April 21st, 2011  Yesterday’s New York Times had an interesting op-ed, “Stumbling into Bad Behavior,” about corruption and unethical conduct in corporate and financial settings. The authors, Max H. Bazerman and Ann E. Tenbrunsel, are academics who wrote a book about ethical blind spots. They note that regulators, prosecutors, and journalists tend to focus on corruption caused by willful actions or ignorance, but this overlooks unintentional lapses: “Our legal system often focuses on whether unethical behavior represents ‘willful misconduct’ or ‘gross negligence.’ Typically people are only held accountable if their unethical decisions appear to have been intentional — and of course, if they consciously make such decisions, they should be. But unintentional influences on unethical behavior can have equally damaging outcomes.”
This caught my attention as it relates to conflicts of interest in medicine. For example, I have long expressed ethical concerns regarding the willful participation of physicians in pharmaceutical promotion. It is a clear conflict of interest to purport to be an unbiased advisor to patients, while at the same time choosing to attend (or deliver) overtly slanted marketing presentations. However, defenders of such participation say they deserve more credit: They cannot be corrupted, and would never willingly deliver biased medical advice no matter how drug or device manufacturers reward them.
These positions are reconcilable given that bias is often unconscious and unwilled. Bazerman and Tenbrunsel note: “[M]uch unethical conduct that goes on, whether in social life or work life, happens because people are unconsciously fooling themselves. They overlook transgressions … because it is in their interest to do so.”
Psychiatry, of course, has a lot to say about how people fool themselves. We discount our own lapses to maintain our self-esteem. We may employ psychological denial to make our troubling inconsistencies disappear, or utilize projection to attribute our faults to others. We may reframe liabilities to look like assets — and we may do all of these outside of our own awareness. Thus, it is entirely consistent sincerely to consider oneself principled, ethical, and unbiased, and yet to be undermined by one’s own unconscious mind.
To me, the most striking paragraph of the op-ed questioned the value of disclosing conflicts of interest, an issue I’ve raised in the past. As chair of Continuing Medical Education (CME) at my medical center, I am forever badgering CME speakers to provide a “disclosure slide” at the start of their talks. (CME is required to maintain medical licensure and stay up to date, so all physicians must attend many hours of CME annually.) This disclosure of financial ties to industry, and other potential sources of bias, is required by state and national CME oversight bodies; the medical center risks its CME accreditation if this rule is not followed. Yet the value of disclosure has always felt tenuous to me. Maybe it’s better than nothing, I thought, but simply disclosing potential conflicts of interest hardly guarantees that the talk will not be biased anyway, nor that the physician audience will know how to evaluate the imparted information given the disclosure.
The New York Times op-ed cites a 2005 study that clarifies this matter of disclosure in a very useful if sobering way. “The Dirt on Coming Clean: Perverse Effects of Disclosing Conflicts of Interest” by Daylian M. Cain, George Loewenstein, and Don A. Moore discusses what disclosure intends to remedy, versus what it may actually do given unconscious as well as conscious factors. The authors point out that people generally do not discount advice from biased advisors as much as they should, even when advisors’ conflicts of interest are disclosed. Moreover, disclosure can actually increase the bias in the delivered information because it leads the disclosers to feel morally licensed and strategically encouraged to exaggerate their advice even further. The paper reports an empirical study conducted with Carnegie Mellon University undergraduates that supports these concerns. The authors conclude:
[D]isclosure cannot be assumed to protect recipients of advice from the dangers posed by conflicts of interest. Disclosure can fail because it (1) gives advisors strategic reason and moral license to further exaggerate their advice and (2) it may not lead to sufficient discounting to counteract this effect. The evidence presented here casts doubt on the effectiveness of disclosure as a solution to the problems created by conflicts of interest. When possible, the more lasting solution to these problems is to eliminate the conflicts of interest.
I couldn’t have said it better myself. The op-ed likewise concludes that, “Good people unknowingly contribute to unethical actions, so reforms need to address the often hidden influences on our behavior.” When it comes to unbiased medical education, neither good intentions nor disclosure of potential bias is sufficient. The solution is to admit we are fallible humans, and to avoid sources of bias, conscious and unconscious. Psychiatry could help — if it weren’t so complicit itself.
March 6th, 2011  I’d like to take this opportunity to comment on the article that appeared in today’s New York Times: “Talk doesn’t Pay, So Psychiatry Turns to Drug Therapy.” Gardiner Harris writes about psychiatry’s shift from talk therapy to drugs, and profiles psychiatrist Donald Levin of Doylestown, PA (a suburb of Philadelphia), who felt financially unable to maintain a psychotherapy practice, and therefore shifted to a high-volume, medication-only practice. It is clear that both the doctor and the journalist consider this a sad state of affairs. Dr. Levin is quoted as saying: “I’m good at it, but there’s not a lot to master in medications. It’s like ‘2001: A Space Odyssey,’ where you had Hal the supercomputer juxtaposed with the ape with the bone. I feel like I’m the ape with the bone now.”
That comparison is apt to rile my colleagues who are serious and careful psychopharmacologists. But Dr. Levin is right: Most medication management in psychiatry is tediously straightforward. Which is why it is mostly done by primary care doctors, not psychiatrists. In the U.S. most antidepressant and antianxiety prescriptions are written by non-psychiatrists. (And even antipsychotics lately, but this is a different and far more worrisome issue.) It seems to me that any self-respecting psychiatrist who limits his or her practice to psychopharmacology, i.e., medication management only, should add some value over a visit to a family doctor, internist, or pediatrician. Either the cases seen should be harder, e.g., “treatment resistant,” or the doctor should offer something more nuanced and sophisticated, or more comprehensive. If so, such a psychiatrist will not be “the ape with the bone.” Unfortunately, my experience suggests this is the exception, and that the shift to medication management has been borne of expediency and financial pressure in many cases, not an earnest scholarly focus on advanced psychiatric medication strategies. And for this reason, the critique that our field is increasingly populated by dumbed-down medication technicians is not the throwaway line it would otherwise be.
In saying this, I invite a rebuttal. If psychiatrists who give meds should add something over other med providers, what do psychiatrists who conduct therapy add over other therapists? The answer is a more comprehensive viewpoint, one that takes into account medical and bodily issues, drug interactions, and similar matters. And the option to prescribe medications when these are needed in addition. If we cannot add this value, we should not charge more than other therapists.
Since I have a mostly-psychotherapy practice myself, I took note of several points made in the article. Most glaring is a starkly misleading statistic. Harris cites a 2005 government survey showing that just 11 percent of psychiatrists “provided talk therapy to all patients.” I’m not sure why that surprises anyone. I’m a huge advocate of psychotherapy, yet I don’t recommend, much less provide, it for everyone. It’s a treatment — it’s expensive, it takes a lot of time, it’s often uncomfortable. I only provide psychotherapy when I predict it will help, and when my patient agrees to it. While I believe it would be helpful for many patients I see, I nonetheless still treat a minority of patients with medication only. In my view, one of the best things about being a psychiatrist is that we have a variety of tools. While I find dynamic psychotherapy more intellectually interesting and humanly engaging than writing prescriptions, I’m glad I can do both. The 11 percent statistic is meaningless.
Another potential confusion in the article are the widely disparate fees cited, with little explanation. At one point Harris writes: “A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.” At least here in San Francisco, this is considerably less than either service is typically worth, even accounting for payment caps by health insurers. Not to mention that psychotherapy is traditionally 50 minutes, not 45. But then Harris writes about “a select group of [New York] psychiatrists [who] charge $600 or more per hour to treat investment bankers,” and later notes that a nearby colleague of Dr. Levin charges “$200 for most [therapy] appointments.” The truth in my experience is that no psychiatrist starves by being a psychotherapist, even though there is more competition from other disciplines and the overall income may be less. Talk does pay, just not quite as much. When psychiatrists complain about comparatively low psychotherapy income, it makes me wonder why they didn’t become surgeons. Seriously, from what I gather surgery is very engaging, very satisfying, and very lucrative. It sounds much better than doing half-hearted, half-assed psychiatry just for the income boost.
As I wrote last year, dynamic psychotherapy is more than merely a treatment technique to place on a shelf alongside medications. It is a perspective that informs our understanding of patients even when we do not offer this specific therapy as treatment. Thinking about our patients dynamically can help us be better medication providers, better CBT (non-dynamic) therapists, better referrers to other professionals. Psychiatrists don’t have to be psychotherapists all the time, but we do need to think psychotherapeutically all the time. The real tragedy highlighted by the NY Times article is not one man’s devolution to an “ape with a bone,” nor even a profession’s. It is the loss of intellectual curiosity — of knowing there is a better way, yet choosing not to pursue it.
February 28th, 2011  The following is my article originally published in San Francisco Medicine (Vol. 83 No. 10, December 2010), the monthly journal of the San Francisco Medical Society. This issue was devoted to “Psychiatry for the Nonpsychiatric Physician.” Reprinted by permission.
The practice of psychiatry is rife with ethical issues. Some critics, such as author-psychiatrist Thomas Szasz, attack the legitimacy of psychiatry itself, claiming it’s unethical to treat mental distress as though it were a medical disease. Psychiatric diagnosis has been challenged on ethical grounds when used to punish political dissidents in other countries, and here in the U.S. when a criminal defendant is found not guilty by reason of insanity. Involuntary psychiatric hospitalization and treatment looms large as a matter of ethical concern. The “5150” became California law in the 1960s and authorizes civil commitment for up to seventy-two hours when a patient is “dangerous to self or others” due to a psychiatric disorder. It soon became the model for such laws nationally, yet revisions and reformulations are constantly put forward.
While each of these issues is profoundly important, they are not the ethical challenges that most psychiatrists face on a day to day basis. Most of us don’t spend our time questioning whether the field is legitimate in general, nor whether making a diagnosis is an ethical act. Most psychiatrists have outpatient practices and rarely contend with involuntary hospitalization or treatment (although it happens). What are the more common ethical challenges in psychiatry?
Clear and professional boundary keeping is the cornerstone of psychiatric practice, especially for those psychiatrists who conduct psychotherapy. Just as a surgeon drapes the surgical field to assure a clean and well-demarcated work space, the psychiatrist establishes a “frame” of time, place, and purpose with each patient to assure a psychologically clean and well-demarcated space to do psychological work. The best known and probably most important ethical rule in psychiatry is not to exploit patients sexually. (Unlike in other specialties, this also extends to former patients.) Less understood is that this attention to psychological boundaries precludes many other social interactions that seem more innocuous. Unlike other physicians, psychiatrists who utilize psychotherapy cannot attend sporting, dining, or other events, public or private, with patients. Since we use the doctor-patient relationship as the very instrument of care, it cannot be put to other purposes. This illustrates something unique about psychiatry: Ethical and clinical issues often overlap. Clear professional boundaries are both an ethical matter and a clinical matter.
Here is another example. Psychiatrists deal with confidentiality dilemmas all the time. For example, young adult patients often have parents who both pay for the treatment and want to know about it. Yet such patients have ethical and legal rights to confidentiality. Other specialties deal with this as well, although in psychiatric practice the presenting problem may be the parental relationship. Thus, what to tell family members — or what to advise the patient to tell — is a matter of both ethical and clinical significance. The same is true of reporting confidential details to third party payers, magnified here by the social stigma attached to psychiatric disorders.
Many psychiatric problems do not cause immediate distress in the patient, but only in those around him. Typical examples include mania, paranoia, narcissism, sociopathy (antisocial behavior), some eating disorders, and so forth. Since subjective distress does not motivate treatment in such conditions, a large part of psychiatric practice is helping patients appreciate the need for treatment and choose it for themselves. While the ethical issues here are not as stark as plainly forcing treatment, there are still several matters to consider. It may be ethically problematic to try to change a patient for the benefit of others, even if the patient would also benefit in the long run. Most physicians would feel qualms about trying to change anything in a patient without that patient’s conscious assent, yet in psychiatry we often have no option but to proceed when the patient lacks the insight and judgment to assent. As a result, there are ethically problematic pressures to persuade the patient, using emotional appeals and slanted arguments — anything to gain cooperation. Such situations place the psychiatrist, at least temporarily, in an adversarial position with respect to the patient’s subjective desires and constitute a conflict of interest between the patient’s wishes and the psychiatrist’s.
A special case of divided loyalties occurs when a patient seeks psychiatric treatment for a reportable behavior. The state mandates the reporting of suspected child or elder abuse, and certain other behaviors. While there is obvious value in such reporting, unfortunately it can also prevent patients from receiving the very treatment than could curtail such behavior in the future. In some such cases, legal reporting requirements may conflict with ethical practice.
Another common set of ethical issues surrounds the placebo effect. Among the various medical specialties, psychiatry stands out in allying with the placebo effect. In internal medicine, a treatment that makes the patient feel better but leaves the infection or tumor unchanged is a failure, and a dangerously misleading one at that. In contrast, a psychiatric treatment that relieves a patient’s depressed mood or anxiety is a success, regardless of whether it changes the patient biologically.
Usually the patient’s subjective experience is the endpoint. Ethical dilemmas arise when honesty falls prey to the need to instill hope. For example, a depressed patient who has failed five medication trials of adequate dosage and duration presents for a sixth. The patient hopes the sixth medication, possibly a heavily promoted new product, will be the long-awaited miracle cure. The psychiatrist knows this track record bodes poorly but doesn’t want to be pessimistic in front of the patient, as success or failure often hinges on the patient’s expectations. So the sixth medication trial proceeds despite the psychiatrist’s better judgment, and it typically fails. Putting aside the placebo effect, the psychiatrist would advise a different approach — psychotherapy maybe, or perhaps a fresh look at the patient’s work history, coping skills, nutrition, exercise, and social support. None of these, however, are what the patient believes in or wants to hear, and thus potentially effective alternatives aren’t even tried.
Speaking of heavily promoted products, psychiatry has the dubious distinction of prescribing the most expensive drugs in the whole medical armamentarium. According to a recent New York Times article, antipsychotics are the top-selling class of pharmaceuticals in America, with annual revenue of about $14.6 billion. Antipsychotics were formerly a niche product, but recently manufacturers have gained FDA approval for a much wider range of indications. Moreover, most antipsychotic prescriptions are now written off-label (not always, or even primarily, by psychiatrists). The burgeoning use of expensive and potentially hazardous antipsychotic medications for relatively minor indications — insomnia, anxiety, nonpsychotic depression, and so forth — has both clinical and ethical implications. Psychiatrists, and all physicians, should recommend treatments based on risk/benefit considerations, and not on extraneous factors such as lavish marketing, financial ties with industry, and so forth. Such conflicts of interest remain endemic in medicine despite recent voluntary restrictions by the pharmaceutical industry and some professional organizations. Psychiatrists in particular should be acutely aware that such influences can, and do, operate unconsciously and despite one’s best intentions. Yet again and again, prominent psychiatrists appear in news headlines about improper funding by industry and failure to disclose financial conflicts of interest. The field risks trading away its most valuable commodity — trust.
This whirlwind tour of psychiatry and ethics has barely scratched the surface. These are only some of the most common ethical issues in clinical practice; there are many other equally worthy contenders. Nonetheless, it illustrates some of the range of issues faced in the field, the many commonalities with other medical specialties, the great overlap with purely clinical decision-making, and the way psychiatry, more than any other medical specialty, is defined and shaped by the social context in which it is practiced.
January 27th, 2011  I always get troubled looks from psychiatry residents when I point out that our field is the domain of the uncertain and the not-well-understood — and that it will always remain so. As soon as the cause of a disease is known, it automatically leaves psychiatry for another specialty. General paresis (advanced syphilis), once identified as an infectious disease, became the domain of internists. Senility (dementia), multiple sclerosis, and many other apparently psychiatric conditions went to the neurologists. Thyroid disorders belong to endocrinology. Brain tumors and hemorrhages are surgical conditions. And so forth. I have little doubt that schizophrenia will someday be understood as due to a slow virus, a complex genetic error, or something else. At that point it will no longer be a psychiatric condition. It will join neurology, internal medicine, or some other specialty. This makes my residents squirm in their seminar chairs, particularly when I point out that the closest analogy to psychiatry’s status in medicine is philosophy’s status among the humanities. Philosophy consists of questions in the humanities that we don’t yet know how to answer. Once we do, that area is no longer considered philosophy. “Natural philosophy” is what we now call science. It isn’t considered philosophy anymore. Logic was one of the classic branches of philosophy; now it is better understood as a branch of mathematics. In the same way, psychiatry consists of questions about human thoughts, feelings, and behavior that we don’t yet know how to answer, not down to the level of mechanism anyway. Once we do, that area is no longer considered part of psychiatry.
It’s no mystery why the residents are uncomfortable. They want and expect certainty. Why did they study all that organic chemistry, memorize all the bones and muscles, spend years learning to diagnose and treat, if in the end they can’t make definitive statements about their chosen specialty? Many will cling to pseudo-certainties for reassurance. Simple-minded factoids like “alcoholism is a disease” or “depression is due to a chemical imbalance” give them something to hang onto. Unfortunately, we don’t really know what causes depression, and alcoholism is disease-like in some respects, but not in others. Most of our field is complicated, messy, and not well understood. Moreover, this need for certainty in an uncertain field leads many psychiatrists, including and perhaps especially those well out of training, to convey unwarranted confidence regarding diagnosis and treatment recommendations. We can come across as smugly self-assured.
Frankly, this very uncertainty — mystery, if you will — is one of the things I like about psychiatry. It isn’t a settled area. It is endlessly debatable, much like an undergraduate philosophy course. Yes, there are concepts and terms to learn, principles to refine and employ, scientific studies to evaluate. There is a body of knowledge, a history, practice guidelines to teach and learn. Most of all, there are real patients to help. Yet as in philosophy, experts in psychiatry can and do disagree. Our diagnostic categories are revised periodically. Treatments come and go. Unscientific fads influence the field, as when American psychiatrists used to diagnose schizophrenia more liberally than our British counterparts, when multiple personality disorder suddenly became common in the 1980s and just as suddenly faded away, and in the way ADHD, PTSD, and bipolar diagnoses are so popular now.
Confident pronouncements of certainty have no place in psychiatry. Humility is the only honest attitude to take to this work. At the same time, the questions we face are fascinating, patients are suffering, and neither can wait for definitive knowledge. We must do the best we can with imperfect knowledge, with limited data and educated guesses, with hunches and subtle impressions. As in life generally, we cannot wait for certainty before acting. As in life generally, this makes psychiatry risky, vibrant… alive.
December 23rd, 2010  December brings the annual pleasures and challenges of holiday gifts and how to deal with them in dynamic psychotherapy. Although it is relatively easy to follow a simple rule about this, ideally a good deal of thought goes into a therapist’s decision about whether to accept a patient’s holiday gift. Below I will give a couple of examples of this from my own practice, and how psychodynamic theory guided my response.
All beginning dynamic therapists are taught not to accept gifts from patients. This rule follows from the principle that the therapist should decline all gratifications from the patient aside from the fee paid. A therapist who is swayed by the patient’s generosity, physical attractiveness, political connections, or other factors invites a conflict of interest in himself, and thus risks distorting the therapy in pursuit of his own needs and desires. Accepting a gift would be an example of this. Afterwards, the therapist may feel disinclined to challenge the patient, to induce anxiety or point out a contradiction. Conversely, the patient may feel the therapist should reciprocate the generosity, leading to disappointment and possibly anger when the therapist fails to do so.
Naturally, patients often do not know this rule, thus some arrive to a year-end session with a gift in hand. These gifts vary. Some are expensive, some less so. Some are “for the office,” others intended more personally for the therapist. Some are homemade, or reflect something personal that had been discussed earlier in the treatment, while others are more generic. Likewise, the nature of the treatment varies from patient to patient, from relatively supportive and concrete, to very “uncovering” transference-based therapy. Given these variables, there is room for some discretion in the no-gifts rule.
A number of years ago I treated a woman who painfully described feeling unvalued by others. Men only appreciated her because she gave them sex; her employer did not value her as a person, but only for her productivity. Our therapy was fairly psychoanalytic in nature. Arriving to a session around the holidays, she handed me a large, beautifully wrapped gift box. It looked store-bought and expensive. I imagined she had taken significant time and trouble to purchase and bring it to me. With some apprehension I told her that we needed to discuss the gift before I could accept it. She was initially hurt by this. However, it soon became clear to both of us that her gift reflected her belief that I, like others in her life, did not value or appreciate her as a person — she hoped I would value the gift and therefore her. On that basis I thanked her but did not accept her gift, a decision she ultimately understood and agreed with.
It turned out very differently with another patient, an older Russian woman who saw me for supportive therapy. Around the holidays she presented me with a bottle of Kahlua, unwrapped if I recall. We had not been working with transference; I did not see how such a gift could damage our work. Also, it is customary in Russia to offer such gifts to one’s doctors. I accepted the bottle with thanks, and pleased my patient. No harm done, and perhaps a bit of good in strengthening our working relationship.
Most dynamic therapies lie between these two extremes, somewhere in the midrange of the analytic-supportive continuum (more about that here). I have accepted inexpensive gifts in such cases, except when I sense that the offer is an unhealthy enactment, or that the patient is sidestepping a useful exploration. As is often the case in conducting dynamic psychotherapy, there is a balance between fostering a warm working relationship, versus encouraging reflection and insight. In my view, a blanket rule of refusing all gifts is unnecessarily cold and inhuman for many patients, while accepting all gifts may appear “normal” but does not encourage reflection, and may introduce conflicts of interest. The matter takes case-by-case consideration, neither unthinking acceptance nor unyielding refusal. It should go without saying that I never expect to receive a gift; it’s also helpful to note that most patients do not offer them.
Occasionally the opposite issue proves useful to explore: Whether the patient expects (or wants) me to give him or her a holiday gift. As we all know at this time of year, both gift-giving and gift-receiving tap deep emotional aspects of our personalities, and sometimes highlight conflicts around themes of self-interest, self-sacrifice, guilt, generosity, reciprocity, and one’s value in the eyes of others. I do not offer my patients holiday gifts, but I do wish them, and you, Happy Holidays.
November 18th, 2010  Earlier this year a reader asked me:
“I would be very interested to hear your thoughts on patients becoming too focused on diagnoses. […] While I was in an RTC as a teenager, and recently in the hospital as an adult, I have found that people almost treat their diagnoses as a competition. I was calling it the alphabet olympics. I also have a friend who will rattle off a bunch of abbreviations for his diagnoses. There is always something new popping up too. Sometimes I wonder if over diagnosing is a mistake some psychiatrists make.”
I’ve seen this too. Here’s my take on the alphabet soup of diagnosis, and whether it’s good for patients to focus on it. First, a little history…
Prior to 1980, before the revolutionary 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), psychiatry tended to lump disorders into a few broad categories. Schizophrenia covered a wide range of presentations, from relatively minor symptoms to devastatingly severe ones. Depression could be brief, prolonged, triggered by obvious stressors or losses, or appear out of nowhere. Neurosis referred to any presumed unconscious conflicts that interfered with life.
DSM-III changed all that. (An excellent historical review article, in pdf format, is available here.) This was the first effort by the American Psychiatric Association (APA) to publish an atheoretical, phenomenological psychiatric nosology. What do these $10 words mean? The idea was to create diagnoses that could be used regardless of one’s school of thought or theory. For example, some psychiatrists thought depression was biological, others considered it psychological. Either way, if a patient had a low mood for two weeks, along with poor sleep, appetite, concentration, and libido, he or she had Major Depressive Disorder according to DSM-III. It didn’t matter why.
This scheme encouraged multiple diagnoses. A given patient could fulfill criteria for Major Depressive Disorder, an Anxiety Disorder, a Personality Disorder, and other disorders, all at the same time. This reflects a drawback of atheoretical diagnosis. An underlying theory, such as Freudian psychoanalytic theory, or a systematic biological or learning theory, can pull together apparently disparate symptoms into a coherent diagnostic formulation. Without such a theory to guide diagnosis, each set of symptoms stands on its own. While some DSM diagnoses had exclusion criteria — they could not be listed in the presence of other diagnoses — this still left plenty of opportunity to list multiple disorders in the same person.
Each edition of the DSM grows in size. One reason is that scientists can’t stand to leave a good category alone — if it can be turned into two good categories. Thus, anorexia and bulimia, which used to be one disorder, are now divided. Depression is divided into major depression, dysthymia, seasonal affective disorder, adjustment disorder with depressed mood, and so forth. Bipolar disorder comes in Type I and Type II, as well as lesser versions. I am not against making these distinctions when there is good reason to do so, and there often is. But one consequence is diagnostic alphabet soup: a growing set of arcane labels usually shortened to three- or four-letter abbreviations. And the nature of atheoretical diagnosis means that any given patient may qualify for several.
Many psychiatrists feel they “understand” a patient better if they can establish one or more DSM diagnoses — although, being atheoretical, such diagnoses don’t actually explain anything. They do, however, point reassuringly to recommended treatments, usually pharmaceutical. Moreover, medications are FDA-approved for each of these indications separately. This has marketing advantages for drug manufacturers. Shyness doesn’t sound like a psychiatric problem to be treated with medication, but “Social Anxiety Disorder,” essentially a synonym for shyness, does. Dividing anxiety into Generalized Anxiety Disorder, Social Anxiety Disorder, and many other types created markets for various medications. In a parallel fashion, health insurers demanded more specific diagnoses in order to pay for psychiatric treatments. There is money, and therefore politics, behind dividing human misery in these particular ways.
Perhaps the most interesting part of my reader’s question is why some patients are attracted to these labels. Her experience with teens and young adults may, in part, reflect embracing these labels in an ironic or mocking way: “Now I have MDD, OCD, and PTSD. Isn’t that a kick?” Probably more relevant is the concrete way a diagnosis seems to account for one’s frightening instability. Better to be “ADHD” than merely a scattered teen who can’t study. The former confers scientific legitimacy, promises specific treatments, and even justifies entitlements such as extra testing time in school. These labels can also ease personal responsibility and humiliation, as when outrageous social behavior can later be attributed to Bipolar Affective Disorder or some other “chemical imbalance.” Despite the persistent stigma of psychiatric diagnosis, these labels have enough psychological and practical advantages that some patients wear them proudly.
The downside to all of this is that individuals can become known, even to themselves, by impersonal diagnostic labels. Knowing oneself as PTSD, ADHD, and/or OCD can dehumanize. It can prematurely close off inquiry and self-reflection. And DSM diagnoses do not actually explain anything; they are better conceptualized as statistical categories. Such diagnoses are useful tools, but like all tools they can be misused.
October 23rd, 2010  I apologize to my loyal readers for not posting in a long while. Fortunately, I was awakened from my torpor by an eye-opening new database that lists some of the money paid to specific doctors by pharmaceutical companies. The Pulitzer Prize winning investigative journalists at ProPublica tapped the public disclosures of seven companies that have begun posting names and compensation on the internet, some as the result of legal settlements. ProPublica’s “Dollars for Docs” provides both an overview of the issue, as well as a handy database search function. It is easy to look up specific doctors, or (as I did) to scan through a whole city or town to see who received money from these seven companies in the past two years.
Some caveats are important. First, the seven companies represent just over a third of all pharmaceutical sales in the U.S. The health care reform law, signed in March, mandates that all drug companies report such data to the federal government beginning in 2013. That information will be posted on a government website. So, this is a preview of the data to come. Research funding is not included here, only speaking, consulting, and related activities. It is also important to keep in mind that listed payments are not automatically unethical or illegitimate. For example, honest consulting relationships between doctors and drug companies reasonably include travel expenses and a consulting fee.
Nonetheless, most of the listed activity is pretty suspect. I first learned about “Dollars for Docs” from Dan Carlat’s blog. As Carlat points out: “The vast majority of payments are for doctors who give ‘educational’ talks to other doctors, presumably focusing on one of the drugs made by the funding company.” And as he notes, the sheer enormity of the database is probably its most striking aspect — published surveys show that well over 100,000 doctors receive cash from drug companies. Most of the amounts in the database are small, up to a few thousand dollars, not much compared to the income of most doctors. But some are considerably higher. My eye-opening experience was to scan the list of San Francisco doctors, where I found a few colleagues I know who added tens of thousands to their income in 2009 and 2010 speaking for drug companies. It makes me think differently about those doctors — which is the point, right?
Supporters of the status quo argue that there are many other potential conflicts of interest, and that not all recipients of industry money are necessarily biased. Both of these points are true, but irrelevant. Money is universally recognized as motivating; that’s why people are paid to work. A universally recognized motivation, voluntarily chosen and standing here in plausible conflict with unbiased patient care, should be unacceptable from the perspective of medical ethics. Medical ethics does not stop with financial conflicts of interest. Physicians are prohibited from sexual relations with patients for similar reasons: A sexual motivation is very likely (although not absolutely guaranteed) to conflict with clinical care. Other systematic sources of bias will be addressed when they can be identified and controlled. The fact that we can’t minimize all sources of bias is not a compelling reason to ignore obvious financial ones.
When comprehensive numbers are available online in 2013, we will finally have meaningful disclosure about this potential conflict of interest. What we as a profession, or as the public, do with these disclosures is another matter. As I’ve noted before, the public seems more concerned than the medical profession itself about industry-fueled bias. To that end, patients may begin to use such public databases as a means to choose doctors. The website of the newly formed Association for Medical Ethics features a searchable database similar to “Dollars for Docs” but with a more explicit message: that accepting industry support is unethical in clinical practice. If this idea catches on — and I suspect it will, at least in some areas — speaking and consulting fees will not be the only financial motivation at play here.
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