In the past decade, the evidence base of psychiatry has been subjected to such unrelenting harsh criticism that, according to its detractors, it has nothing to offer the practicing clinician. The harshness of indictment of the scientific evidence supporting clinical psychiatry may have served to undermine mental health clinicians’ motivation to read the professional literature. Among the critics is Marcia Angell, M.D., the former editor of the New England Journal of Medicine for two decades, who famously wrote in the New York Review of Books in 2009, “…conflicts of interest and biases exist in virtually every field of medicine particularly those that rely heavily on drugs or devices. It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines” (2). In 2011, in the same journal, Marcia Angell extended her criticism in two scathing indictments of psychopharmacology and its evidence base (3) (4).
The widespread criticism of the development of DSM-5 made it awkward to insist publicly that there was a credible evidence base in psychiatry. Allen Francis, M.D, the editor of DSM-IV, vehemently complained about DSM-5 and its development. According to Dr. Francis, there was a lack of scientific basis for the classification of psychiatric disorders in DSM-5, and the DSM-5 enterprise itself had been corrupted by drug company money (5) http://www.psychologytoday.com/search/query?keys=Allen+Francis%2C+M.D.&x=7&y=9
Wrongdoing on the part of pharmaceutical companies, several book-length anti-psychiatry screeds, and Senator Grassley’s criticism of the financial reporting practices of many leaders in the field of psychiatry, further undermined the public’s confidence in the scientific basis of psychiatry.
Ironically, proponents of one of the most rigorous approaches to the analysis of data gathered from mental health studies, the evidence based approach, have claimed that the evidence based approach has made the reading of journals obsolete. (6) The evidence based approach uses a statistical method called meta-analysis to make a judgment about the usefulness of a particular approach to treatment. Meta-analysis is a statistical technique that provides answers about treatment effectiveness by combining the data from many studies at once. According to evidenced based methodology, most clinical questions about treatment can be answered simply by consulting a single meta-analysis, rather than by consulting many individual studies. According to the proponents, this saves the busy clinician the time and effort of reading the original studies, which is important as it has been estimated that the busy medical practitioner has only about thirty minutes to read the clinical literature each week. Nonetheless, it is clearly the case that meta-analyses may obscure important distinctions between studies that could prove essential in understanding the nuances of treatments, their side effects, and the methods by which they are administered.
Reading the literature in mental health can be laborious and boring. With the integrity of its authors under assault, and its methods vilified in the blogosphere and daily newspapers, a question in practical professional ethics could be raised: is reading the scientific literature in mental health any longer a professional ethical obligation?
These recent critiques of psychiatry and the mental health literature have served important functions by educating the public about major shortcomings in scientific studies of mental health and the treatment of psychiatric illness. An important and it would seem largely unintended consequence is to weaken the impetus for the further development of scientific psychiatry. There seems to be a large portion of the public and a significant number of professionals who view the development of scientific approaches to the understanding and treatment of mental illness with alarm. (7) The development of a science of psychiatry and psychology suggests to these critics a bureaucratic homogenization of human psyches and the reckless adoption of cookie cutter treatment approaches for people who may differ from each other greatly aside from the similarity of some psychiatric symptoms.
In psychiatry and other mental health disciplines there has often been what seemed to be a somewhat romanticized individualistic approach to treatment that emphasized patient trust and therapist empathy versus a more allegedly cold hearted technological approach to treatment. Behavior modification and psychopharmacology are exemplars of the technological approach. The distinction between the individualized approach and the technological approach is spurious. Behavior modification and psychopharmacology can be delivered with warmth and empathy, and non-directive forms of treatment can be delivered in a cold and tyrannical manner. Yet for many, scientific progress in psychiatry is seen as a threat that will lead to a more impersonal delivery of treatment.
Psychiatry and psychology are in their infancies as sciences. They, like other medical disciplines, are riddled with problems that must be acknowledged and addressed. Other medical disciplines have not abandoned science as their core value in understanding their fields and approaches to treatment. Mental health science in all of its imperfections is the best we have now. It, like other scientific knowledge bases, is highly likely to improve as new advances are made. It is reasonable for mental health patients to expect their difficulties will be addressed based on the best available scientific evidence. Such evidence is found in the current psychiatric and psychological literature. Mental health professionals are obligated ethically to give this literature their attention.
1. Shapin S. Never Pure The Johns Hopkins University Press: Baltimore, Maryland 2010 P.19
2. Angell, M. Drug companies & doctors: a story of corruption, The New York Review of Books. January 15, 2009.
3. Angell, M. The epidemic of mental illness: Why? The New York Review of Books. June 23, 2011.
4. Angell, M. The illusions of psychiatry, The New York Review of Books. July 14, 2011.
5. Francis. A. 2013. Saving Normal: An Insiders Revolt Against Out of Control Psychiatric Diagnosis, DSM-5, Big Pharma and the Medicalization of Ordinary Life. New York: Harper Collins
6. Sackett, D.L., Straus, S.E., Richardson, W.S., Rosenberg, W., R. and R.B. Haynes 2000. Evidence-Based Medicine: How to Practice and Teach EBM. London: Harcourt Publishers Limited.
7. Gupta, M. 2014 Is Evidence-based Psychiatry Ethical? New York: Oxford University Press.
Copyright, Stuart L. Kaplan, M.D. 2014
Stuart L. Kaplan, M.D., is the author of Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created the Diagnosis. Available at Amazon.com.