- The Washington Times - Sunday, August 12, 2001

It's painful for a practitioner when he has to vehemently challenge his own field. For more than two decades as a psychiatrist and medical educator, I've seen the tremendous relief of suffering that quality mental health care can bring.
Psychotherapy and modern medications are often lifesaving. But I also recognize dangerous abuses within the system — not to mention the squandering of what I would estimate to be about one-third to one-half of our huge annual expenditure for such services.
You can legitimately ask if there is a role for my personal and anecdotal critique of a clinical field replete with scholarly research, professional journals, and "statistically significant" data. Without boring you with the usual list of credentials, I can only respond that I believe myself to be a competent physician, offering my observations as honestly as I can. And I believe we need more such open discussion of the many crucial, but confusing, issues within our mental health system.
My main concerns fall into four general areas: misdiagnosis, inappropriate treatment, abuse of the system by mental health practitioners and patients alike, and the deterioration of the relationship between provider and consumer (maybe in part because we call them "provider" and "consumer").
While my critical brush paints broadly, I think most readers will appreciate obvious exceptions.
To start, accurate diagnosis of mental illness is still very much in its infancy. Our recognized diagnostic authority (the book DSM-IV-TR) is surrounded by controversy. Why do transsexuals have a mental disorder, while we've decided that homosexuals don't? Is multiple personality disorder (now called dissociative identity disorder) a phenomenon actually induced by therapists? Can we accurately distinguish between the sadness that is a part of normal life from mood disorders and other psychiatric conditions? Do we know the difference between merely active, maturing kids and those with ADHD?
And to be very politically incorrect, are serious chronic misuses of alcohol and other drugs really mental illnesses — or sometimes just personal decisions?
Of equal concern is often a cascade of changing diagnoses applied over the years to the same person. The differences may depend more on the examiner than upon the patient's condition. Yesterday's schizophrenia may be today's bipolar disorder. Or today's mood disorder may be tomorrow's personality disorder. Additionally, labels can become easy — and dangerous — substitutes for a real understanding of the problems.
Less experienced examiners, including those still in training such as residents, can be more prone to mistakes. And regardless of expertise, an accurate evaluation still can't be rushed — special risk within the resource-poor public sector. Just as with heart surgery and other major procedures, these evaluations are often life-altering events, setting a course — proper or not — that may be maintained for decades. Unfortunately, a "diagnosis" sometime barely rises to the level of someone's "best guess."
Treatment presents another area of problems. These days it seems we have a drug for just about every human discomfort and misbehavior. If elderly patients are occasional disruptive in a nursing home, give them an antipsychotic. Kids who are unruly can get stimulants. Uncomfortable in social situations? There are SSRI-type drugs for you. Life is rough with a lot of sadness? If the first antidepressant doesn't work, we have lots more.
Just in case we do run out of individual choices, we can start combining medications. People can get stuck in a lifetime of endless psychopharmacology.
And none of this even takes into consideration that psychiatric medications are nowhere near 100 percent effective; they can have very significant side effects and drug interactions, including death; and, with few if any exceptions, they have unknown mechanisms of action.
Mental health services are very much open to abuses of several types. One of the most prevalent and costly is the use of psychiatric evaluations to obtain disability payments. Such entitlements are obviously appropriate for some. But not all people with "depression," "anxiety," or "PTSD" currently getting disability payments rise to the level of significant impairment. In a twist of irony, mental health professionals become their enablers.
Prescribed psychiatric drugs are also funneled into illicit street use, with stimulants being a prime example.
Other problems include misuse of the insanity defense to try to avoid punishment; unnecessary hospitalizations, especially of children; and a philosophical blurring of the boundaries of the exercise of free will (have "wrong," "bad," and "evil" simply been replaced by psychiatric labels?).
Finally, there is what is perhaps the most malignant problem of all: the perversion of the relationships between caregiver and patient. This can include patients being seen largely as profit centers by what I prefer to call the "biz-med complex" (hospitals, doctors, insurance plans, etc.); inappropriate sexual relationships within the therapeutic setting; the perceived need by many even earnest practitioners to hurriedly "treat and street" patients by whatever expediencies are available; some outlandish — if not outright fraudulent fees; and the deterioration of a truly caring and healing relationship between patient and professional.
I have no doubt my comments will be severely criticized by some people. But if they contribute to a meaningful discussion of both the strengths and the weakness of our chaotic mental health system, I'll consider that a victory for patients and practitioners alike.

Tom Minogue, M.D., is a board-certified psychiatrist on the medical faculty of the University of Illinois at Urbana-Champaign. His books include "We Did All We Could, but Your Healthcare Died" and "Trust Me, I'm a Doctor."

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