Introduction: More Dives and Intellectual Jujitsu

Perhaps no branch of medicine has been the subject of so much controversy as psychiatry. Almost everything about our profession has been doubted and debated: our assumptions about the nature of psychiatric disorders from psychoanalysis to neuropsychiatry, and our interventions from ECT to CBT. Those who query and quarrel are often from outside the fold of the profession, albeit at times with help from insiders like the late great Thomas Szasz.¹ Recently, the most impassioned polemic has frequently come from other mental health disciplines-those closest to us always know our weaknesses best. The intrinsic division within our own house has also been the subject of T. M. Luhrmann’s ethnography of psychiatry.²

As of March 2, 28 states and the District of Columbia have approved medical marijuana, and there is an ever-burgeoning list of psychiatric conditions that meet the criteria for state programs-despite the concerns of many psychiatrists about the increased risk of psychosis, especially for those individuals with a diathesis.³ Yet this is also regrettably a topic on which there has been rhetoric that too often obfuscates reason on both sides. Christopher Fichtner, MD, and Howard Moss, MD, may prolong the controversy by providing more of a pro argument for medical marijuana. Medical marijuana as a phenomenon in the culture of medicine has been driven far more by the public and politicians than by practitioners and professionals. Except perhaps for our colleagues with expertise in complementary and alternative medicines, many mainstream psychiatrists are playing scientific catch-up.

No issue in psychiatry has been as contentious and protracted as the arguments and counterarguments over the DSM diagnostic system. In our own social life, most of us have learned that there are subjects where the disagreement is so intense we have to change the subject. This is exactly what we have in the article by Bruce Cuthbert, PhD, on the National Institutes of Mental Health Research Domain Criteria (RDoC). Cuthbert discusses this research-based diagnostic system and offers instructive comparisons and contrasts with DSM. The acronym RDoC is the latest chapter in psychiatry’s ongoing story of the search for a holy grail of biological etiology. Those who think this a quixotic or futile quest may take some solace in that any criteria still leave ample room for the judgment and experience of the practicing clinician.

Another article in this Special Report redux hones in on one of the most popular targets of the media: that psychiatric disorders are overdiagnosed in an effort to medicalize and medicate normal variants in human behavior. Psychiatric detractors give a variety of rationales-some suggestive of conspiracy theories-for this tendency. Rahil R. Jummami, MD, Emily Hirsch, and Glenn Hirsch, MD, take on one of the most heated topics-the diagnosis and treatment of ADHD in children. Mining the epidemiological data field, they draw interesting, and at times opposing, conclusions as befits a Special Report dedicated to dissension. Readers can decide after reading the article whether ADHD is really over-or perhaps even under-diagnosed as well as parse out the logical fallacy that a diagnosis leads ineluctably to medication management.

The last article is arguably on a subject that is the most oriented toward future debates-physician-assisted suicide (PAS) for patients with mental illness. PAS has been legal and ethical not only in Europe for years but more contemporaneously in our neighbor to the north-Canada. No other issue in our series has aroused such polarized and powerfully held opinions, and this is not surprising given that PAS or PAD (physician-assisted dying), depending on your view, goes to the heart of the ethical commitment of psychiatry as a profession of healers of the mind.⁴ We urge readers to seriously consider the positives and negatives of this momentous change in our evaluation and balancing of the age-old tension in mental health care between compassion and suffering and begin to formulate their own position and justifications for a question that urgently confronts us all.

References:

1. Szasz T. The Myth of Mental Illness. New York: Harper; 1974.

2. Luhrmann TM. Of Two Minds. New York: Vintage Books; 2000.

3. ProCon.org. The Leading Source for Pros and Cons of Controversial Issues. http://medicalmarijuana.procon.org/view.resource.php?resourceID=000881. Accessed April 5, 2017.

4. Pies R, Geppert CM. Not just a matter of semantics. Psychiatric Times. 2017;34(2)6-7.