For reasons that mostly escape me, I am once again sticking my nose in psychiatry’s business. Really its business—the Diagnostic and Statistical Manual that is one of the American Psychiatric Association’s major sources of income. Every so often, the APA renews its franchise on the terminology of mental illness by revamping the DSM. The DSM-III came out in 1980, the DSM-IV came out in 1994 and was minorly revised in 2000, and planning began immediately for DSM-V. That book was scheduled for release in 2011, moved up to 2012, and then recently delayed another year.

That’s an indication that all is not well in the revision process. Psychiatrists are once again fighting about which of our foibles are mental illnesses, which forms of suffering are the symptoms of what diseases, and, of course, the granddaddy of all these worries, what a mental illness is in the first place. Does a man who prefers teenage girls as his sexual partners (but who does not coerce them sexually) have pedohebephilic disorder, or is he just a creep (or for that matter responding in an unfortunate manner to a society that bombards us with images of tarted up teenagers and holds them up as the epitome of desire)? Is an adolescent who is socially maladjusted and sometimes hearing voices, but nowhere near psychotic, suffering from attenuated psychotic symptoms syndrome and in need of Abilify, and its devastating effect on metabolism, as a preventive, or is he just a weird kid? If someone you love dies and you experience in your grief five or more of the nine symptoms of major depressive disorder, are you mentally ill or just mourning your loss?

I don’t know the answers either. I do know that the most decisive thing the APA has done so far is to rename the DSM-V. It’s now the DSM-5, the better to name subsequent editions in keeping with modern naming conventions—you know, DSM 5.1, DSM 5.2 and so on. I also know that when you start to ask psychiatrists to tell you about their view of the process, they can get mighty touchy, especially if they think you are the Enemy. Which is the occasion for this post—an email response I got from a psychiatrist who had written what I thought was an interesting article suggesting that maybe the DSM was no longer necessary, that psychiatry didn’t really need its own diagnostic manual, costing 75 or 100 dollars a pop, since the United Nations’ World Health Organization supplies the International Classification of Diseases, a list of all our afflictions, physical and mental, for exactly free. (I’d link to the article, but for reasons that will become clear in a minute, I don’t want to reveal this doctor’s identity.) I wrote him to see if I could interview him further on this subject. Here is his response, unedited.

I most likely won’t be able to help you. After reading the reviews of you book on Amazon it appears to be another psychiatry bashing book. Depression is a medical illness, in fact in industrial nations it is the leading cause of disability. Doubting the reality of depression is in the same ballpark as doubting evolution. Therefore I believe your book is rather irresponsible and a disservice to people who are suffering. Depression is different in that it effects the self and everyone’s experience is different, but it is not fair to generalize your own or a few patient’s experience to everyone.

Regarding the debate about the DSM-V, one of my fears it that it will be yet another tool used against mental health. However I believe both sides in the debate are interested in making psychiatry more scientific in its diagnoses. My guess is your paper is going to suggest the debate on the DSM-V supports your own view that mental illness is someone a construct. I would urge you to think take a different approach to the debate and if you are interested in learning about the actual concerns in the scientific community about moving the nosology in psychiatry further then I can provide you with some useful info. If on the other hand you are going to repeat the same old theme about psychiatrists and how we construct mental illness then I will not be a part of that.

Now, I’ll admit to having gone a little hard on psychiatrists in my book. But I have to say that I haven’t seen the ill effects of it on them or their grasp on the mental health franchise. Nor would it be fair to say that I didn’t back up everything I said, including my contention that mental illness is at least partly constructed by psychiatrists, with scientific evidence. Speaking of evidence, it’s not my fault that there simply isn’t any to support their idea that depression is a simple biochemical imbalance. And when you consider that day in and day out they keep telling people this, and that people end up taking drugs with known side effects, not to mention start to think of themselves as biochemically defective and their depressions as personally meaningless, you really have to wonder who is more irresponsible here.

Not that I would want to diagnose disagreement as pathology, but you really have to wonder about this kind of thin-skinnedness. I mean, this doctor is a smart guy who wrote a pretty decent little paper, and he has to know that it is a fundamental violation of intellectual integrity to make conclusions about what a book says based on its reviews, let alone its Amazon reviews. He’s got to know that he only undercuts himself by doing that, that he’d be better off politely declining than going off half-cocked like this, especially if his interlocutor is an irresponsible hothead who wants people to suffer and kill themselves, and is also writing for a national magazine with a big circulation. Why would he provoke such a person, who, after all, might post his name and other particulars along with his intemperate and grammar-challenged outburst ? (Which I won’t. In fact, in my response to him, in which I reminded him that there is a difference between criticism and bashing, I repeated my admiration for his paper, so I wouldn’t want to help him torpedo his own credibility.)

So why would an otherwise intelligent man do something so dumb?

That, by the way, is a very common question in therapy. People come in, and you’re impressed by their grasp on themselves, their articulacy, their common sense, and they tell you about something they did that they know was dumb. What was the blind spot? More often than not, the answer has something to do with anxiety. Nobody’s at their best when they’re anxious. The urgency of that upwelling feeling leads us to do stupid shit.

Here’s what I think. I think the psychiatric profession suffers from an unresolved inferiority complex. I think they’re so worried about whether or not they really belong in medicine that when someone points out some of the stresses in the relationship between psychiatry and the rest of medicine, they get worried. I think Dr X is sick and tired of people pointing it out, and has not yet learned to sort out the bashers from the criticizers. He feels bashed by all of them/us. More important, my doubts (and really that’s what I am about psychiatry, including psychotherapy—doubtful) awaken his own, and he can’t tolerate that. So he lashes out.

Too bad. Because I have, to my great surprise and delight, met psychiatrists recently, important psychiatrists, who can indeed tolerate their doubts, who don’t insist that people who oppose them are creationists or dangerous, and who have the mark of intelligence described so well by Scott Fitzgerald: the ability to hold two opposing thoughts in their minds at the same time.  This guy just isn’t one of them. I suppose he suffers from doubt-deficit syndrome.

Out hawking my book, I’ve been surprised by a question that nearly every interviewer asks in one form or another: Who are you trying to piss off here?

Now part of this is undoubtedly because my book can be read as an extended rant. That intrigues talk show hosts because they are the carnival barkers of American culture, and unless they have a genuine freak on their hands, they need a fight, preferably a polarized, intractable, unresolvable “debate.” Midget wrestling, as my buddy Garret Keizer calls it.

And then the poor talk show hosts read the book (or the press release) and they realize, perhaps at the last minute, maybe even while they are on the air, that I’m not going to denounce antidepressants as the spawn of Satan, which means that the psychiatrist they have on the phone, who is ready to argue that antidepressants are manna from heaven, and I are not going to oblige the audience with a screaming match, and that actually my book is fighting an entirely different battle, one that doesn’t really fit into the pre-established narrative. So when they discover, as Leonard Lopate did, that I’m making a “nuanced argument,” they aren’t necessarily happy.

Anyway, while I wasn’t trying to piss anyone off, at least not anyone in particular, I think the people I have made the most angry are the people dependent on that polarized debate. Who aren’t just the carnival barkers, and who sometimes include people with depression. Sometimes the anger has nothing to do with me or what I have said–as in the many emails that call me out for daring to say that antidepressants are evil, which I of course do not believe. But sometimes the anger is directed at the correct target: People are pissed because I have muddied the waters.

Case in point: I was asked to give a talk to a patient group in a large American city, as part of an ongoing lecture series the group sponsors. The person who asked me to speak was very enthusiastic about the prospect, and even willing to scare up a little extra money for my trouble. She had to get her board of directors’ approval, she told me, but she was pretty sure this would not be a problem. A few days later, I got some email from her

We discussed in our board meeting having you as a guest lecturer…and although there was complete consensus that your topic is fascinating and important to convey, just not for our core audience – many of whom have struggled most of their lives with severe depression and mania and multiple hospitalizations.  So I apologize for reaching out to you before I put it before the board.  I got carried away by the chance to have you present such an interesting and provocative topic…without thoroughly considering our audience

When the drug companies started testing their SSRIs, the results were weak. Eventually, the drugs would flunk about half of their tests and pass the others with a gentleman’s C. But it didn’t really matter. FDA approval is binary. Either your drug is approved or it isn’t; its license doesn’t have an asterisk. It’s like the old question about what you call the guy who graduated last in his medical school class. (Doctor)

Not only that, but they had no reason to think that anyone would ever know the truth of their pallid results. No one except regulators, that is. FDA bureaucrats did briefly wonder if it was a good idea to approve one drug–Celexa–based on such weak studies, but they decided that since they’d already approved Prozac, Paxil, and Z0loft based on similarly dismal numbers, they really didn’t have any choice but to keep doing it.

But then Irving Kirsch and some colleagues used the Freedom of Information Act to dig up the studies mouldering in the FDA’s vault, did the analysis, and, in 2002, published the results. Subsequent studies, like the one that came out in January, have expanded on this finding, most recently to show that the drugs work primarily for severely depressed patients–which to me, means mostly that the Hamilton does what it is supposed to do: measure the effects of antidepressants on severely depressed patients. And, no surprise, in the few head-to-head studies, the tricyclics like imipramine, the drugs for which the Hamilton was invented, do better against severe depression than the SSRIs. (And shock treatment does best of all, but that’s a whole different problem.)

 Kirsch’s conclusion from his research–that placebo effects explain antidepressant action–is reasonable, but for one thing. It’s not correct. It flies in the face of what we know about the placebo effect (which is, of course, very little, research money for a sugar pill a poor investment for an industry dependent on patents): that placebo effects tend to wear off relatively quickly. But there are millions of people happily taking their SSRIs, people who weren’t severely depressed in the first place, who put up with the trouble and expense and side effects to do so, and who find life without the drugs unpleasant enough not to stop.

A much more reasonable conclusion is that whatever SSRIs are doing for these people (and they are surely doing something–drugs that tweak serotonin, like LSD and Ecstasy and psilocybin are pretty psychoactive, after all) is not showing up on Max Hamilton’s test. Using the Hamilton to find out what the drugs do to the walking wounded is like using a magnet to find feathers. So in this respect the industry is simply reaping the rewards of its own laziness, hoist on their own petard, as the Bard would have said. And the placebo effect, while real, remains something different from the drug effect, whose contours are still poorly understood.

But can this probelm be solved? Can the drug companies come up with an instrument to measure what SSRIs actually do in the people who benefit from them? No doubt. In fact, some of this research has already been done, like a recent study that showed that the drugs affect personality, lowering something called neuroticism and increasing something else called extraversion. What made patients’ depression scores go down, these researchers said, was the fact that with their personalities changed. Their lives got better with the change wrought by the drugs, just as someone suddenly able to play better tennis or sing the high notes might feel happier. Do the drug companies want to be in the business of changing personality? No, they do not. At least not officially. Because that’s what bad drugs–drugs like cannabis and LSD–do. We’re not supposed to change who we are with drugs. That would be cheating.

Pharma might change their tune if they can reverse engineer results like these, use them to create the “disease” constituted by the pre-drug personality. They’ll have to call it something less obvious than Prozac-deficit disorder, but that’s what it will be. And I wouldn’t be surprised if they’re working on it right now.