How American Psychiatry Can Save Itself: Part 2

In the February 2012 issue of Psychiatric Times, I discussed and rebutted some common criticisms of psychiatry, such as its alleged lack of “objective” diagnostic criteria and its supposed tendency to “medicalize normality.”¹I also suggested that most current criticism of DSM-5 misses the fundamental problem with the recent DSMs—namely, that in the absence of either a sound biological basis for the main disorders or a rich description of the patient’s experience of the disorders (phenomenology), the DSM framework has inadvertently left clinicians with “the worst of both worlds.”

Here I address what, in my estimation, are the primary reasons for the American public’s disenchantment with psychiatry; how the profession ought to address these issues; and how we need to replace the DSM’s categorical system with one that is clinically useful for both clinicians and patients.

What must be done?

So far, I have discussed problems with American psychiatry that, in my view, are largely peripheral to the central concerns of the average clinician—as well as to the average person who suffers from a serious psychiatric illness. In particular, the “loss of faith” in psychiatry that many in the general public evince stems from another set of concerns, both more pressing and more pragmatic than the academic debates swirling around DSM-5.

I very much doubt that many Americans lose sleep over whether psychiatry has a “unified model” of so-called mental illness; nor do I believe that the public’s animus toward psychiatry² stems primarily from concerns over the DSM-5’s development or content (although well-publicized critiques of the process have certainly not enhanced the profession’s stature).

I believe the American public’s jaundiced perceptions of psychiatry stem from the confluence of 5 main factors, specifically:

1. Psychiatry’s inability, thus far, to develop robustly effective, well-tolerated treatments for several major disorders, such as schizophrenia, autism, and most of the severe personality disorders (despite our having moderately effective treatments for bipolar disorder, panic disorder, and several other conditions).

2. Psychiatry’s increasingly and inappropriately close ties with the pharmaceutical industry in recent decades.

3. The decline, over the past decade, in the use of psychotherapy among US psychiatrists³ and the attendant public perception that psychiatrists “no longer listen” to their patients.

4. A lack of understanding among the general public of the benefits of psychiatric treatments, and not simply the risks; for example, the erroneous belief that psychiatric medications are highly “addictive” or merely “cosmetic” in their effect.⁴

5. Vituperative attacks on psychiatry by critics both within and out-side the profession, often exacerbated by Internet-based anti-psychiatry groups and lurid depictions of psychiatry in the media.^2,4

So, what is required to regain the confidence of the general public? On a concrete level, psychiatry needs to advance goals and initiatives that address each of the factors noted; for example, by: (1) lobbying for more robust and better-funded research to develop more effective and better-tolerated treatments; (2) restraining the influence of pharmaceutical companies on psychiatric education and practice while seeking a healthier and more transparent relationship with such companies; (3) ensuring that comprehensive psychotherapy training is a central part of every psychiatric residency program; (4) bolstering “outreach” and public education efforts² as well as improving communication with non-psychiatric physicians; and (5) rebutting unwarranted attacks on psychiatry while remaining receptive to constructive criticism from within and outside the profession.⁵