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Anti-Psychiatry Prejudice? A response to Dr. Lieberman



Facets of the field

Kelly Hills (@rocza) was kind enough to call my attention to the guest post on SciAmMind by Jeffrey Lieberman, incoming president of the American Psychiatric Association (APA).


Frankly, I'm appalled by Lieberman's post, especially as it was invited. Although masquerading as a reasoned critique, it is anything but that. Rather, the piece is self-promotional and condescending.

Rather than respond to critics of the APA’s new Diagnostic and Statistical Manual of Mental Disorders, aka DSM-5, the Bible of psychiatry with sound arguments, Lieberman stoops to disparaging characterizations of critics as “real people who don’t want to improve mental healthcare,” and that he, as Professor and president-elect of the APA, is in a far better position to understand and solely make decisions.

Besides that it contained no data or sound arguments to his critics, the fact that Lieberman failed to disclose his own extensive conflicts of interest is quite telling, and precisely why the field of psychiatry is getting such a bad name.

I am not anti-psychiatry. I have seen the good that can come both from medications that are used judiciously and monitored carefully, and of different “talk,” insight-based therapies.

Over my decades of internal medicine practice, I have seen a shift in psychiatry that appears largely driven by reimbursement constraints and by heavy pharmaceutical detailing. Psychiatrists—and other physicians—are not reimbursed for listening carefully to patients, a time-consuming but ultimately cost-effective technique. They are paid by volume of patients seen and procedures performed, and in the case of psychiatry, effectively for medications prescribed.

To respond more specifically to Dr. Lieberman’s assertions:

To characterize critics as “misguided and misleading ideologues and self-promoters who are spreading scientific anarchy” is rather ironic, given that it is psychiatrists who have the financial gain through promoting their field and by periodically changing the ground rules. In fact, even the DSM manual is a cash cow for the APA, costing $199 per copy. New diagnoses and coding are also opportunities to sell ancillary products, be it billing software or coding classes, as happens in some other specialties.

Dr. Lieberman complains whiningly, “No other medical specialty is targeted by such an 'anti' movement.” He continues, “Being 'against' psychiatry strikes me as no different than being 'against' cardiology or orthopedics or gynecology.” 
Yes, Dr. Lieberman, psychiatry is different. These other specialties, in most cases, are far more evidence based, with more readily measured outcomes.

Lieberman then asserts, in an arrogant and offensive tone, “Like most prejudice, this one is largely based on ignorance or fear–no different than racism…many people made uncomfortable by mental illness and psychiatry, don’t recognize their feelings as prejudice. But that is what they are.”
 No. Instead, having no personal gain at stake, others are looking at psychiatry more objectively than you. We are looking for data, for evidence, and are listening to the growing numbers of patients saying that they have been harmed by medications—meds often forced on them by the medical-legal system.

As Duke University’s Dr. Allen Frances notes in the Annals of Internal Medicine, “Psychiatric diagnosis is facing a renewed crisis of confidence caused by diagnostic inflation.”
 Critics are also fueled by psychiatry’s attempts to medicalize normal human behavior, such as grief. Such efforts fly in the face of commonsense and inspire ridicule.
 Dr. Frances concludes, “These changes will probably lead to substantial false-positive rates and unnecessary treatment. Drug companies take marketing advantage of the loose DSM definitions by promoting the misleading idea that everyday life problems are actually undiagnosed psychiatric illness caused by a chemical imbalance and requiring a solution in pill form. This results in misallocation of resources, with excessive diagnosis and treatment for essentially healthy persons (who may be harmed by it) and relative neglect of those with clear psychiatric illness (whose access to care has been sharply reduced by slashed state mental health budgets).”

Even the Director of the National Institutes of Mental Health (NIMH), Dr. Thomas Insel, has rejected the DSM, stating:

“The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.

Patients with mental disorders deserve better…NIMH will be re-orienting its research away from DSM categories.

Conflicts of Interest

Let’s look at who stands to gain by the new DSM.
 First, there is the product itself. While I never thought I would agree with anything on Fox News (yes, this reveals recognition of my own bias), Dr. Ablow, in Be Wary of the APA, said of the new criteria, “But those labels aren’t driven just by science, but by political, economic and commercial forces within the American Psychiatric Association that may have nothing to do with the wellbeing of patients – or with reality. 
The labels in the DSM-V (like the Diagnostic and Statistical Manuals that came before it) have really become little more than the roadmap by which psychiatrists chase both insurance reimbursement and applause from special interest groups who lobby—sometimes very effectively—for one diagnosis to be included, or another to be removed.”

And Dr. Frances chides, “I believe that the American Psychiatric Association (APA)'s financial conflict of interest, generated by DSM publishing profits needed to fill its budget deficit, led to premature publication of an incompletely tested and poorly edited product. The APA refused a petition for an independent scientific review of the DSM-5 that was endorsed by more than 50 mental health associations. Publishing profits trumped public interest.

 New psychiatric diagnoses are now potentially more dangerous than new psychiatric drugs, because diagnostic expansions may lead to drug company promotions that dramatically increase the use of unnecessary medications, with high cost and potentially harmful side effects.”

Dr Lieberman states that the panel recommending the new APA definitions was carefully vetted and lacked conflicts of interest. The standards for claiming financial purity are pretty low:
 the amount they could receive from drug companies was set at $10,000 a year and stock holdings to $50,000, excluding research grants, were allowed.

Tufts and Harvard researchers found that 57 per cent of the APA work groups drafting the manual – had links to industry. 
I know. They are just prejudiced against psychiatry. Such examination is a witch hunt.

Perhaps the most egregious statement in Lieberman's opinion piece occurred when he referred to prior ethical lapses and barbaric treatment of patients, saying dismissively, “However, that was then and now is now."

Yes, Dr. Lieberman, now is now, and ethical lapses are still occurring. I have spent months following up on information from Dr. Carl Elliott and writing substantive, well-documented posts, such as that on why I now call for an investigation of the UMN Department of Psychiatry, on Conflicts of Interest and the whole series on Dan Markingson's death, still in progress.

Surely you are aware of the controversy surrounding the UMN’s Department of Psychiatry, and particularly around conduct of the CAFE and CATIE studies. After all, you were the Principal Investigator on these multi-center studies. Are you in denial as to the ethical breaches that occurred on this study?

Why didn’t you mention in your article that you were the PI on the study that Dr. Carl Elliott, I, and others, have been criticizing? Didn't you feel that was relevant, or that readers would know what to make of that information?

Only buried in the fine print is mention of your research on schizophrenia and anti-psychotic medications. And even the fine print doesn’t happen to mention your having received research grants from: Allon; GlaxoSmithKline; Janssen Pharmaceutica Products, L.P. (US); Merck & Co., Inc; Novartis Pharmaceuticals Corporation; Pfizer Inc.; Sepracor Inc.; Targacept 
Served on the advisory board for: Bioline; GlaxoSmithKline; Intra-Cellular Therapies, Inc.; Eli Lilly and Company; Pierre Fabre; Psychogenics; Received patents from: Repligen Corporation

You ask why there is mistrust of psychiatry and psychiatrists? You, sir, have just answered that by your omissions and by your undocumented attacks on your critics.

Do you believe the more than 2500 signatories, including those of three former editors of the New England Journal of Medicine, a former editor of the British Medical Journal, the editor of the Lancet, and numerous scholars from all over the world, are just prejudiced against psychiatry, when they ask for an investigation of UMN's Department of Psychiatry by Minnesota Governor Mark Dayton?


So many symptoms are now being medicalized, even absurdly, grief. It makes me wonder if there a DSM 5 diagnosis for someone who is self-serving, can’t accept criticism, and believes critics are prejudiced bigots?

I was very disappointed to see Dr. Lieberman’s shallow, self-serving and evidence-free diatribe appear in Scientific American as a guest opinion. He failed to reveal important conflicts of interest. He made serious claims for which he presented no evidence. He has made thinly veiled personal attacks on his critics, without offering anything substantive to counter rationally. Dr. Lieberman has failed to offer any evidence to refute assertions that Dr. Elliot and others have made, on a point by point basis.

Dr. Lieberman, instead of publishing evidence-free attacks on your critics, I invite you instead to respond point-by-point to Dr. Carl Elliott's well-documented assertions regarding ethical lapses and other problems in the CAFE and CATIE trials, on which you were the lead investigator.


Psychiatry tag cloud - Scrag/wikipedia

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The views expressed are those of the author and are not necessarily those of Scientific American.

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