CanJPsychiatry 2013;58(10):555–559
In Review
Psychiatry and Fads: Why Is This Field Different From All Other Fields? Edward Shorter, PhD, FRSC1 1
Hannah Professor of the History of Medicine, Professor of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario. Correspondence: History of Medicine Program, Faculty of Medicine, University of Toronto, 150 College Street, Room 83G, Toronto, ON M5S 3E2; [email protected].
Key Words: fads in psychiatry, dexamethasone suppression test, selective serotonin reuptake inhibitors, Diagnostic and Statistical Manual of Mental Disorders—Fifth Edition, DSM-5, classification, diagnostic categories, diagnosis, psychiatric diagnosis Received January 2013, revised, and accepted March 2013.
Fads in psychiatry are little more than bad ideas with short half-lives. They have arisen because of the great discontinuities that have swept psychiatry unlike other specialties in the 20th century: the transition in the 1920s from asylum-based biological psychiatry to psychoanalysis, and the transition in the 1960s from psychoanalysis to a biological model based on psychopharmacology. In no other medical specialty has the knowledge base been scrapped and rebuilt, and then again scrapped and rebuilt. In these great transitions, when psychiatry each time has had to reconstruct from scratch, bad ideas have crept in with good. Psychiatry, in its heavy use of consensus conferences, is often unable to employ science as a means of discarding fads, which, once installed, are often difficult to remove. Each of the great paradigms of psychiatry in the last hundred years has given rise to fads, and psychopharmacology is no exception, with faddish uses of neurotransmitter doctrine claiming centre stage. Only when psychiatry becomes firmly linked to the neurosciences will its subjugation to the turbulence of faddism be moderated. WWW
La psychiatrie et les modes passagères: pourquoi ce domaine est-il différent de tous les autres? Les modes en psychiatrie ne sont guère plus que de mauvaises idées ayant de brèves demi-vies. Elles sont apparues en raison des grandes discontinuités qui ont balayé la psychiatrie comme nulle autre spécialité au 20e siècle : la transition dans les années 1920 de la psychiatrie biologique des asiles à la psychanalyse, et la transition dans les années 1960 de la psychanalyse à un modèle biologique fondé sur la psychopharmacologie. Aucune autre spécialité médicale n’a vu sa base de connaissances démolie et reconstruite, puis démolie et reconstruite encore. Dans ces grandes transitions, où chaque fois la psychiatrie a dû recommencer à neuf, de mauvaises idées se sont insinuées avec les bonnes. La psychiatrie, qui s’appuie lourdement sur les conférences consensuelles, est souvent incapable d’employer la science comme moyen d’éliminer les modes qui, une fois en place, sont souvent difficiles à écarter. Chacun des grands paradigmes de la psychiatrie des 100 dernières années a donné lieu à des modes, et la psychopharmacologie ne fait pas exception, avec sa mode d’utiliser la doctrine des neurotransmetteurs qui réclame le centre de la scène. Ce n’est que lorsque la psychiatrie deviendra fermement liée aux neurosciences qu’elle pourra calmer sa fascination pour la turbulence des modes passagères.
One of the things I’m exquisitely sensitive about, particularly in American psychiatry . . . is that we have long been a fad-prone group of professionals. Whatever new trendy thing comes along, we not only buy into it, but we package it, market it, push it to extremes and overdo it. —Ross J Baldessarini1, p 24
O
ther medical specialties can err. Cardiology discovers an overdependence on invasive procedures. Nevertheless, most medical specialties do not periodically scrap their www.TheCJP.ca
entire knowledge base to rebuild again from zero. In the retrospect of time, as we look back over the past hundred years, this is exactly what has happened in psychiatry, leaving the field vulnerable to bad ideas along with good as psychiatry slowly rebuilds. Psychiatry as a clinical discipline aspires to the neurosciences for its scientific base. Nevertheless, other neuroscientists often just roll their eyes at a field that relies on patients’ own accounts of their woes as its database. Gripped in the turbulence of changing paradigms, psychiatry has taken a couple of colossally wrong turns over the years. The Canadian Journal of Psychiatry, Vol 58, No 10, October 2013 W 555
In Review
The whole DSM concept and the ditching of effective but out-of-patent drug classes in favour of blockbusters would be 2 good examples. And these fundamental problems require recognition and confrontation by psychiatry. However, fads as well seem to drive much of psychiatry. Under what circumstances does faddishness develop? Is it because in psychiatry diseases are poorly understood, whereas in orthopedic surgery they are well understood?2 No, it is more complicated than that. Cancer, for example, is poorly understood, yet there are few fads in cancer chemotherapy or radiation oncology because 1. the evidence base is rigorously biological rather than verbal stories, and 2. because both cancer chemotherapy and radiation oncology have been building in a steady and continuous manner. In psychiatry, the basic problem is that, from the early 20th century to the present, the field has lurched back and forth among paradigms in a way that has happened in no other discipline.3 Each lurch has sprayed off its own accumulation of fads and bad ideas. Around 1900, psychiatry was imbedded in an asylum-based biological paradigm. The operative diagnostic concept was degeneration, and the knowledge that a patient’s ear was too big or there was a crazy grandmother in the family tree sufficed to confirm the diagnosis of degenerative insanity. Such diagnoses themselves had trajectories that lasted for decades (degeneration first surfaced in psychiatry in 1860) and were not in themselves faddish. Nevertheless, the biological spin of the day gave rise to a vogue for eugenics, or trying to maximize the soundness of the gene pool; the therapeutics of the day included such short-lived frills and furbelows as dietary treatments for psychiatric disorders (in chic private nervous clinics) and blue-light wands that emitted mild buzzes for cataleptic stupors. With the triumph of psychoanalysis in the 1920s, a different set of fads rushed on board. Psychoanalysis, though profoundly wrong-headed, was not a fad, simply because it stayed around for decades and even today has a certain following (mainly in university departments of English). However, it gave rise to such vogue-ish notions as “la belle indifférence” (actually, Jean-Martin Charcot’s term) as a supposed sign of hysteria: the patient gaily chattered about symptoms that in and of themselves must have been quite unendurable. Freud saw it as a mechanism of “repression.”4 But la belle indifférence came and went, and today only Abbreviations DSM
Diagnostic and Statistical Manual of Mental Disorders
DST
dexamethasone suppression test
HPA hypothalamic–pituitary–adrenal NE norepinephrine SSRI
selective serotonin reuptake inhibitor
556 W La Revue canadienne de psychiatrie, vol 58, no 10, octobre 2013
Clinical Implications •
Psychiatric knowledge has been subject to great upheavals during the past century and many former truths have now been discredited.
•
There are valid biological tests in psychiatry, such as the DST.
•
Psychiatry is more subject to fads than other medical specialties, and booms in diagnoses or therapies must be carefully assessed.
Limitations •
This research is based on historical sources, not contemporary clinical data.
•
It is often difficult to separate fads from science: what appears today as a fad may tomorrow be viewed as a building block of knowledge.
very senior clinicians will even have heard of it. It may be considered one of the many fads that psychoanalysis tossed off. And then psychoanalysis was toast. In the 1960s, an entirely new paradigm rushed into psychiatry, a revival of biological thinking but this time based on psychopharmaceuticals rather than gloomy genetic notions about the species going to pot. Now, consider the disruption caused by each of these huge discontinuities in paradigms. The shift from the first biological psychiatry to psychoanalysis basically threw out all previously accumulated biological knowledge in favour of theories about unconscious conflict. For example, the Vienna psychiatry professor Theodor Meynert had indicted in 1884 the forebrain as the locus of psychiatric illness.5 Forgotten. And the recent (re-)discovery of the prefrontal cortex as a crucial site6 occurred to much loud self-congratulation, as psychiatry was unaware that others had trodden these lanes far, far before. Psychoanalysis had wiped the slate clean. And then psychoanalysis itself dissolved, and dogmas, such as unconscious conflict that had dominated psychiatry for the previous 50 years, were simply tossed out the window, and, again, psychiatry faced a blank slate. With the help of industry, the knowledge base of psychiatry became psychopharmacology. Thus here is the problem: with each paradigm shift, with each blank slate, we start again building psychiatry’s knowledge base from zero. And in all the fumbling that goes with such construction, inevitably bad ideas slip in with the good. If the bad ideas are identified quickly as useless, they become fads. If they have a longer half-life, they qualify simply as failed concepts. Thus that is the difference between a fad and a bad idea: a fad is a bad idea with a short half-life. A bad idea with a long half-life, such as the hysteria diagnosis or Oedipal conflict, we call a failed concept. Fads are just failed concepts that are disposed of quickly, such as the Feingold Diet in the treatment of attention-deficit hyperactivity disorder, a low salicylate diet www.LaRCP.ca
Psychiatry and Fads: Why Is This Field Different From All Other Fields?
that banned artificial chemicals, introduced in the 1960s by pediatrician-allergist Ben Feingold.7 Consider psychopharmacology, a field rife with fads. There is nothing faddish about the basic concept of psychopharmacology: serious mental diseases are diseases of the brain, and pharmacotherapy is capable of reaching into the wiring of the brain and rejigging it. Psychiatry now possesses effective medications, and this is a precious acquisition not to be scorned. But a whole latticework of fads has been woven about the basic notion that drugs work. It was once thought that given neurotransmitters were specific for given disorders, and a whole faddish apparatus was erected by Joseph Schildkraut in 1965 called the NE hypothesis of depression8; it was the idea that depression was caused by a shortage of NE. This was discarded soon enough owing to the discovery that the biogenic amine neurotransmitters interact in many psychiatric disorders.9,10 Nevertheless, the NE hypothesis basked briefly in the limelight—a complete fad. Other fads in psychopharmacology are driven by pharmaceutical advertising, a product not of science but of the struggle for market share. Despite the US Food and Drug Administration’s supposedly rigorous surveillance of the content of pharma advertising, fads pop up. The idea that depression can be successfully treated by inhibiting the reuptake of serotonin gave rise to the SSRIs, a drug class that gained powerful currency. But whatever the real mechanism of action of the SSRIs—agents undoubtedly effective in anxiety and obsessive–compulsive disorder—they are not formidable antidepressants, and the actual neurochemistry of affective disorders is veiled yet in shadow. The SSRIs have been a fad. Psychiatry is probably more vulnerable to fads and bad ideas that other medical specialties because in psychiatry it is almost impossible to disprove anything. People ride in with a fad, such as Seasonal Affective Disorder (commonly referred to as SAD) proposed by Norman Rosenthal in 1984 (see Rosenthal et al11). It has low face value, and the data on it are difficult to interpret. But, the question is, how to get rid of the wretched thing? Not knowing the brain mechanisms involved in the production of psychiatric disease, we find it difficult to demonstrate that a hypothesis fails. The problem is compounded in that patient data are mainly oral testimony and the outcomes are often indeterminate. In cardiology, it is relatively easy to cast doubt on the idea that moonbeams cause heart attacks. Less so in psychiatry, because to discredit the hypothesis that moonbeams cause depression one would need some notion of the biological mechanisms involved in depression. Or else one would require an elaborate epidemiologic study that only a pharmaceutical company could finance. Of course, other medical fields are not exempt from bad ideas. In retrospect, bleeding and purging turned out to be terrible ideas, and were disproved with proper scientific data: patients who were bled did less well than those who www.TheCJP.ca
were not.12 But other fields are less vulnerable to short-term bad ideas because there is a basic consensus in cardiology or nephrology about mechanisms, and the barrier of dubiety over which bad ideas would have to clamber is very high. In psychiatry, this barrier is quite low, and thus the door is opened for fads and bad ideas to march in and stay around for the longest time ever. Hysteria marched in some time during the 17th century and was frog-marched out again by the women’s movement in the 1970s. Psychoanalysis marched in with Sigmund Freud’s The Interpretation of Dreams in 1900 and began to seep out with the triumph of psychopharmacology and the biological paradigm in the 1960s and after. Thus there are basically 2 mechanisms for getting rid of fads and bad ideas, and one of them is heavily used in psychiatry. One mechanism is scientific disproof, demolishing a notion with scientific data. The notion floated in the 1950s that schizophrenia was caused by toxic metabolites—adrenaline metabolized into adrenochrome13—was abolished with data. That concept was a fad rather than a bad idea because it lasted only for a few years: from the adrenochrome hypothesis of Abram Hoffer and Humphrey Osmond in Saskatoon in 1954 to the demonstration in 1959 by Seymour Kety at the National Institute of Mental Health that people with schizophrenia had no adrenochrome in their urine and that they metabolized adrenaline at the same rate as control subjects.14,15 Of course, psychiatry shares this fondness for scientific examination of hypotheses with other medical fields. Nevertheless, in psychiatry, fads and bad ideas are usually abolished by consensus rather than by data. And this is a profoundly unscientific way of proceeding because consensus emerges from group process and not from research. Consensus conferences are much commoner in psychiatry than in other fields. A Google search for “consensus conference cardiology” produced 118 000 hits; a search for “consensus conference psychiatry” produced 458 000 hits. And often the consensus arises from without the discipline! It was a consensus arising from the women’s movement about female psyches being largely identical to male that led to the abolition of the hysteria diagnosis in the 1970s: hysteria was mainly a female diagnosis and postulated that women’s brains were different from men’s. Thus among the drafters of DSM-3, which appeared in 1980, there was consensus that hysteria had no place. Nobody ever disproved that women were not hysterical. It has largely been consensus rather than systematic disproof that has led to the vanishment of psychoanalysis in psychiatry. People became convinced of the efficacy of pharmacotherapy and of the correctness of a genetic approach to understanding psychiatric illness. In psychoanalysis, there was no place for either psychopharmacology or genetics— both of which postulated brain mechanisms rather than psychodynamics in what used to be called mental illness, a term that now appears dated. The Canadian Journal of Psychiatry, Vol 58, No 10, October 2013 W 557
In Review
Thus it happens that on the shattered ruins of psychiatry’s past the fads and fashions of today are built. Unquestionably, there is faddism in diagnosis, and Joel Paris has blown the whistle on the bipolar spectrum.16 However, it is in pharmacological therapeutics that the real differences between fads and science begin to become manifest. Why do some drug classes disappear and others spread with almost viral speed? Could it be demonstrations of differential efficacy? Readers familiar with the history of drug treatments in psychiatry can only smile at this proposition. Why did the barbiturates and amphetamines disappear, with small exceptions, from the psychiatric formulary? Both were useful in the treatment of mood disorders and anxiety. Was it that they were so dangerous and addictive? Doctor, have you tried getting your patients off Paxil (paroxetine) and Effexor (venlafaxine)? Or were they defeated by a consensus, crystallized around pharmaceutical advertising, that the benzodiazepines must be superior because they were newer (and patent-protected)? The benzos were actually an excellent drug class themselves. Why were they defeated by the SSRIs? Was it through scientific data? Or was it through massive pharmaceutical hype about the dangers of addictiveness (which many senior clinicians believe were vastly overblown).17 Thus the constant waxing and waning of different drug classes may be seen as the result of the march of science, though people who know the history of psychopharmaceuticals will raise an eyebrow.18 Or it may be seen as the playing out of endless fads and bad ideas against the backstory of billions of dollars in profit for the pharmaceutical industry. And why is it that no new SSRIs have been launched in the past 20 years? (The last, sertraline, was patented in 1981.) Is it because science has been unable to produce new variants? Or because a consensus is forming in psychiatry that inhibiting the reuptake of serotonin in the brain is probably not the route to the therapeutic grail? (This is a vast subject, and, from the gigantic literature, let me cite only 2 things, one written by David Healy19 and one by me.20 Thus the form but not the content of the earlier period of biological psychiatry has seeped back into the post1960s version of biological thinking, or “the second biological psychiatry,”3, p 239 as one might call it. The form asserts that the brain is the platform of mental pathology. Nevertheless, the content of the post-1960s decades has been largely psychopharmacology and not what the Europeans did so well in the earlier years, the refined study of psychopathology, discerning, for example, the difference between anguish and anxiety.21 (Anguish is the somatic expression of mental anxiety.) Today, residents understand what is meant by psychopathology, but their sense of it is the DSM-style checklist, not the subtle differentiations among various kinds of psychotic thinking, for example, at which the Germans and French once excelled (see, for example, Lexikon der Psychiatrie [Dictionary of Psychiatry], edited by Christian Müller,22 where the section on different kinds of psychoses extends for 7 pages—and the section on psychopharmakologie is a mere 3 pages long.) The faddism 558 W La Revue canadienne de psychiatrie, vol 58, no 10, octobre 2013
in North America is that of the checklist, a takeout menu of 3 out of 9 symptoms qualifying a patient for a given diagnosis. One more point. Psychiatry must be cautious about discarding, as fads, concepts that are in fact useful and worthy of pursuit. This happened with the DST, a biochemical marker for melancholia conceived in 1968,23 then discarded in a wave of doubt in the 1980s. (The nonsuppression of cortisol after the administration of dexamethasone indicates that the HPA axis is dysfunctional, a biochemical anomaly frequently found in melancholic depression.) The DST came to be considered insufficiently sensitive and specific for depression, but in fact it was only for DSM-3–style major depression, itself an artifact, that the DST fell short.24 For melancholic illness, the DST had about the same sensitivity and specificity as the electroencephalogram in interictal epilepsy.25 It is often claimed that there are no diagnostic tests in psychiatry.26 But this is quite incorrect. We have major illnesses wrapped about the HPA axis, and endocrinological tracers for them. Psychiatry’s hypersensitivity to fads had led it to reject one of the few biological markers for affective illness that exists. The take-home message is that we must struggle mightily to avoid confusing fads and science. It is only the former that we wish to discard, not the latter. What does the future hold in store? Will there be salvation from the ardently desired foundation of neuroscience for clinical practice?27 It is probably true that when psychiatry becomes firmly linked to the neurosciences its subjugation to the turbulence of faddism will be moderated. Nevertheless, this has been a long time coming, and in quotidian psychiatry today it is difficult to point to any single medication or diagnosis as the fruit of neuroscience. True, the neurosciences should let us the more easily disprove fads. However, right now, this is just a dim glimmer on the horizon.
Acknowledgements
This research was supported in part by the Canadian Institutes for Health Research, grant number AMS-94659. The Canadian Psychiatric Association proudly supports the In Review series by providing an honorarium to the authors.
References
1. Healy D, interviewer. Ross J Baldessarini interviewed by David Healy [in 1998]. In: Ban TA, series editor. Gershon S, volume editor. An oral history of neuropsychopharmacology: the first fifty years. Peer interviews. Vol 5: neuropsychopharmacology. Brentwood (TN): American College of Neuropsychopharmacology; 2011. p 13–35. 2. Paris J. Fads in psychiatry. Can J Psychiatry. 2013;58(10):560–565. 3. Shorter E. A history of psychiatry from the era of the asylum to the age of Prozac. New York (NY): Wiley; 1997. 4. Freud S. Die Verdrängung (1915). In: Freud A, Bonaparte M, Bibring E, et al, editors. Sigmund Freud, Gesammelte Werke. Vol 10. Frankfurt am Main (DE): S Fischer Verlag; 1946. p 248–261. 5. Meynert T. Klinik der Erkrankungen des Vorderhirns. Vienna (AT): Braumüller; 1884. 6. Andreasen NC, O’Leary DS, Cizaldo T, et al. Schizophrenia and cognitive dysmetria: a positron-emission tomography study of dysfunctional prefrontal-thalamic-cerebellar circuitry. Proc Nat Acad Sci. 1996;93:9985–9990. www.LaRCP.ca
Psychiatry and Fads: Why Is This Field Different From All Other Fields? 7. Feingold BF. Why your child is hyperactive. New York (NY): Random House; 1985. 8. Schildkraut JJ. The catecholamine hypothesis of affective disorders. Am J Psychiatry. 1965;122:609–622. 9. Pradhan SN, Bose S. Interactions among central neurotransmitters. In: Lipton MA, DiMascio A, Killam KF, editors. Psychopharmacology: a generation of progress. New York (NY): Raven Press; 271–281. 10. Hirschfeld RM. History and evolution of the monoamine hypothesis of depression. J Clin Psychiatry. 2000;61(Suppl 6):4–6. 11. Rosenthal NE, Sack DA, Gillin JC, et al. Seasonal affective disorder. A description of the syndrome and preliminary findings with light therapy. Arch Gen Psychiatry. 1984;41:72–80. 12. Morabia A. Pierre-Charles-Alexandre Louis and the evaluating of bloodletting. J R Soc Med. 2006;99:158–160. 13. Hoffer A, Osmond H, Smythies J. Schizophrenia: a new approach. J Ment Sci. 1954;100:29. 14. Kety SS. Biochemical theories of schizophrenia. Science. 1959;129:1590–1596. 15. Kopin IJ, interviewer. Seymour S Kety interviewed by Irwin J Kopin [in 1995]. In: Ban TA, series editor. Max Fink, volume editor. An oral history of neuropsychopharmacology: the first fifty years. Peer interviews. Vol 2: neurophysiology. Brentwood (TN): American College of Neuropsychopharmacology; 2011. p 211–228. 16. Paris J. The bipolar spectrum: diagnosis or fad? New York (NY): Routledge; 2012. 17. Shorter E. Before Prozac: the troubled history of mood disorders in psychiatry. New York (NY): Oxford University Press; 2009.
www.TheCJP.ca
18. Detre T. The way we were and the way we are. In: Ban TA, Healy D, Shorter E, editors. Reflections on twentiethcentury psychopharmacology. Vol 4: the history of psychoneuropharmacology and the CINP, as told in autobiography. Budapest (HU); Animula; 2004. p 217–222. 19. Healy D. The antidepressant era. Cambridge (MA): Harvard University Press; 1997. 20. Shorter E. How everyone became depressed: the rise and fall of the nervous breakdown. New York (NY): Oxford University Press; 2013. 21. Postel J. Dictionnaire de psychiatrie et de psychopathologie clinique. Paris (FR): Larousse; 1998. p 29. 22. Müller C. Lexikon der psychiatrie. Berlin (DE): Springer; 1973. p 407–409, 409–415. 23. Carroll BJ, Martin FIR, Davies B. Resistance to suppression by dexamethasone of plasma 11-OHCS levels in severe depressive illness. BMJ. 1968;2:285–287. 24. Shorter E, Fink M. Endocrine psychiatry: solving the riddle of melancholia. New York (NY): Oxford University Press; 2010. 25. Carroll BJ. Diagnostic validity and laboratory studies: rules of the game. In: Robins LN, Barrett JE, editors. The validity of psychiatric diagnosis. New York (NY): Raven; 1989. p 229–245. 26. Frances AJ. Psychiatric fads and overdiagnosis. Normality is an endangered species [Internet blog]. Psychology Today. 2010 Jun 2. Available from: http://www.psychologytoday.com/blog/ dsm5-in-distress/201006/psychiatric-fads-and-overdiagnosis. DSM5 in distress: the DSM’s impact on mental health practice and research [blog series]. 27. Insel T, Cuthbert B, Garvey M, et al. Research domain criteria (RDoC): toward a new classification framework for research on mental disorders. Am J Psychiatry. 2010;167:748–749.
The Canadian Journal of Psychiatry, Vol 58, No 10, October 2013 W 559
In Review
Psychiatry and Fads: Why Is This Field Different From All Other Fields? Edward Shorter, PhD, FRSC1 1
Hannah Professor of the History of Medicine, Professor of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario. Correspondence: History of Medicine Program, Faculty of Medicine, University of Toronto, 150 College Street, Room 83G, Toronto, ON M5S 3E2; [email protected].
Key Words: fads in psychiatry, dexamethasone suppression test, selective serotonin reuptake inhibitors, Diagnostic and Statistical Manual of Mental Disorders—Fifth Edition, DSM-5, classification, diagnostic categories, diagnosis, psychiatric diagnosis Received January 2013, revised, and accepted March 2013.
Fads in psychiatry are little more than bad ideas with short half-lives. They have arisen because of the great discontinuities that have swept psychiatry unlike other specialties in the 20th century: the transition in the 1920s from asylum-based biological psychiatry to psychoanalysis, and the transition in the 1960s from psychoanalysis to a biological model based on psychopharmacology. In no other medical specialty has the knowledge base been scrapped and rebuilt, and then again scrapped and rebuilt. In these great transitions, when psychiatry each time has had to reconstruct from scratch, bad ideas have crept in with good. Psychiatry, in its heavy use of consensus conferences, is often unable to employ science as a means of discarding fads, which, once installed, are often difficult to remove. Each of the great paradigms of psychiatry in the last hundred years has given rise to fads, and psychopharmacology is no exception, with faddish uses of neurotransmitter doctrine claiming centre stage. Only when psychiatry becomes firmly linked to the neurosciences will its subjugation to the turbulence of faddism be moderated. WWW
La psychiatrie et les modes passagères: pourquoi ce domaine est-il différent de tous les autres? Les modes en psychiatrie ne sont guère plus que de mauvaises idées ayant de brèves demi-vies. Elles sont apparues en raison des grandes discontinuités qui ont balayé la psychiatrie comme nulle autre spécialité au 20e siècle : la transition dans les années 1920 de la psychiatrie biologique des asiles à la psychanalyse, et la transition dans les années 1960 de la psychanalyse à un modèle biologique fondé sur la psychopharmacologie. Aucune autre spécialité médicale n’a vu sa base de connaissances démolie et reconstruite, puis démolie et reconstruite encore. Dans ces grandes transitions, où chaque fois la psychiatrie a dû recommencer à neuf, de mauvaises idées se sont insinuées avec les bonnes. La psychiatrie, qui s’appuie lourdement sur les conférences consensuelles, est souvent incapable d’employer la science comme moyen d’éliminer les modes qui, une fois en place, sont souvent difficiles à écarter. Chacun des grands paradigmes de la psychiatrie des 100 dernières années a donné lieu à des modes, et la psychopharmacologie ne fait pas exception, avec sa mode d’utiliser la doctrine des neurotransmetteurs qui réclame le centre de la scène. Ce n’est que lorsque la psychiatrie deviendra fermement liée aux neurosciences qu’elle pourra calmer sa fascination pour la turbulence des modes passagères.
One of the things I’m exquisitely sensitive about, particularly in American psychiatry . . . is that we have long been a fad-prone group of professionals. Whatever new trendy thing comes along, we not only buy into it, but we package it, market it, push it to extremes and overdo it. —Ross J Baldessarini1, p 24
O
ther medical specialties can err. Cardiology discovers an overdependence on invasive procedures. Nevertheless, most medical specialties do not periodically scrap their www.TheCJP.ca
entire knowledge base to rebuild again from zero. In the retrospect of time, as we look back over the past hundred years, this is exactly what has happened in psychiatry, leaving the field vulnerable to bad ideas along with good as psychiatry slowly rebuilds. Psychiatry as a clinical discipline aspires to the neurosciences for its scientific base. Nevertheless, other neuroscientists often just roll their eyes at a field that relies on patients’ own accounts of their woes as its database. Gripped in the turbulence of changing paradigms, psychiatry has taken a couple of colossally wrong turns over the years. The Canadian Journal of Psychiatry, Vol 58, No 10, October 2013 W 555
In Review
The whole DSM concept and the ditching of effective but out-of-patent drug classes in favour of blockbusters would be 2 good examples. And these fundamental problems require recognition and confrontation by psychiatry. However, fads as well seem to drive much of psychiatry. Under what circumstances does faddishness develop? Is it because in psychiatry diseases are poorly understood, whereas in orthopedic surgery they are well understood?2 No, it is more complicated than that. Cancer, for example, is poorly understood, yet there are few fads in cancer chemotherapy or radiation oncology because 1. the evidence base is rigorously biological rather than verbal stories, and 2. because both cancer chemotherapy and radiation oncology have been building in a steady and continuous manner. In psychiatry, the basic problem is that, from the early 20th century to the present, the field has lurched back and forth among paradigms in a way that has happened in no other discipline.3 Each lurch has sprayed off its own accumulation of fads and bad ideas. Around 1900, psychiatry was imbedded in an asylum-based biological paradigm. The operative diagnostic concept was degeneration, and the knowledge that a patient’s ear was too big or there was a crazy grandmother in the family tree sufficed to confirm the diagnosis of degenerative insanity. Such diagnoses themselves had trajectories that lasted for decades (degeneration first surfaced in psychiatry in 1860) and were not in themselves faddish. Nevertheless, the biological spin of the day gave rise to a vogue for eugenics, or trying to maximize the soundness of the gene pool; the therapeutics of the day included such short-lived frills and furbelows as dietary treatments for psychiatric disorders (in chic private nervous clinics) and blue-light wands that emitted mild buzzes for cataleptic stupors. With the triumph of psychoanalysis in the 1920s, a different set of fads rushed on board. Psychoanalysis, though profoundly wrong-headed, was not a fad, simply because it stayed around for decades and even today has a certain following (mainly in university departments of English). However, it gave rise to such vogue-ish notions as “la belle indifférence” (actually, Jean-Martin Charcot’s term) as a supposed sign of hysteria: the patient gaily chattered about symptoms that in and of themselves must have been quite unendurable. Freud saw it as a mechanism of “repression.”4 But la belle indifférence came and went, and today only Abbreviations DSM
Diagnostic and Statistical Manual of Mental Disorders
DST
dexamethasone suppression test
HPA hypothalamic–pituitary–adrenal NE norepinephrine SSRI
selective serotonin reuptake inhibitor
556 W La Revue canadienne de psychiatrie, vol 58, no 10, octobre 2013
Clinical Implications •
Psychiatric knowledge has been subject to great upheavals during the past century and many former truths have now been discredited.
•
There are valid biological tests in psychiatry, such as the DST.
•
Psychiatry is more subject to fads than other medical specialties, and booms in diagnoses or therapies must be carefully assessed.
Limitations •
This research is based on historical sources, not contemporary clinical data.
•
It is often difficult to separate fads from science: what appears today as a fad may tomorrow be viewed as a building block of knowledge.
very senior clinicians will even have heard of it. It may be considered one of the many fads that psychoanalysis tossed off. And then psychoanalysis was toast. In the 1960s, an entirely new paradigm rushed into psychiatry, a revival of biological thinking but this time based on psychopharmaceuticals rather than gloomy genetic notions about the species going to pot. Now, consider the disruption caused by each of these huge discontinuities in paradigms. The shift from the first biological psychiatry to psychoanalysis basically threw out all previously accumulated biological knowledge in favour of theories about unconscious conflict. For example, the Vienna psychiatry professor Theodor Meynert had indicted in 1884 the forebrain as the locus of psychiatric illness.5 Forgotten. And the recent (re-)discovery of the prefrontal cortex as a crucial site6 occurred to much loud self-congratulation, as psychiatry was unaware that others had trodden these lanes far, far before. Psychoanalysis had wiped the slate clean. And then psychoanalysis itself dissolved, and dogmas, such as unconscious conflict that had dominated psychiatry for the previous 50 years, were simply tossed out the window, and, again, psychiatry faced a blank slate. With the help of industry, the knowledge base of psychiatry became psychopharmacology. Thus here is the problem: with each paradigm shift, with each blank slate, we start again building psychiatry’s knowledge base from zero. And in all the fumbling that goes with such construction, inevitably bad ideas slip in with the good. If the bad ideas are identified quickly as useless, they become fads. If they have a longer half-life, they qualify simply as failed concepts. Thus that is the difference between a fad and a bad idea: a fad is a bad idea with a short half-life. A bad idea with a long half-life, such as the hysteria diagnosis or Oedipal conflict, we call a failed concept. Fads are just failed concepts that are disposed of quickly, such as the Feingold Diet in the treatment of attention-deficit hyperactivity disorder, a low salicylate diet www.LaRCP.ca
Psychiatry and Fads: Why Is This Field Different From All Other Fields?
that banned artificial chemicals, introduced in the 1960s by pediatrician-allergist Ben Feingold.7 Consider psychopharmacology, a field rife with fads. There is nothing faddish about the basic concept of psychopharmacology: serious mental diseases are diseases of the brain, and pharmacotherapy is capable of reaching into the wiring of the brain and rejigging it. Psychiatry now possesses effective medications, and this is a precious acquisition not to be scorned. But a whole latticework of fads has been woven about the basic notion that drugs work. It was once thought that given neurotransmitters were specific for given disorders, and a whole faddish apparatus was erected by Joseph Schildkraut in 1965 called the NE hypothesis of depression8; it was the idea that depression was caused by a shortage of NE. This was discarded soon enough owing to the discovery that the biogenic amine neurotransmitters interact in many psychiatric disorders.9,10 Nevertheless, the NE hypothesis basked briefly in the limelight—a complete fad. Other fads in psychopharmacology are driven by pharmaceutical advertising, a product not of science but of the struggle for market share. Despite the US Food and Drug Administration’s supposedly rigorous surveillance of the content of pharma advertising, fads pop up. The idea that depression can be successfully treated by inhibiting the reuptake of serotonin gave rise to the SSRIs, a drug class that gained powerful currency. But whatever the real mechanism of action of the SSRIs—agents undoubtedly effective in anxiety and obsessive–compulsive disorder—they are not formidable antidepressants, and the actual neurochemistry of affective disorders is veiled yet in shadow. The SSRIs have been a fad. Psychiatry is probably more vulnerable to fads and bad ideas that other medical specialties because in psychiatry it is almost impossible to disprove anything. People ride in with a fad, such as Seasonal Affective Disorder (commonly referred to as SAD) proposed by Norman Rosenthal in 1984 (see Rosenthal et al11). It has low face value, and the data on it are difficult to interpret. But, the question is, how to get rid of the wretched thing? Not knowing the brain mechanisms involved in the production of psychiatric disease, we find it difficult to demonstrate that a hypothesis fails. The problem is compounded in that patient data are mainly oral testimony and the outcomes are often indeterminate. In cardiology, it is relatively easy to cast doubt on the idea that moonbeams cause heart attacks. Less so in psychiatry, because to discredit the hypothesis that moonbeams cause depression one would need some notion of the biological mechanisms involved in depression. Or else one would require an elaborate epidemiologic study that only a pharmaceutical company could finance. Of course, other medical fields are not exempt from bad ideas. In retrospect, bleeding and purging turned out to be terrible ideas, and were disproved with proper scientific data: patients who were bled did less well than those who www.TheCJP.ca
were not.12 But other fields are less vulnerable to short-term bad ideas because there is a basic consensus in cardiology or nephrology about mechanisms, and the barrier of dubiety over which bad ideas would have to clamber is very high. In psychiatry, this barrier is quite low, and thus the door is opened for fads and bad ideas to march in and stay around for the longest time ever. Hysteria marched in some time during the 17th century and was frog-marched out again by the women’s movement in the 1970s. Psychoanalysis marched in with Sigmund Freud’s The Interpretation of Dreams in 1900 and began to seep out with the triumph of psychopharmacology and the biological paradigm in the 1960s and after. Thus there are basically 2 mechanisms for getting rid of fads and bad ideas, and one of them is heavily used in psychiatry. One mechanism is scientific disproof, demolishing a notion with scientific data. The notion floated in the 1950s that schizophrenia was caused by toxic metabolites—adrenaline metabolized into adrenochrome13—was abolished with data. That concept was a fad rather than a bad idea because it lasted only for a few years: from the adrenochrome hypothesis of Abram Hoffer and Humphrey Osmond in Saskatoon in 1954 to the demonstration in 1959 by Seymour Kety at the National Institute of Mental Health that people with schizophrenia had no adrenochrome in their urine and that they metabolized adrenaline at the same rate as control subjects.14,15 Of course, psychiatry shares this fondness for scientific examination of hypotheses with other medical fields. Nevertheless, in psychiatry, fads and bad ideas are usually abolished by consensus rather than by data. And this is a profoundly unscientific way of proceeding because consensus emerges from group process and not from research. Consensus conferences are much commoner in psychiatry than in other fields. A Google search for “consensus conference cardiology” produced 118 000 hits; a search for “consensus conference psychiatry” produced 458 000 hits. And often the consensus arises from without the discipline! It was a consensus arising from the women’s movement about female psyches being largely identical to male that led to the abolition of the hysteria diagnosis in the 1970s: hysteria was mainly a female diagnosis and postulated that women’s brains were different from men’s. Thus among the drafters of DSM-3, which appeared in 1980, there was consensus that hysteria had no place. Nobody ever disproved that women were not hysterical. It has largely been consensus rather than systematic disproof that has led to the vanishment of psychoanalysis in psychiatry. People became convinced of the efficacy of pharmacotherapy and of the correctness of a genetic approach to understanding psychiatric illness. In psychoanalysis, there was no place for either psychopharmacology or genetics— both of which postulated brain mechanisms rather than psychodynamics in what used to be called mental illness, a term that now appears dated. The Canadian Journal of Psychiatry, Vol 58, No 10, October 2013 W 557
In Review
Thus it happens that on the shattered ruins of psychiatry’s past the fads and fashions of today are built. Unquestionably, there is faddism in diagnosis, and Joel Paris has blown the whistle on the bipolar spectrum.16 However, it is in pharmacological therapeutics that the real differences between fads and science begin to become manifest. Why do some drug classes disappear and others spread with almost viral speed? Could it be demonstrations of differential efficacy? Readers familiar with the history of drug treatments in psychiatry can only smile at this proposition. Why did the barbiturates and amphetamines disappear, with small exceptions, from the psychiatric formulary? Both were useful in the treatment of mood disorders and anxiety. Was it that they were so dangerous and addictive? Doctor, have you tried getting your patients off Paxil (paroxetine) and Effexor (venlafaxine)? Or were they defeated by a consensus, crystallized around pharmaceutical advertising, that the benzodiazepines must be superior because they were newer (and patent-protected)? The benzos were actually an excellent drug class themselves. Why were they defeated by the SSRIs? Was it through scientific data? Or was it through massive pharmaceutical hype about the dangers of addictiveness (which many senior clinicians believe were vastly overblown).17 Thus the constant waxing and waning of different drug classes may be seen as the result of the march of science, though people who know the history of psychopharmaceuticals will raise an eyebrow.18 Or it may be seen as the playing out of endless fads and bad ideas against the backstory of billions of dollars in profit for the pharmaceutical industry. And why is it that no new SSRIs have been launched in the past 20 years? (The last, sertraline, was patented in 1981.) Is it because science has been unable to produce new variants? Or because a consensus is forming in psychiatry that inhibiting the reuptake of serotonin in the brain is probably not the route to the therapeutic grail? (This is a vast subject, and, from the gigantic literature, let me cite only 2 things, one written by David Healy19 and one by me.20 Thus the form but not the content of the earlier period of biological psychiatry has seeped back into the post1960s version of biological thinking, or “the second biological psychiatry,”3, p 239 as one might call it. The form asserts that the brain is the platform of mental pathology. Nevertheless, the content of the post-1960s decades has been largely psychopharmacology and not what the Europeans did so well in the earlier years, the refined study of psychopathology, discerning, for example, the difference between anguish and anxiety.21 (Anguish is the somatic expression of mental anxiety.) Today, residents understand what is meant by psychopathology, but their sense of it is the DSM-style checklist, not the subtle differentiations among various kinds of psychotic thinking, for example, at which the Germans and French once excelled (see, for example, Lexikon der Psychiatrie [Dictionary of Psychiatry], edited by Christian Müller,22 where the section on different kinds of psychoses extends for 7 pages—and the section on psychopharmakologie is a mere 3 pages long.) The faddism 558 W La Revue canadienne de psychiatrie, vol 58, no 10, octobre 2013
in North America is that of the checklist, a takeout menu of 3 out of 9 symptoms qualifying a patient for a given diagnosis. One more point. Psychiatry must be cautious about discarding, as fads, concepts that are in fact useful and worthy of pursuit. This happened with the DST, a biochemical marker for melancholia conceived in 1968,23 then discarded in a wave of doubt in the 1980s. (The nonsuppression of cortisol after the administration of dexamethasone indicates that the HPA axis is dysfunctional, a biochemical anomaly frequently found in melancholic depression.) The DST came to be considered insufficiently sensitive and specific for depression, but in fact it was only for DSM-3–style major depression, itself an artifact, that the DST fell short.24 For melancholic illness, the DST had about the same sensitivity and specificity as the electroencephalogram in interictal epilepsy.25 It is often claimed that there are no diagnostic tests in psychiatry.26 But this is quite incorrect. We have major illnesses wrapped about the HPA axis, and endocrinological tracers for them. Psychiatry’s hypersensitivity to fads had led it to reject one of the few biological markers for affective illness that exists. The take-home message is that we must struggle mightily to avoid confusing fads and science. It is only the former that we wish to discard, not the latter. What does the future hold in store? Will there be salvation from the ardently desired foundation of neuroscience for clinical practice?27 It is probably true that when psychiatry becomes firmly linked to the neurosciences its subjugation to the turbulence of faddism will be moderated. Nevertheless, this has been a long time coming, and in quotidian psychiatry today it is difficult to point to any single medication or diagnosis as the fruit of neuroscience. True, the neurosciences should let us the more easily disprove fads. However, right now, this is just a dim glimmer on the horizon.
Acknowledgements
This research was supported in part by the Canadian Institutes for Health Research, grant number AMS-94659. The Canadian Psychiatric Association proudly supports the In Review series by providing an honorarium to the authors.
References
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