Psychiatrists Should Not Fall Back on DSM

The polemics between Drs Pies and Wakefield and Horwitz (“An Epidemic of Depression,” Psychiatric Times, November 2008, page 44) have validity, but their commentaries did not touch on the real bone of contention. Dr Pies does not believe that just because psychosocial precipitators of a depression—specifically, bereavement—are known, somehow the significance of the depression should be viewed differently.

And he has a point. Can there be depression without cause? The whole universe functions on the principle of cause and effect. There have to be antecedents to all forms of depression. But just because the cause is known to the sufferer and to the observer, should the depression be viewed as less severe despite the same degree of suffering? Psychoanalysts consider melancholia as being not too different from bereavement. Both are a reaction to the loss of something loved—the only difference is that in melancholia, the sufferer is not consciously aware of what he or she has lost because of repression. Even the defenses that prevent one from seeing his loss remain unconscious. But the metapsychological explanation for melancholia is conceptualized as a grief reaction for loss of someone, loss of something in the loved person that lessens his value, or loss of something in one’s own self that results in loss of self–esteem and narcissistic injury. These etiological explanations make us immediately recall how, after loss of a limb or loss of functions from a stroke, a person reacts with depression.

Wakefield and Horwitz are right in that as soon as one labels a psychological phenomenon such as a grief reaction using the DSM diagnostic category of MDD, out go the psychosocial antecedents and other contextual realities of the patient’s problems. The doctor reaches for the prescription pad to write a 30–day supply of the antidepressant that was touted in the last CME lecture.

What is amazing is the degree of passion that is being wasted on the importance of whether a patient’s symptoms cross the magical threshold of making it into a DSM category. Would the approach to the patient differ if he is on this or that side of the track?

The problem lies in our having created an atheoretical Frankenstein in the DSMs. Nothing like this text exists in the rest of medicine, perhaps in all of science. It has made the whole field rudderless. The human mind is incapable of dealing with disease states without associating them with causes. The current DSM edition, while ostensibly eschewing etiology, subtly favors neurobiological antecedents in conceptualizing the origins of mental disorders. Unfortunately, in the real world, all these neurobiological theories are immensely useless in dealing with the actual complaints of the patients, which are psychological and context–laden to the gills. Psychiatrists are fleeing en masse from taking any interest in what the patient really has to say in favor of selectively listening to determine which drug should be prescribed.

It is this loss of a psychological approach to the patient that Drs Wakefield and Horwitz are grieving about—and for that they get my vote, despite all the evidence–based immaculate arguments of Dr Pies to the contrary. I thank them for pointing out that the unleashing of DSM criteria on the field is destroying it.

Surendra Kelwala, MD Livonia, Mich

Dr Pies responds:

I thank Dr Kelwala for his thoughtful comments, and I suspect that our positions are actually fairly close regarding the diagnosis and treatment of depression. For example, I think we would both agree that the mere identification of a (putative) psychosocial precipitant or loss should not automatically remove the depressed or grieving patient’s condition from the realm of clinical disorder. I also agree that there is no “magical threshold” that must be crossed in order to declare a patient’s condition a DSM–level disorder; on the contrary, as I propose in another article, depressive states exist on a continuum of manifest symptoms and experiential (phenomenological) features.¹ I suspect that Dr Kelwala and I would also agree that the treatment of the depressed patient should not depend on some theoretical “threshold” for normality or abnormality but rather should focus on the patient’s safety, comfort, treatment preferences, and requirements for personal growth and recovery.

On the other hand, I am not convinced that merely providing a DSM diagnosis of major depression (if correctly arrived at) necessarily leads the average psychiatrist to become a thoughtless automaton, discarding all that we have learned about psychodynamics, social context, spiritual issues, and so on. Nor am I convinced that identifying someone as having a DSM–IV MDD leads us reflexively to reach for the “prescription pad.” To the extent this does occur, I suspect it is because one is working in a system that encourages psychiatrists to do 15–minute “med checks” and farms out psychotherapy to nonphysician mental health “providers.” DSM should not be used as a whipping boy for all the deficiencies of a mental health system that has badly broken down in this country!

On the other hand, as I noted in my commentary, there are many limitations to the categorical approach of DSM, which truly need to be remedied in the upcoming DSM–V. This certainly includes developing a psychodynamic and existential understanding of the patient. Ultimately—as I hope to show in a forthcoming editorial—psychiatric nosology should strive to link psychodynamic and phenomenological features to biogenetic and biochemical markers of disease.¹

Ronald Pies, MD Boston

Dr Pies is professor of psychiatry and lecturer on bioethics and humanities at SUNY Upstate Medical University in Syracuse and clinical professor of psychiatry at Tufts University in Boston.

Reference

1. Pies R. The anatomy of sorrow: a spiritual, phenomenological, and neurological perspective. Philos Ethics Humanit Med. 2008;3:17. June 17, 2008. http://www.peh–med.com/content/3/1/17. Accessed May 4, 2009.