psychiatry: Rethinking Conventional Wisdom. Can J Psychiatry. 2023;68(2):81-85.