Anatomy of an Epidemic (40 page)

This was a topic that psychiatry did not like to talk about or acknowledge. Yet, at the same time, everyone understood what gave psychiatrists a competitive advantage in the therapy marketplace. New Jersey psychiatrist Arthur Platt was at a professional meeting in the late 1970s when a keynote speaker laid it out for them: “He said, ‘What is going to save us is that we’re physicians,’” Platt recalls.
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They could write prescriptions and the psychologists and social workers couldn’t, and that was an economic landscape that presented the field with an obvious solution. If the image of psychotropic drugs could be rehabilitated, psychiatry would thrive.

The process that led to the rehabilitation of psychiatric drugs in the public’s mind got under way in the 1970s. Threatened by Szasz’s criticism that psychiatrists did not really function as “doctors,” the APA argued that psychiatrists needed to more explicitly embrace this role. “A vigorous effort to remedicalize psychiatry should be strongly supported,” said the APA’s Sabshin in 1977.
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Numerous articles appeared in the
American Journal of Psychiatry
and other journals explaining what this meant. “The medical model,” wrote University of Kentucky psychiatrist Arnold Ludwig, is based on the “premise that the primary identity of the psychiatrist is as a physician.”
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Mental disorders, said Paul Blaney, from the University of Texas, were to be seen as “organic diseases.”
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The psychiatrist’s focus should be on making the proper diagnosis, which arose from
a cataloguing of the “symptoms and signs of illness,” said Samuel Guze, from Washington University. It was only psychiatrists, he added, that had the “medical training necessary for the optimal application of the most effective treatments available today for psychiatric patients: psychoactive drugs and ECT [electroshock].”
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Theirs was a model of care straight out of internal medicine. The doctor in that setting took a patient’s temperature, or tested blood glucose levels, or did some other diagnostic test, and then once the illness was identified, prescribed the appropriate drug. “Remedicalization” of psychiatry meant that the Freudian couch was to be trotted off to the Dumpster, and once that happened, psychiatry could expect to see its public image restored. “The medical model is most strongly linked in the popular mind to scientific truth,” explained Tufts University psychiatrist David Adler.
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In 1974, the APA picked Robert Spitzer from Columbia University to head up the task force that would, through a revision of the APA’s
Diagnostic and Statistical Manual
, prompt psychiatrists to treat patients in this way. DSM-II, which had been published in 1967, reflected Freudian notions of “neurosis,” and Spitzer and others argued that such diagnostic categories were notoriously “unreliable.” He was joined by four other biologically oriented psychiatrists on the task force, including Samuel Guze at Washington University. DSM-III, Spitzer promised, would serve as “a defense of the medical model as applied to psychiatric problems.”
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The manual, said APA president Jack Weinberg in 1977, would “clarify to anyone who may be in doubt that we regard psychiatry as a specialty of medicine.”
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Three years later, Spitzer and his colleagues published their handiwork. DSM-III identified 265 disorders, all of which were said to be distinct in kind. More than one hundred psychiatrists had contributed to the five-hundred-page tome, authorship that indicated it represented the collective wisdom of American psychiatry. To make a DSM-III diagnosis, a psychiatrist would determine if a patient had the requisite number of symptoms said to be characteristic of the disease. For instance, there were nine symptoms common to “major depressive episode,” and if five were present, then a diagnosis of this illness could be made. The new manual, Spitzer boasted, had been
“field tested,” and those trials had proven that clinicians in different facilities, when faced with the same patient, were likely to arrive at the same diagnosis, proof that diagnosis would no longer be as subjective as before. “These [reliability] results were so much better than we had expected” they would be, he said.
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Psychiatry now had its medical-model “bible,” and the APA and others in the field rushed to extol it. DSM-III is an “amazing document … a brilliant tour de force,” Sabshin said.
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“The development of DSM-III,” said Gerald Klerman, “represents a fateful point in the history of the American psychiatric profession … [and] its use represents a reaffirmation on the part of American psychiatry to its medical identity and its commitment to scientific medicine.”
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Thanks to DSM-III, wrote Columbia University psychiatrist Jerrold Maxmen, “the ascendance of scientific psychiatry became official … the old [psychoanalytical] psychiatry derives from theory, the new psychiatry from fact.”
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But as critics at the time noted, it was difficult to understand why this manual should be regarded as a great
scientific
achievement. No scientific discoveries had led to this reconfiguring of psychiatric diagnoses. The biology of mental disorders remained unknown, and the authors of DSM-III even confessed that this was so. Most of the diagnoses, they said, “have not yet been fully validated by data about such important correlates as clinical course, outcome, family history, and treatment response.”
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It was also evident that the boundary lines between disease and no disease had been arbitrarily drawn. Why did it require the presence of five of nine symptoms said to be characteristic of depression for a diagnosis of the illness to be made? Why not six such symptoms? Or four? DSM-III, wrote Theodore Blau, president of the American Psychological Association, was more of “a political position paper for the American Psychiatric Association than a scientifically-based classification system.”
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None of that mattered, however. With the publication of DSM-III, psychiatry had publicly donned a white coat. The Freudians had been vanquished, the concept of neurosis basically tossed into the trash bin, and everyone in the profession was now expected to embrace the medical model. “It is time to state forcefully that the
identity crisis is over,” Sabshin said.
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Indeed, the
American Journal of Psychiatry
urged its members to “speak with a united voice, not only to secure support, but to buttress [psychiatry’s] position against the numerous other mental health professionals seeking patients and prestige.”
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The medical model and DSM-III, observed University of Tennessee psychiatrist Ben Bursten in 1981, had been used to “rally the troops … to thwart the attackers [and] to rout the enemy within.”
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Indeed, it wasn’t only the Freudians who had been vanquished. Loren Mosher and his band of social psychiatrists also had been roundly defeated and sent packing.

When Mosher started his Soteria Project in 1971, everyone understood that it threatened the “medical model” theory of psychiatric disorders. Newly diagnosed schizophrenia patients were being treated in an ordinary home, staffed by nonprofessionals, without drugs. Their outcomes were to be compared with patients treated with drugs in a hospital setting. If the Soteria patients fared better, what would that say about psychiatry and its therapies? From the minute that Mosher proposed it, the leaders of American psychiatry had tried to make sure it would fail. Although Mosher headed up the Center for Schizophrenia Studies at the NIMH, he’d still needed to obtain funding for Soteria from the grants committee that oversaw NIMH’s extramural research program, which was composed of psychiatrists from leading medical schools, and that committee slashed his initial request of $700,000 for five years to $150,000 for two years. This ensured that the project would struggle with finances from the outset, and then, in the mid-1970s, when Mosher began reporting good results for his Soteria patients, the committee struck back. The study had “serious flaws” in its design, it said. Evidence that Soteria patients had superior outcomes was “not compelling.”
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Mosher must be biased, the academic psychiatrists concluded, and they demanded that Mosher be removed as the primary investigator. “The message was clear,” Mosher said, in an interview twenty-five years later. “If we were getting outcomes this good, then I must not be an honest scientist.”
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Soon after that, the grants committee shut off funding for the experiment altogether, and Mosher was pushed from his job at the NIMH, even though the
committee had grudgingly concluded, in its final review of the project, that “this project has probably demonstrated that a flexible, community based, non-drug residential psychosocial program manned by non-professional staff can do as well as a more conventional community mental health program.”

The NIMH never funded an experiment of this type again. Furthermore, Mosher’s ouster provided everyone in the field with a clear message: Those who did not get behind the biomedical model would not have much of a future.

Once DSM-III was published, the APA set out to market its “medical model” to the public. Although professional medical organizations have always sought to advance the economic interests of their members, this was the first time that a professional organization so thoroughly adopted the marketing practices familiar to any commercial trade association. In 1981, the APA established a “division of publications and marketing” to “deepen the medical identification of psychiatrists,” and in very short order, the APA transformed itself into a very effective marketing machine.
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“It is the task of the APA to protect the earning power of psychiatrists,” said APA vice president Paul Fink in 1986.
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As a first step, the APA established its own press in 1981, which was expected to bring “psychiatry’s best talent and current knowledge before the reading public.”
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The press was soon publishing more than thirty books a year, with Sabshin happily noting in 1983 that the books “will provide much positive public education about the profession.”
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The APA also set up committees to review the textbooks it published, intent on making sure that authors stayed on message. Indeed, in 1986, as it readied publication of
Treatment of Psychiatric Disorders
, the APA’s Roger Peele—one of the organization’s elected officials—worried anew about this concern. “How do we organize 32,000 members for advocacy?” he asked. “Who should be allowed to speak to the issue of the treatment of
psychiatric illness? Only researchers? Only the academic elite? … Only members appointed by APA presidents?”
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Very early on, the APA realized that it would be valuable to develop a nationwide roster of “experts” that could promote the medical-model story to the media. It established a “public affairs institute” to oversee this effort, which involved training members “in techniques for dealing with radio and television.” In 1985 alone, the APA ran nine “How to Survive a Television Interview” workshops.
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Meanwhile, every district branch in the country identified “public affairs representatives” who could be called on to speak to the press. “We now have an experienced network of trained leaders who can effectively cope with all varieties of media,” Sabshin said.
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Much like any commercial organization selling a product, the APA regularly courted the press and exulted when it received positive coverage. In December 1980, it held a daylong media conference on “new advances in psychiatry” that “was attended by representatives of some of the nation’s most prestigious and widely circulated newspapers,” Sabshin crowed.
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Next, it placed “public service spots” on television to tell its story, an effort that included sponsoring a two-hour program on cable television titled
Your Mental Health
. It also developed “fact sheets” for distribution to the media that told of the prevalence of mental disorders and the effectiveness of psychiatric drugs. Harvey Rubin, chair of the APA’s public affairs committee, taped a popular radio program that carried the medical-model message to listeners around the country.
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The APA had launched an all-out media blitz—it handed out awards to journalists whose stories it liked—and every year Sabshin detailed the good publicity this effort was generating. In 1983, he noted that “with the help and urging of the Division of Public Affairs,
U.S. News and World Report
published a major cover story on depression, which included substantial quotes from prominent psychiatrists.”
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Two years later, Sabshin announced that “APA spokespersons were placed on the Phil Donahue program,
Nightline
and other network programs.” That same year, it “helped develop a
Reader’s Digest
book chapter on mental health.”
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All of this paid big dividends. Newspaper and magazine headlines
now regularly told of a “revolution” under way in psychiatry. Readers of the
New York Times
learned that “human depression is linked to genes” and that scientists were uncovering the “biology of fear and anxiety.” Researchers, the paper reported, had discovered “a chemical key to depression.”
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Societal belief in biological psychiatry was clearly taking hold, just as the APA hoped, and in 1984, Jon Franklin of the
Baltimore Evening Sun
wrote a seven-part series titled “The Mind-Fixers” on the astonishing advances that were being made in the field.
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He put this revolution into a historical context: