links between drug companies and

Links Between Drug Companies and Psychiatry

Diagnosis in mental health is detailed in the fourth Diagnostic and

Statistical Manual (DSM-IV), published by the American Psychiatric

Association. The New York Times today published a report of a study

claiming to show links between the authors of DSM-IV and

pharmaceutical companies. The report stated,

The researchers found that 95 -- or 56 percent -- of 170 experts

who worked on the

1994 edition of the manual, called the Diagnostic and Statistical

Manual, or

D.S.M, had at least one monetary relationship with a drug maker in

the years from 1989 to 2004. The most frequent tie involved money

for research, according to the study, an analysis of financial

records and conflict-of-interest statements.

Honestly, I'm not surprised or upset by the relationship. DSM-IV is

published by psychiatrists for use by psychiatrists. It reflects a

medical model of mental illness, and most of the experts who work on

it are researchers in the biological side of treatment. Most of

psychiatry is conducted drug treatment. Psychiatrists prescribe

medication. Psychologists, social workers, psychotherapists and

counselors conduct psychotherapy. A few psychiatrists still dabble in

psychotherapy, but they are a dying breed.

Not surprisingly, then, DSM-IV works fine for medical management of

mental illness. It stinks as a diagnostic tool for psychotherapy. Let

me show you how it works. A person is diagnosed along five "axes:"

I. Clinical disorders

II. Personality disorders or mental retardation

III. General medical conditions

IV. Psychosocial stressors

V. Global Assessment of Functioning

Axis I disorders correspond to depression, anxiety, and other problems

that we normally treat (and are advertised on TV). Axis II refers to

personality problems that are long-standing. (Why personality

disorders and mental retardation are linked is beyond me.) Axis III

details medical status. It's important to know this, as many medical

illnesses may manifest the same symptoms as depression or anxiety.

Axis IV describes psychosocial stressors in very general terms. Axis V

describes a person's level of functioning with a 0 to 100 scale.

So, for example, a person might have the following diagnoses:

I. Major depressive disorder, moderate, recurrent

II. Borderline personality disorder

III. No diagnosis

IV. Problems with the primary support group

V. Current GAF 57

There are myriad problems with this scheme. First, the use of the term

"axis" implies that each axis is independent from the others. Nothing

could be further from the truth. People with personality disorders,

for example, are more likely to have anxiety and depressive disorders

than others without personalty disorders.

Second, we don't really know what a "disorder" is. In most cases,

there is evidence of both psychosocial and biological causes for a

client's complaints. Both psychological and biological treatments are

effective for the same "disorders." So, what are we really treating?

Third, this scheme doesn't describe the quality of the client's life

very effectively, and that's what we really deal with in

psychotherapy. Axis IV, where this should be placed, is very general,

and poorly delineated. "Problems with the Primary Support Group,"

covers a lot of ground, from arguing with your wife to repeated sexual

abuse of a child.

Fourth, assessment of these disorders remains rooted in the clinical

interview. We've known since the 1950's, with a book by Paul Meehl

that clinical interviewing is not very reliable. Unfortunately,

psychologists, who are the true experts in assessment, have dropped

the ball entirely. We have not generated the kind of data necessary to

add psycosocial assessment to the diagnostic manual.

So, why do we need diagnosis at all? We need it to describe what we're

treating. We need it to organized our research into better treatment

methods. So as a result, we limp along with the diagnostic manuals as