CanJPsychiatry 2013;58(10):560–565
In Review
Why Is Psychiatry Prone to Fads? Joel Paris, MD1 1
Research Associate, Sir Mortimer B Davis Jewish General Hospital, Montreal, Quebec; Professor of Psychiatry, McGill University, Montreal, Quebec. Correspondence: McGill University, Montreal, QC H3T 1E4; [email protected].
Key Words: psychiatric fads, psychiatric diagnosis, psychiatric treatment Received January 2013, revised, and accepted March 2013.
Psychiatry has long been prone to fads. The main reason is that mental illness is poorly understood and can be difficult to treat. Most diagnostic fads have involved the extension of well-known categories into broader spectra. The most prominent treatment fads have involved the overuse of pharmacological interventions and a proliferation of methods for psychotherapy. The best antidote to fads is a commitment to evidence-based psychiatry. WWW
Pourquoi la psychiatrie est-elle portée sur les modes? Depuis longtemps, la psychiatrie est portée sur les vogues ou les modes. La principale raison en est que la maladie mentale est mal comprise et qu’elle peut être difficile à traiter. La plupart des modes diagnostiques ont impliqué une extension de catégories bien connues en spectres plus larges. Les traitements les plus en modes ont fait appel à la sur utilisation des interventions pharmacologiques et à la prolifération de méthodes psychothérapeutiques. Le meilleur antidote aux modes est un engagement de la psychiatrie fondée sur les données probantes.
A
fad is an idea that arouses short-lived enthusiasm, is quickly adopted, and abandoned when it fails to live up to expectations. As described by Best,1 fads have a 3-phase life cycle: “emerging, surging, and purging.”p 123
Mackay’s2 Extraordinary Popular Delusions and the Madness of Crowds made fun of outlandish and faddish ideas, but assumed that intelligent people should be immune to them. Gardner,3 in Fads and Fallacies in the Name of Science, showed how science, or at least popular science, is also infected by fads. One would like to assume that researchers, trained in a culture of doubt, as well as physicians, trained in EBM, would be cautious about following the latest thing. However, both in the history of medicine4 and of psychiatry,5 fads have been common. Medical fads are most likely to develop when diseases are poorly understood, and when treatment methods are not effective. Patients with treatable conditions, and their physicians, are less likely to be attracted to unusual practices. In contrast, patients with chronic or terminal illnesses, and their caregivers, may well be attracted to such practices. Sick people can be desperate, and physicians sometimes seek desperate remedies.6 They are susceptible to fads because they badly want to help patients; by and large, fads in medicine are misguided attempts to do good. Psychiatry, a specialty that deals with illnesses that cause profound suffering, but in which disease processes are poorly understood, and in which treatment methods are not predictably effective, is an ideal medium for diagnostic and treatment fads. 560 W La Revue canadienne de psychiatrie, vol 58, no 10, octobre 2013
Fads, Cognitive Biases, and Social Contagion
Physicians are trained to depend on empirical data for clinical decisions. The practice of medicine tends to support hope and certainty. In contrast, science, committed to objectivity, supports a culture of doubt. Nevertheless, even basic science has its fads. As the great 19th-century biologist Thomas Huxley7 archly put it: “The great tragedy of science—the slaying of a beautiful theory by an ugly fact.” In principle, new data can overthrow any existing theory. Nevertheless, that is not necessarily what happens— at least in the short run. Researchers, like everyone else, become emotionally attached to their favourite ideas. This makes them seek ways to explain away unpleasant facts. As the physicist Max Planck8 once remarked: A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it. Incorrect conclusions can also be the result of cognitive errors and biases. These mechanisms have been the subject of a large body of research. Many years ago, Festinger9 introduced the term cognitive dissonance, a similar concept to confirmation bias.10 What both mechanisms describe is that once one has already made up one’s mind, new data will be interpreted the light of preconceived ideas. A great deal of research in social psychology supports the principle that reasoning does not work from first principles, and that reasoning is used to support emotional intuitions.11 Thus medical scientists who are strongly attached to a theory www.LaRCP.ca
Why Is Psychiatry Prone to Fads?
reduce cognitive dissonance by interpreting contradictory evidence in a way that does not undermine their beliefs. Another source of cognitive bias is the availability heuristic.12,13 Here error derives from depending on what comes to mind, rather than on what is most probable. This kind of error is particularly likely in clinical practice. If one has just seen a series of patients with a given diagnosis and offered them a given treatment, one is tempted to view future patients as having the same condition and (or) requiring the same therapy. Pharmaceutical companies make use of the availability heuristic by providing physicians with pens and calendars featuring their products. Every time you write a note, you see the name of the drug being marketed, and are more likely to prescribe it. These principles also affect diagnosis: patients may be perceived as fitting the category that most easily comes to mind. Finally, fads proliferate because of social contagion.14 Ideas are picked up from social groups, and shared concepts promote social bonding. In medicine, practitioners often follow what they hear from colleagues, from lectures, and from journals. Fads can spread rapidly when they fit needs for easy answers about diagnosis and treatment—and when supported by experts.
Diagnostic Fads
Diagnosis is an essential part of medical practice. Classifying disease helps physicians communicate with each other and, ideally, describes categories of illness with a specific etiology, a likely prognosis, and a predictable response to treatment.15 Nevertheless, in contrast to the rest of medicine, diagnoses in psychiatry have no gold standard, and cannot be confirmed by biological markers, such as laboratory tests, imaging, or genetic linkages.16 Psychiatric diagnoses are entirely dependent on the observation of signs and symptoms. In the absence of an understanding of etiology and pathogenesis, most diagnoses in current use describe syndromes, not diseases. Fifty years ago, most psychiatrists did not take diagnosis seriously. Categories were used for record-keeping rather than for treatment planning. However, psychiatry eventually fell under attack for its negligence. Reliability was low, even for important diagnoses, such as schizophrenia and Abbreviations AD antidepressant ADHD
attention-deficit hyperactivity disorder
AP antipsychotic ASD
autistic spectrum disorder
BD
bipolar disorder
BSD
bipolar spectrum disorder
DD
dissociative disorder
DSM
Diagnostic and Statistical Manual of Mental Disorders
EBM
evidence-based medicine
MDD
major depressive disorder
www.TheCJP.ca
Clinical Implications •
Psychiatrists should be skeptical of diagnostic expansion and of new forms of treatment.
•
Cautious conservatism in practice should be based on evidence.
Limitations •
Genuine breakthroughs in diagnosis and treatment appear from time to time.
•
The evidence base for psychiatry remains thin.
manic-depression.17 The specialty suffered criticism from anti-psychiatrists, and earned little respect from medical colleagues. The development of DSM-III18 was an attempt to address these problems. Nevertheless, even today, with DSM-5 being recently published, psychiatric diagnosis remains entirely phenomenological. These problems will not be resolved until more is understood about the etiology and pathogenesis of mental disorders. Despite great progress in neuroscience, none of its findings have shed light on the pathways leading to specific forms of mental illness. However, these limitations have not prevented clinicians and researchers from promulgating novel diagnostic concepts, or extending those already in existence. Diagnostic fads tend to develop in areas of psychiatry that are inadequately studied, and are applied to patients who do not respond to standard therapy. Many fads take an established diagnostic entity, and suggest it can be applied to a much broader spectrum of patients with related symptoms. One interesting aspect of these diagnostic fads is that they can be attractive to patients. In modern psychiatry, patients like diagnoses that suggest chemical imbalances, even if there is no evidence that major mental disorders, or common disorders such as depression and anxiety, are associated with specific changes in neurotransmitters19 Instead of feeling inadequate, patients can see themselves as struggling with a problem outside their personal control. In this review, I will consider 5 examples of diagnostic fads that have been prominent in the last 2 decades. The first 4 extend a well-established diagnosis to a vast range of patients: MDD, BSDs, ADHD in adults, and ASDs. None of these conditions can be reliably identified by biological markers, and all depend entirely on clinical observation. Therefore, their boundaries with other disorders, and with normal variation, are ultimately a matter of clinical opinion. The fifth group, DDs, is different, in that diagnoses are almost entirely an artefact of questionable theories and therapeutic methods.
Major Depressive Disorder
Psychiatrists have long been taught that depression can be a symptom, a syndrome, or a disease. However, the idea that depression is one disorder, varying only in relation to severity, is questionable.20 For example, patients with melancholia have severe depression associated with prominent physical symptoms, and can sometimes be The Canadian Journal of Psychiatry, Vol 58, No 10, October 2013 W 561
In Review
psychotic.21 These severely ill patients respond much better to AD therapy,22 and to electroconvulsive therapy.23 In contrast, patients with milder symptoms are often better described as unhappy,24 and do not belong in the same category. Similar problem arise in anxiety disorders— most particularly with the currently faddish diagnosis of posttraumatic stress disorder.25 The overdiagnosis of MDD (which is not necessarily all that major) has led to screening programs in the community that only succeed in identifying symptoms that usually get better without treatment.26 The diagnostic criteria for a major depressive episode require only 5 out of 9 listed criteria for as little as 2 weeks. Owing to this extremely broad definition, prevalence is very high—up to 50% or more during a lifetime.27 These conclusions reflect a unitary theory of depression,28 influential for 40 years, in which all cases lie on a continuum of severity. The main reason for an overdiagnosis of depression is the wish to treat patients with ADs. While these drugs are not always superior to placebos in milder cases,22 11% of the entire population of the United States is now taking one of these agents.29 These drugs are necessary and useful for severe depression, and can be effective in several other conditions, but prescribing them indiscriminately for unhappiness has not contributed to population health.
Bipolar Spectrum Disorders
BD I is one of the few conditions in psychiatry that closely resembles a medical illness. Although we do not know its etiology, classical BD has a characteristic clinical picture and course, as described by Kraepelin30 BD I is also a diagnosis that points to a specific response to treatment with mood stabilizers, especially lithium.31 There can also be little doubt about the validity of BD II, characterized by hypomania rather than full mania.32 However, when the precise criteria for a hypomanic episode (4 days of continuous abnormal mood) are ignored, patients with euphoric episodes lasting only a few hours may be given a BD II diagnosis.33,34 The concept of a BSD has been invoked to support the expansion of bipolarity as a way of describing any pattern of mood instability35 and has been claimed to affect millions of untreated patients who experience mood swings.36 The fad for BSDs has reached the point where surveys using the concept identify over 30% of depressed patients as having occult bipolarity.37 Some surveys have even suggested that close to one-half of all psychiatric patients could meet broadened bipolar criteria.38 Nevertheless, these claims are based entirely on clinical observation. We do not know whether so-called soft bipolar symptoms, such as short-term mood instability and irritability, belong in the same category as classical bipolarity. The bipolar fad has also spread to child psychiatry, and this disorder, long considered to appear only after puberty, is now being diagnosed in children with behavioural disorders. However, children with irritable and unstable mood do not develop 562 W La Revue canadienne de psychiatrie, vol 58, no 10, octobre 2013
classical BD with time, and do not respond to treatments developed for adult patients with BD.39 The bipolar fad would not be worrying except that making the diagnosis in more patients leads to a wider prescription of drugs with significant side effect profiles.40 The long-term use of mood stabilizers and APs for patients who do not have classical forms of the disorder should be of particular concern when these drugs are prescribed to children.
Attention-Deficit Hyperactivity Disorder
ADHD has been the subject of a vast research literature, and the use of stimulants to treat children with classical features of the disorder has a well-established evidence base.41 However, even in pediatric populations, diagnostic boundaries are unclear. When the core features of ADHD are present, treatment with stimulants is most likely to be successful, but not all children with symptoms of limited attention do well on these agents.42 The most important current fad arises from the extension of the ADHD diagnosis into adult populations. It is well established that not all children with this diagnosis recover by adulthood.43 However, to diagnose ADHD in an adult, a definite history in childhood has first to be established, which may require a careful review of school records. What too often happens in practice is that the diagnosis is made based on a history of problems with attention owing to any cause. Sometimes the diagnosis is confirmed by psychological testing, a procedure that is very nonspecific.44 As even in cases where diagnoses are made more carefully, one sees massive comorbidity,45 the boundaries of the disorder in adulthood remain uncertain. The main result of overdiagnosis of adult ADHD is that many patients are unnecessarily prescribed stimulants. As normal people also have better attention on these regimes,46 one may see short-term therapeutic effects. But high comorbidity suggests that many of these patients could need different methods of treatment.
Autism Spectrum Disorders
Autism and related conditions have long been considered rare. More recently they have been diagnosed more and more frequently in adults and in children. A recent survey in South Korea47 garnered a fair amount of attention from the media by reporting that spectrum diagnoses can be found in 3% to 4% of the general population. Clearly something has happened to the definition, which has steadily broadened. The autism spectrum is a severe group of disorders that have been extended to include Asperger syndrome and other milder conditions into a broader ASD. In the absence of a gold standard, it is tempting to see everyone with eccentricity and social awkwardness as falling within these boundaries. Nevertheless, children are different in temperament, and varying trait profiles can be adaptive under the right circumstances. Highly introverted children can go into occupations, such as computer science, that make use of a lack of sensitivity to social cues. It seems www.LaRCP.ca
Why Is Psychiatry Prone to Fads?
likely that we are not seeing a diagnostic epidemic of autism—proof of which would require prospective data,48 as well as biological markers.
Dissociative Disorders
This group of disorders is rare, so rare in fact that they may not even exist. Symptoms such as depersonalization and derealization are common in many disorders, but can sometimes present as a separate syndrome,49 a clinical picture of interest to transcultural psychiatrists.50 In contrast, multiple personality disorder (now called dissociative identity disorder), in which several personalities coexist, is the result of interactions between enthusiastic therapists and patients with a flair for drama.51 Sibyl, a patient who became the subject of a best-selling book, later admitted that she produced alternative personalities only because her therapist asked for them,52 and it has documented that the child abuse that she reported to her therapist was a fabrication.53 The enthusiasm for diagnosing DDs was also associated with an incorrect theory of memory, leading to false memories and false accusations of child abuse.51 This malignant fad did great damage to patients and families.
Treatment Fads Psychopharmacology Fads
We do not usually view psychopharmacology as susceptible to fads. In principle, the prescription of drugs should be evidence-based, and supported by systematic clinical trials. New agents are regulated by government bodies, and are only approved when empirical data are sufficient. That is the ideal. In practice, drugs and drug combinations can be allowed on the market based on 2 or 3 studies, without enough data to justify a meta-analysis.54 Moreover, physicians can prescribe drugs off-label, with or without encouragement from pharmaceutical representatives. The most serious current problem in psychopharmacology is the tendency to prescribe APs for a wide variety of indications, despite serious side effects. The use of APs as augmenting agents for depression is only weakly supported by evidence.55 Their use has become very common in the management of anxiety and insomnia,56 problems long managed with less troublesome agents (such as benzodiazepines). The off-label use of these drugs, developed for other purposes, and associated with a long list of problems, must be considered a fad. Other psychopharmacological fads are less dangerous. A good example is the use of 2 ADs instead of 1, a procedure of doubtful value.57 This is part of a larger trend in practice to manage psychiatric patients with polypharmacy, sometimes with as many as 5 or 6 agents.58 Of even broader significance, many physicians prefer to prescribe the latest agent within a drug group, rather than sticking to triedand-true drugs whose effects and side effects are known. Once a drug goes generic, its level of prescription plummets immediately.59 This observation demonstrates the power of pharmaceutical marketing. www.TheCJP.ca
In summary, drug therapy can reflect as much about fashion as science. This need not be so, for a conservative approach to practice would use drugs more sparingly. Psychiatrists may usefully remember that most of the great advances in psychopharmacology occurred 40 years ago; we could manage perfectly well with the agents available in 1973. Atypical APs are not more effective than typicals.60 Secondgeneration ADs are no more effective than tricyclics, and none are particularly better than any other.61 Anticonvulsant mood stabilizers are no better than (and are probably inferior to) lithium.62 The glory days of psychopharmacology are behind us, and given the cost of drug development, industry may not be seriously interested in developing agents that would have something new to offer. There are more profits to be made by introducing so-called me-too drugs, or by marketing old ones in extended release forms.
Psychotherapy Fads
The history of psychotherapy is, in some ways, a sad story, with the field jumping from one fad to another. The problem can be traced back to psychoanalysis, which encouraged speculation, not research.63 Even now, the tradition of proclaiming a new method of therapy, and backing it up based on clinical experience alone, remains common. Clinical trials of psychotherapy only began about 50 years ago. Research eventually led to the publication of texts64 summarizing what became a large literature. These empirical studies do not support an endless profileration of methods. What they consistently show is that all psychotherapies work in much the same way and produce much the same results.65 Despite these findings, the psychotherapy field continues to generate schools proclaiming the value of new procedures, labelled with 3-letter acronyms to make them look scientific.66 There should only be one form of psychotherapy, making use of the best ideas from all sources. The most extensive support for any form of psychological treatment is for cognitive-behavioural therapy,67 an approach that capitalizes on the common factors that make talking therapy effective. Newer methods are little but variations on this theme. To understand the proliferation of psychotherapies, one needs to consider how these treatments are marketed. No pharmaceutical representatives knock on the doors of clinicians to suggest they write prescriptions for talking therapy. Instead, therapists create a niche by publishing a book, supported by a series of lectures and workshops, yielding a profit for originating a method. This has made psychotherapy a proprietary activity, associated with a person rather than with an idea. The Antidote to Fads The best antidote to fads is a serious commitment to EBM.68 Evidence-based psychiatry means that practice is based on solid data—not just single studies, which are often never replicated,69 but a large number of studies in clinically representative samples, pointing in the same direction, and The Canadian Journal of Psychiatry, Vol 58, No 10, October 2013 W 563
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sufficient for meta-analysis. In diagnosis, the American Psychiatric Association should not be revising its manual in a radical way until strong evidence is available to support new categories.70 In treatment, older drugs, whose effects are best known, are generally preferable to newer drugs, and established psychotherapies are the most effective choices. Following these principles would lead to a much more conservative approach to the practice of psychiatry. And that is just as it should be.
Acknowledgements
Dr Paris has no conflicts of interest to declare. The Canadian Psychiatric Association proudly supports the In Review series by providing an honorarium to the authors.
References
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The Canadian Journal of Psychiatry, Vol 58, No 10, October 2013 W 565
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Why Is Psychiatry Prone to Fads? Joel Paris, MD1 1
Research Associate, Sir Mortimer B Davis Jewish General Hospital, Montreal, Quebec; Professor of Psychiatry, McGill University, Montreal, Quebec. Correspondence: McGill University, Montreal, QC H3T 1E4; [email protected].
Key Words: psychiatric fads, psychiatric diagnosis, psychiatric treatment Received January 2013, revised, and accepted March 2013.
Psychiatry has long been prone to fads. The main reason is that mental illness is poorly understood and can be difficult to treat. Most diagnostic fads have involved the extension of well-known categories into broader spectra. The most prominent treatment fads have involved the overuse of pharmacological interventions and a proliferation of methods for psychotherapy. The best antidote to fads is a commitment to evidence-based psychiatry. WWW
Pourquoi la psychiatrie est-elle portée sur les modes? Depuis longtemps, la psychiatrie est portée sur les vogues ou les modes. La principale raison en est que la maladie mentale est mal comprise et qu’elle peut être difficile à traiter. La plupart des modes diagnostiques ont impliqué une extension de catégories bien connues en spectres plus larges. Les traitements les plus en modes ont fait appel à la sur utilisation des interventions pharmacologiques et à la prolifération de méthodes psychothérapeutiques. Le meilleur antidote aux modes est un engagement de la psychiatrie fondée sur les données probantes.
A
fad is an idea that arouses short-lived enthusiasm, is quickly adopted, and abandoned when it fails to live up to expectations. As described by Best,1 fads have a 3-phase life cycle: “emerging, surging, and purging.”p 123
Mackay’s2 Extraordinary Popular Delusions and the Madness of Crowds made fun of outlandish and faddish ideas, but assumed that intelligent people should be immune to them. Gardner,3 in Fads and Fallacies in the Name of Science, showed how science, or at least popular science, is also infected by fads. One would like to assume that researchers, trained in a culture of doubt, as well as physicians, trained in EBM, would be cautious about following the latest thing. However, both in the history of medicine4 and of psychiatry,5 fads have been common. Medical fads are most likely to develop when diseases are poorly understood, and when treatment methods are not effective. Patients with treatable conditions, and their physicians, are less likely to be attracted to unusual practices. In contrast, patients with chronic or terminal illnesses, and their caregivers, may well be attracted to such practices. Sick people can be desperate, and physicians sometimes seek desperate remedies.6 They are susceptible to fads because they badly want to help patients; by and large, fads in medicine are misguided attempts to do good. Psychiatry, a specialty that deals with illnesses that cause profound suffering, but in which disease processes are poorly understood, and in which treatment methods are not predictably effective, is an ideal medium for diagnostic and treatment fads. 560 W La Revue canadienne de psychiatrie, vol 58, no 10, octobre 2013
Fads, Cognitive Biases, and Social Contagion
Physicians are trained to depend on empirical data for clinical decisions. The practice of medicine tends to support hope and certainty. In contrast, science, committed to objectivity, supports a culture of doubt. Nevertheless, even basic science has its fads. As the great 19th-century biologist Thomas Huxley7 archly put it: “The great tragedy of science—the slaying of a beautiful theory by an ugly fact.” In principle, new data can overthrow any existing theory. Nevertheless, that is not necessarily what happens— at least in the short run. Researchers, like everyone else, become emotionally attached to their favourite ideas. This makes them seek ways to explain away unpleasant facts. As the physicist Max Planck8 once remarked: A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it. Incorrect conclusions can also be the result of cognitive errors and biases. These mechanisms have been the subject of a large body of research. Many years ago, Festinger9 introduced the term cognitive dissonance, a similar concept to confirmation bias.10 What both mechanisms describe is that once one has already made up one’s mind, new data will be interpreted the light of preconceived ideas. A great deal of research in social psychology supports the principle that reasoning does not work from first principles, and that reasoning is used to support emotional intuitions.11 Thus medical scientists who are strongly attached to a theory www.LaRCP.ca
Why Is Psychiatry Prone to Fads?
reduce cognitive dissonance by interpreting contradictory evidence in a way that does not undermine their beliefs. Another source of cognitive bias is the availability heuristic.12,13 Here error derives from depending on what comes to mind, rather than on what is most probable. This kind of error is particularly likely in clinical practice. If one has just seen a series of patients with a given diagnosis and offered them a given treatment, one is tempted to view future patients as having the same condition and (or) requiring the same therapy. Pharmaceutical companies make use of the availability heuristic by providing physicians with pens and calendars featuring their products. Every time you write a note, you see the name of the drug being marketed, and are more likely to prescribe it. These principles also affect diagnosis: patients may be perceived as fitting the category that most easily comes to mind. Finally, fads proliferate because of social contagion.14 Ideas are picked up from social groups, and shared concepts promote social bonding. In medicine, practitioners often follow what they hear from colleagues, from lectures, and from journals. Fads can spread rapidly when they fit needs for easy answers about diagnosis and treatment—and when supported by experts.
Diagnostic Fads
Diagnosis is an essential part of medical practice. Classifying disease helps physicians communicate with each other and, ideally, describes categories of illness with a specific etiology, a likely prognosis, and a predictable response to treatment.15 Nevertheless, in contrast to the rest of medicine, diagnoses in psychiatry have no gold standard, and cannot be confirmed by biological markers, such as laboratory tests, imaging, or genetic linkages.16 Psychiatric diagnoses are entirely dependent on the observation of signs and symptoms. In the absence of an understanding of etiology and pathogenesis, most diagnoses in current use describe syndromes, not diseases. Fifty years ago, most psychiatrists did not take diagnosis seriously. Categories were used for record-keeping rather than for treatment planning. However, psychiatry eventually fell under attack for its negligence. Reliability was low, even for important diagnoses, such as schizophrenia and Abbreviations AD antidepressant ADHD
attention-deficit hyperactivity disorder
AP antipsychotic ASD
autistic spectrum disorder
BD
bipolar disorder
BSD
bipolar spectrum disorder
DD
dissociative disorder
DSM
Diagnostic and Statistical Manual of Mental Disorders
EBM
evidence-based medicine
MDD
major depressive disorder
www.TheCJP.ca
Clinical Implications •
Psychiatrists should be skeptical of diagnostic expansion and of new forms of treatment.
•
Cautious conservatism in practice should be based on evidence.
Limitations •
Genuine breakthroughs in diagnosis and treatment appear from time to time.
•
The evidence base for psychiatry remains thin.
manic-depression.17 The specialty suffered criticism from anti-psychiatrists, and earned little respect from medical colleagues. The development of DSM-III18 was an attempt to address these problems. Nevertheless, even today, with DSM-5 being recently published, psychiatric diagnosis remains entirely phenomenological. These problems will not be resolved until more is understood about the etiology and pathogenesis of mental disorders. Despite great progress in neuroscience, none of its findings have shed light on the pathways leading to specific forms of mental illness. However, these limitations have not prevented clinicians and researchers from promulgating novel diagnostic concepts, or extending those already in existence. Diagnostic fads tend to develop in areas of psychiatry that are inadequately studied, and are applied to patients who do not respond to standard therapy. Many fads take an established diagnostic entity, and suggest it can be applied to a much broader spectrum of patients with related symptoms. One interesting aspect of these diagnostic fads is that they can be attractive to patients. In modern psychiatry, patients like diagnoses that suggest chemical imbalances, even if there is no evidence that major mental disorders, or common disorders such as depression and anxiety, are associated with specific changes in neurotransmitters19 Instead of feeling inadequate, patients can see themselves as struggling with a problem outside their personal control. In this review, I will consider 5 examples of diagnostic fads that have been prominent in the last 2 decades. The first 4 extend a well-established diagnosis to a vast range of patients: MDD, BSDs, ADHD in adults, and ASDs. None of these conditions can be reliably identified by biological markers, and all depend entirely on clinical observation. Therefore, their boundaries with other disorders, and with normal variation, are ultimately a matter of clinical opinion. The fifth group, DDs, is different, in that diagnoses are almost entirely an artefact of questionable theories and therapeutic methods.
Major Depressive Disorder
Psychiatrists have long been taught that depression can be a symptom, a syndrome, or a disease. However, the idea that depression is one disorder, varying only in relation to severity, is questionable.20 For example, patients with melancholia have severe depression associated with prominent physical symptoms, and can sometimes be The Canadian Journal of Psychiatry, Vol 58, No 10, October 2013 W 561
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psychotic.21 These severely ill patients respond much better to AD therapy,22 and to electroconvulsive therapy.23 In contrast, patients with milder symptoms are often better described as unhappy,24 and do not belong in the same category. Similar problem arise in anxiety disorders— most particularly with the currently faddish diagnosis of posttraumatic stress disorder.25 The overdiagnosis of MDD (which is not necessarily all that major) has led to screening programs in the community that only succeed in identifying symptoms that usually get better without treatment.26 The diagnostic criteria for a major depressive episode require only 5 out of 9 listed criteria for as little as 2 weeks. Owing to this extremely broad definition, prevalence is very high—up to 50% or more during a lifetime.27 These conclusions reflect a unitary theory of depression,28 influential for 40 years, in which all cases lie on a continuum of severity. The main reason for an overdiagnosis of depression is the wish to treat patients with ADs. While these drugs are not always superior to placebos in milder cases,22 11% of the entire population of the United States is now taking one of these agents.29 These drugs are necessary and useful for severe depression, and can be effective in several other conditions, but prescribing them indiscriminately for unhappiness has not contributed to population health.
Bipolar Spectrum Disorders
BD I is one of the few conditions in psychiatry that closely resembles a medical illness. Although we do not know its etiology, classical BD has a characteristic clinical picture and course, as described by Kraepelin30 BD I is also a diagnosis that points to a specific response to treatment with mood stabilizers, especially lithium.31 There can also be little doubt about the validity of BD II, characterized by hypomania rather than full mania.32 However, when the precise criteria for a hypomanic episode (4 days of continuous abnormal mood) are ignored, patients with euphoric episodes lasting only a few hours may be given a BD II diagnosis.33,34 The concept of a BSD has been invoked to support the expansion of bipolarity as a way of describing any pattern of mood instability35 and has been claimed to affect millions of untreated patients who experience mood swings.36 The fad for BSDs has reached the point where surveys using the concept identify over 30% of depressed patients as having occult bipolarity.37 Some surveys have even suggested that close to one-half of all psychiatric patients could meet broadened bipolar criteria.38 Nevertheless, these claims are based entirely on clinical observation. We do not know whether so-called soft bipolar symptoms, such as short-term mood instability and irritability, belong in the same category as classical bipolarity. The bipolar fad has also spread to child psychiatry, and this disorder, long considered to appear only after puberty, is now being diagnosed in children with behavioural disorders. However, children with irritable and unstable mood do not develop 562 W La Revue canadienne de psychiatrie, vol 58, no 10, octobre 2013
classical BD with time, and do not respond to treatments developed for adult patients with BD.39 The bipolar fad would not be worrying except that making the diagnosis in more patients leads to a wider prescription of drugs with significant side effect profiles.40 The long-term use of mood stabilizers and APs for patients who do not have classical forms of the disorder should be of particular concern when these drugs are prescribed to children.
Attention-Deficit Hyperactivity Disorder
ADHD has been the subject of a vast research literature, and the use of stimulants to treat children with classical features of the disorder has a well-established evidence base.41 However, even in pediatric populations, diagnostic boundaries are unclear. When the core features of ADHD are present, treatment with stimulants is most likely to be successful, but not all children with symptoms of limited attention do well on these agents.42 The most important current fad arises from the extension of the ADHD diagnosis into adult populations. It is well established that not all children with this diagnosis recover by adulthood.43 However, to diagnose ADHD in an adult, a definite history in childhood has first to be established, which may require a careful review of school records. What too often happens in practice is that the diagnosis is made based on a history of problems with attention owing to any cause. Sometimes the diagnosis is confirmed by psychological testing, a procedure that is very nonspecific.44 As even in cases where diagnoses are made more carefully, one sees massive comorbidity,45 the boundaries of the disorder in adulthood remain uncertain. The main result of overdiagnosis of adult ADHD is that many patients are unnecessarily prescribed stimulants. As normal people also have better attention on these regimes,46 one may see short-term therapeutic effects. But high comorbidity suggests that many of these patients could need different methods of treatment.
Autism Spectrum Disorders
Autism and related conditions have long been considered rare. More recently they have been diagnosed more and more frequently in adults and in children. A recent survey in South Korea47 garnered a fair amount of attention from the media by reporting that spectrum diagnoses can be found in 3% to 4% of the general population. Clearly something has happened to the definition, which has steadily broadened. The autism spectrum is a severe group of disorders that have been extended to include Asperger syndrome and other milder conditions into a broader ASD. In the absence of a gold standard, it is tempting to see everyone with eccentricity and social awkwardness as falling within these boundaries. Nevertheless, children are different in temperament, and varying trait profiles can be adaptive under the right circumstances. Highly introverted children can go into occupations, such as computer science, that make use of a lack of sensitivity to social cues. It seems www.LaRCP.ca
Why Is Psychiatry Prone to Fads?
likely that we are not seeing a diagnostic epidemic of autism—proof of which would require prospective data,48 as well as biological markers.
Dissociative Disorders
This group of disorders is rare, so rare in fact that they may not even exist. Symptoms such as depersonalization and derealization are common in many disorders, but can sometimes present as a separate syndrome,49 a clinical picture of interest to transcultural psychiatrists.50 In contrast, multiple personality disorder (now called dissociative identity disorder), in which several personalities coexist, is the result of interactions between enthusiastic therapists and patients with a flair for drama.51 Sibyl, a patient who became the subject of a best-selling book, later admitted that she produced alternative personalities only because her therapist asked for them,52 and it has documented that the child abuse that she reported to her therapist was a fabrication.53 The enthusiasm for diagnosing DDs was also associated with an incorrect theory of memory, leading to false memories and false accusations of child abuse.51 This malignant fad did great damage to patients and families.
Treatment Fads Psychopharmacology Fads
We do not usually view psychopharmacology as susceptible to fads. In principle, the prescription of drugs should be evidence-based, and supported by systematic clinical trials. New agents are regulated by government bodies, and are only approved when empirical data are sufficient. That is the ideal. In practice, drugs and drug combinations can be allowed on the market based on 2 or 3 studies, without enough data to justify a meta-analysis.54 Moreover, physicians can prescribe drugs off-label, with or without encouragement from pharmaceutical representatives. The most serious current problem in psychopharmacology is the tendency to prescribe APs for a wide variety of indications, despite serious side effects. The use of APs as augmenting agents for depression is only weakly supported by evidence.55 Their use has become very common in the management of anxiety and insomnia,56 problems long managed with less troublesome agents (such as benzodiazepines). The off-label use of these drugs, developed for other purposes, and associated with a long list of problems, must be considered a fad. Other psychopharmacological fads are less dangerous. A good example is the use of 2 ADs instead of 1, a procedure of doubtful value.57 This is part of a larger trend in practice to manage psychiatric patients with polypharmacy, sometimes with as many as 5 or 6 agents.58 Of even broader significance, many physicians prefer to prescribe the latest agent within a drug group, rather than sticking to triedand-true drugs whose effects and side effects are known. Once a drug goes generic, its level of prescription plummets immediately.59 This observation demonstrates the power of pharmaceutical marketing. www.TheCJP.ca
In summary, drug therapy can reflect as much about fashion as science. This need not be so, for a conservative approach to practice would use drugs more sparingly. Psychiatrists may usefully remember that most of the great advances in psychopharmacology occurred 40 years ago; we could manage perfectly well with the agents available in 1973. Atypical APs are not more effective than typicals.60 Secondgeneration ADs are no more effective than tricyclics, and none are particularly better than any other.61 Anticonvulsant mood stabilizers are no better than (and are probably inferior to) lithium.62 The glory days of psychopharmacology are behind us, and given the cost of drug development, industry may not be seriously interested in developing agents that would have something new to offer. There are more profits to be made by introducing so-called me-too drugs, or by marketing old ones in extended release forms.
Psychotherapy Fads
The history of psychotherapy is, in some ways, a sad story, with the field jumping from one fad to another. The problem can be traced back to psychoanalysis, which encouraged speculation, not research.63 Even now, the tradition of proclaiming a new method of therapy, and backing it up based on clinical experience alone, remains common. Clinical trials of psychotherapy only began about 50 years ago. Research eventually led to the publication of texts64 summarizing what became a large literature. These empirical studies do not support an endless profileration of methods. What they consistently show is that all psychotherapies work in much the same way and produce much the same results.65 Despite these findings, the psychotherapy field continues to generate schools proclaiming the value of new procedures, labelled with 3-letter acronyms to make them look scientific.66 There should only be one form of psychotherapy, making use of the best ideas from all sources. The most extensive support for any form of psychological treatment is for cognitive-behavioural therapy,67 an approach that capitalizes on the common factors that make talking therapy effective. Newer methods are little but variations on this theme. To understand the proliferation of psychotherapies, one needs to consider how these treatments are marketed. No pharmaceutical representatives knock on the doors of clinicians to suggest they write prescriptions for talking therapy. Instead, therapists create a niche by publishing a book, supported by a series of lectures and workshops, yielding a profit for originating a method. This has made psychotherapy a proprietary activity, associated with a person rather than with an idea. The Antidote to Fads The best antidote to fads is a serious commitment to EBM.68 Evidence-based psychiatry means that practice is based on solid data—not just single studies, which are often never replicated,69 but a large number of studies in clinically representative samples, pointing in the same direction, and The Canadian Journal of Psychiatry, Vol 58, No 10, October 2013 W 563
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sufficient for meta-analysis. In diagnosis, the American Psychiatric Association should not be revising its manual in a radical way until strong evidence is available to support new categories.70 In treatment, older drugs, whose effects are best known, are generally preferable to newer drugs, and established psychotherapies are the most effective choices. Following these principles would lead to a much more conservative approach to the practice of psychiatry. And that is just as it should be.
Acknowledgements
Dr Paris has no conflicts of interest to declare. The Canadian Psychiatric Association proudly supports the In Review series by providing an honorarium to the authors.
References
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