Over the past couple of days, I have been deeply absorbed in two new books on American psychiatry—books that are, without exaggeration, poles apart on the question of psychiatry's direction and influence.
Ethan Watters's insightful and original study Crazy Like Us: The Globalization of the American Psyche (Free Press, 2010) demonstrates how widely and deeply DSM diagnoses have permeated other cultures, to the point of redefining how they think about mental illness. By contrast, Judith Warner's troubling and highly tendentious We've Got Issues: Children and Parents in the Age of Medication (Riverhead, 2010) not only does an about-face on her earlier book, Perfect Madness: Motherhood in the Age of Anxiety, but also tries to cast scholars like Watters as hysterical "naysayers" who are exaggerating the risks of overmedication and, in doing so, creating fresh problems for those seeking remedies for their suffering.
The differences between these two books are striking. Watters and Warner have focused on more or less the same phenomenon, but come up with diametrical assessments of it, a source of interest in itself. Watters contends, "It turns out that we have not only been changing the way the world talks about and treats mental illness—we have been changing the mental illnesses themselves." Warner writes, quite seriously, "People who share the views I used to espouse don't see themselves as prejudiced. They believe they are raising their voices in protest of a world that's gone mad, and, in particular, providing necessary push back against a pharmaceutical industry that's grown way too powerful." Their "naysaying" is "voiced as concern," she concedes, "but what it really is, most of the time, is prejudice. And it's a poison."
Because Watters's perspective is so original and his book so full of facts and evidence, I will save my comments on it for a separate post. A brilliant book, it deserves a thoughtful read, as well as all the praise that has been bestowed on it.
With Warner's book, on the other hand, one wonders in disbelief how a popular and talented New York Times columnist could build her book around claims such as "People who share the views I used to espouse don't see themselves as prejudiced," and not feel a twinge of embarrassment in doing so. Her judgment is all the more surprising because the book is explicitly an about-face on Perfect Madness, where American "hyper-parenting" (compared with France's more laissez-faire approach to child-rearing) struck Warner four years ago as "just plain crazy," not least in its emphasis on Ritalin as a means of advancing what she viewed as frenzied American perfectionism.
All that has gone in We've Got Issues, an aggressive, but rather shallow diatribe that draws from the same pool of anxiety as critics of the pharmaceutical industry, yet turns on them, ultimately, as perpetrators of a "poisonous" prejudice. It would be difficult to find a more-perfect example of Warner's bad faith, not least because, as she writes, she held the same perspective for years. (She had reason to do so. The Food and Drug Administration warned in May 2007 that SSRI antidepressants were increasing suicidality in children and teens, but most of that is swept under the rug in her book.) All the evidence and facts that her critics can marshal—indicating negligible advantages to blockbuster drugs and highly questionable but momentous decisions by influential psychiatrists that their colleagues have denounced as bad science—are simply deleted or mischaracterized in We've Got Issues, to the point where the whole exercise smells frankly of dishonesty.
Warner simply lines up the titles of books that irk her, mine among them, deletes all their multiple supporting footnotes, including to hundreds of relevant studies and articles, and isolates a phrase or two to make their arguments seem hyperbolic. From her drive-by assessment of my book Shyness: How Normal Behavior Became a Sickness, for instance, one would never know that the book reached deeply into an actual archive—a substantial body of papers on the revisions to the third and fourth editions of the DSM, which led to the creation of 112 new mental disorders in the 1980s, some of them so absurdly ill-defined that one participant was led to reveal to the New Yorker magazine in January 2003: "There was very little systematic research [in what we did], and much of the research that existed was really a hodgepodge—scattered, inconsistent and ambiguous. I think the majority of us recognized that the amount of good, solid science upon which we were making our decisions was pretty modest."
And what is Warner's archive? Certainly not the results of one study, which found that only one-in-five patients taking antidepressant medication actually has symptoms of depression. The rest are taking drugs for which they have no clear medical need. Nor is Warner's thesis shaken by her own reports of watching the superb 2008 Frontline documentary "The Medicated Child," and seeing pediatricians put children with diagnoses of bipolar disorder on what she admits are "dizzying numbers of drugs," with results so unfortunate that one boy named Jacob is left "with a terrible, neck-wrenching tic." No, Warner, whose book exudes "the passion of a new convert," as her Times colleague aptly notes, relies far more on journalism than scientific studies of medication. She also draws from interviews with psychiatrists like Peter Kramer over whether he believes his colleagues overprescribe.
It is of course much easier to ask the inventor of terms such as "cosmetic psychopharmacology" whether he thinks his colleagues overprescribe, turning a practical issue into a loaded moral one, than whether he thinks the drugs that they do prescribe in large numbers actually work, outweigh their many known hazards and side effects, and whether the DSM criteria on which their prescription is based are unequivocally correct. Warner's framing that scientific issue as an emotional one gets the issue precisely wrong. To the critics she is so quick to mischaracterize, the problem needing careful assessment is not that psychiatrists are misleading the public. We can take their prescription treatments as based on good intentions, yet still ask whether the prescriptions themselves are doing a great deal of harm.
That Warner gets this key issue wrong is a major reason she is so tone-deaf to all the discussions now unfolding around her, including by former editors of the DSM acknowledging, in ways that DSM-5 wrangling fortunately has forced to a head, that serious diagnostic mistakes were made in the past. (Frances's blog on this site, "DSM-5 in Distress," includes posts such as "DSM-5 Sexual Disorders Make No Sense" and, more relevant here, "DSM-5 Will Expand the 'Epidemic' of ADD" [his quotes, not mine].) It's a shame, too, that Warner's interview with Kramer didn't tackle another of his phrases, "diagnostic bracket creep," which would have put the matter of overdiagnosis far more centrally up for discussion, without unpleasant charges that the scholars assessing it are perpetrating "prejudice" and "poison."
One closes Warner's rambling and surprisingly poorly written book with an unshakable impression that she has done a profound disservice to the issues she wanted to discuss. One learns a lot more about the contentions dividing American psychiatry by reading the op eds of former DSM-editor Frances, including ones titled "It's Not Too Late to Save ‘Normal': Psychiatry's Latest DSM Goes Too Far in Creating New Mental Disorders." Of all the ironies, that piece has been reprinted at least once with the title, "Allen Frances: "Let's Save Normalcy from the Psychiatrists." Indeed.