Psychiatry's valid but dishonest reconsiderations

USA Today (Society for the Advancement of Education), March, 2008 by Richard E. Vatz, Jeffrey A. Schaler

Regarding the claim of more than 55% of Americans suffering from mental illness, Paul McHugh, former chief of psychiatry at Johns Hopkins Hospital, incredulously and famously stated, "Fifty percent of Americans mentally impaired--are you kidding me?" McHugh is one of the more skeptical psychiatrists whose writing reveals significant agreement with Szasz and yet, who, one may assume due to sociologically approved distaste for Szasz among mental health professionals, refuses to give him credit for his original skepticism and critiques of psychiatry. One finds in McHugh's impressive, if not original, treatise in Commentary ("How Psychiatry Lost Its Way," December 1999) many criticisms of psychiatry that first were made by Szasz, including the following:

* We are witnessing a proliferation of new, nonorganic, bogus psychiatric disorders.

* Psychiatry utilizes reliability of psychiatric disorders (testing to see if diagnosticians agree on what psychiatric disease patients suffer from) instead of focusing on the gold standard: the validity of psychiatric diagnosis or, in other words, whether it measures what it claims to measure.

* In psychiatry, as opposed to somatic medicine, the symptom is the disease, rather than a sign for the disease.

* There is collusion between some pharmaceutical companies and some psychiatric diagnosticians.

* The problematic DSM approach of "using experts and descriptive criteria in identifying psychiatric diseases has encouraged a productive industry."

* There is a profound consequence of self-fulfilling prophesy in the public positing of new psychiatric disorders.

* Positing "biological markers" for psychiatric disorders is unreliable and invalid.

* The changing of behaviors by psychotropic drags ("Everyone is more attentive when on Ritalin ...") affects anyone who takes them and cannot be used validly as indicative of psychiatric disorders.

Actually, there is the one point for which McHugh does give Szasz credit: "Exercises in mental cosmetics should be offensive to anyone who values the richness of human psychological diversity."

From discussions long ago with McHugh, we know the personal distaste he has for Szasz, but this should not prevent him nor his psychiattic brethren from citing the lineage of these important and compelling points. There still are profound differences between Szasz and his psychiatric critics, including the vital component of free will claimed by Szasz in literally all alleged psychiatric disorders from "drag addiction" to "anorexia nervosa," but their differences are narrowing, and McHugh should have acknowledged that.

These points serve as continuing topoi for new skeptics in psychiatry. One now can find the objections to the overdiagnosis and overmedicating of children and, to a lesser extent, women and people in general in book after book. All of these criticisms are intellectually and academically indebted to Szasz's work.

The new self-skepticism in psychiatry has reached its current zenith with the publication of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. The authors, Allan V. Horwitz and Jerome C. Wakefield, are not physicians, but professors of sociology and social work, respectively. They combine the in-house skepticism of psychiatric diagnosis--this time focusing on depressive disorder--with the ethically suspect ignoring of Szaszian ideational and evidentiary lineage. The book's main contention is that normal sadness has been "medicalized" or "pathologized" into "depressive disorder" due to the ignoring of the normalcy of sadness in many contexts, as well as the lack of use of exclusionary criteria, the proper utilization of which eliminate most instances of normal, situational depression's falsely being diagnosed as disordered depression. In addition, the arbitrariness of DSM's duration criteria and its lack of confronting its own criteria of intensity and length of time of suffering add to the misdiagnoses. The book potentially is quite significant to the practice of psychiatry, because limiting diagnoses of disordered depression--often cited as resulting in the invalidating of up to 20% of psychiatric diagnoses--would put quite a crimp into the patient numbers, prescription counts, and third-party coverage. The consequences of acceding to their recommendations are not addressed by Horwitz and Wakefield.