Is psychiatry more guesswork than medical science? That's the provocative question posed by psychotherapist Gary Greenberg in The Book of Woe: The DSM and the Unmaking of Psychiatry.
Greenberg argues many basic tenets of psychiatry are based on soft science and the Diagnostic and Statistical Manual of Mental Disorders (DSM) — the reference book psychiatrists use to guide diagnoses and treatments — is largely a work of fiction. He also contends the many psychological disorders the DSM describes have no definitive biological markers, are often diagnosed by hunch, and may not even be real.
What's more, psychiatrists have a financial incentive to use the DSM's diagnostic labels because insurance companies require them to do so before paying for treatment.
The net result: Many people diagnosed with depression, anxiety, bipolar disorder, and other "official" mental-health conditions may come to view their problems as biological problems — like heart disease or cancer — and falsely believe the only solution is a drug.
That kind of thinking, Greenberg argues, prevents them from taking active steps to heal, recover, and manage their problems in healthy ways.
"By telling somebody they're suffering from a disease, it changes the way people understand themselves and their problems," Greenberg tells Newsmax Health, arguing that psychiatrists need to stop treating everyday problems like "pathological diseases" with biological roots requiring medical treatment.
"Let's say I'm depressed and I go to my doctor and my doctor says I have a biochemical imbalance and puts me on Prozac ... Instead of thinking about [how to cope with] the problems I have, I think I have a chemical imbalance. In many cases, that explanation guides the way the patient thinks about his own condition and suffering."
The problem, he says, is there is little scientific evidence that brain chemistry is at the root of many mental disorders. Drugs don't cure such conditions, but treat only symptoms. Psychiatrists should do more to help troubled individuals see their problems as issues they can address or manage by changing their behaviors and their thinking to cope, he argues.
"We have this idea that our lives are our lives to live, that basically we understand our lives are something we are supposed to fashion and make something of," he explains.
"And our society depends on the idea that we take responsibility for our lives. And while there are many problems with that idea, there are even more problems when you put it outside of your [power] — when you say: 'There's nothing I can do about my depression, but take the pills my doctors gives me. ' "
Greenberg’s book is the result of two years of research and interviews with many insiders in the psychiatric establishment on the DSM. First published in 1952 and frequently revised, the DSM reflects the official take of modern-day psychiatry on mental illness. But over the years, the book has taken many controversial and even embarrassing positions that were later reversed or overturned.
Homosexuality, for instance, was deemed a mental illness until 1973 and controversies over the book's waffling positions on autism have dogged its authors right through the latest, fifth edition, published this year. Greenberg and other critics say the book pushes doctors to diagnose ever more illnesses based on fuzzy definitions of symptoms and prescribe a growing list of powerful, sometimes risky drugs.
As a result, sadness over a job loss or divorce can qualify as clinical depression.
Greenberg is not arguing that psychotherapy does not help people. But he contends the most effective therapy helps patients take control of their lives and focus on solution-oriented ways to deal with their struggles instead of diagnosing possible biochemical causes, which are often unknown and unknowable.
"Psychotherapy works by the placebo effect, but that doesn’t mean it's a scam," he says. "It's based on the relationship between therapist and patient. But a DSM diagnosis doesn't have much to do with that.
"The problem is that we expect a diagnosis of a medical condition to be something that is scientifically ascertained through scientific findings, but that isn’t always the case with mental illnesses … Psychiatry doesn’t have any biomarkers for mental illnesses, so the DSM's attempts to put mental health into medical language fails. I don’t think it's doable."
Greenberg knocks the American Psychiatric Association (APA) and drug companies for turning psychiatry into a money-making enterprise that treats individuals' daily life struggles as illnesses that require medication.
"It has a lot to do with economics and the way healthcare is funded. We need we have to have a [DSM] diagnosis to attach a payment to service," he says. "So in that respect economic incentive is behind all of these efforts. The incentive has to do with money and power. If you want to get money to research some kind of mental disorder [from] the National Institutes of Health, you have to tie your research to a specific diagnosis. The rest of the research that is done is done by the pharmaceutical companies, and it's far easier to get your drug approved if you have a specific condition it treats. "
Not surprisingly, the Book of Woe — like Greenberg's 2010 book Manufacturing Depression — has sparked intense debate in the mental-health community. Critics — including some within the APA (which declined a request for comment from Newsmax Health) — have suggested Greenberg's ideas are irresponsible and could lead some seriously ill patients to stop taking antidepressants and other meds.
"I'm not advocating that people on meds stop taking them," he says. "And by the way some patients' lives have been saved and vastly improved by virtue of treatment of psychiatrists. But psychiatrists do not treat mental disorders; they treat symptoms. It's not only that there’s no cure, but the reason for the underlying mechanisms for these disorders is not well understood."
He adds that he is concerned that the debate over his book might cause lead some suicidal patients to stop taking their medications.
"I'm more than vaguely concerned about the precious life of any person," he says. "But I believe the truth is the most important thing. And I’m sure whatever damage my book might do is doing less damage than psychiatric drugs are doing."
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