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On Oct 16 an enthusiastic piece was published in the Scientific American on “The Rise of All-Purpose Antidepressants.” It was simply thrilling, the author noted, that Prozac and its cousins turned out to be effective, not just in depression, but . . .
Wait for it.
Everything. The psychiatric diseases for which the Prozac-style SSRIs are now prescribed “off-label” – meaning for indications not officially approved by FDA – encompass virtually the entire range of disorders outside of psychosis and mental retardation.
Doctors can prescribe an agent for any indication they choose, once the Food and Drug Administration has approved it for the indication the company submitted. In the late 1980s and early -90s, the companies submitted their Prozac-style drugs for “depression,” and readily obtained that indication, the only one they were allowed to advertise for. Later, they got anxiety. Then the SSRIs all went off patent and it was no longer worthwhile for industry to fund trials, because the generic companies would just cannibalize the market.
So now, in the world of Big Pharma, the SSRIs have been forgotten. But they haven’t been forgotten in the trenches of clinical medicine and doctors prescribe them all the time for everything imaginable. And with some success. As drugs, the SSRIs are not inert; they are just not very good “antidepressants,” if one is treating serious depression.
The point that I want to make, however, is about all these new diagnoses, not about how often the SSRIs, rightly or wrongly, are prescribed. There must be something wrong with a system of diagnosis in which one single drug class treats everything.
Look at all the disorders that now are said to respond to “antidepressants”: fluoxetine (Prozac) is good for major depressive disorder, obsessive-compulsive disorder, bulimia nervosa, social phobia, and menstrual distress, called “premenstrual dysphoric disorder,” just to make it sound like you must be depressed if you’re grumpy around your period.
Ah, but Paxil is not in the shade! It turns out that, in addition to “major depressive disorder,” Paxil also works for “generalized anxiety disorder” and “post-traumatic stress disorder” -- in addition to some of the other things that Prozac is good for.
And sertraline (Zoloft) is good for “panic disorder” (in addition to everything else).
These are supposed to be separate diseases, right? And yet it turns out that a handful of drugs with similar mechanisms are effective for all of them. There is a complete lack of differential responsiveness, one of the key concepts in psychopathology: The disease in question responds differentially to a specific agent. Digitalis strengthens the beating of the heart but it does nothing for hives.
The implication is that these DSM diagnoses – that span the entire range of everything a psychiatrist is likely to see in office practice – are not separate diseases at all but slightly different presentations of the same underlying disorder. What is that disorder? It was once called “nerves.” Then under the influence of Freud it was called “psychoneurosis.” These were seen as unitary concepts, incapable of being subdivided into a riot of different disorders. It was DSM-3 that said there were nine different kinds of anxiety, and that post-traumatic stress disorder was a disease of its own, and that “generalized anxiety” was different from “depression.”
But maybe these are not different diseases. They don’t respond differentially to anything. Anxiety often turns into depression, which then turns back again into anxiety. People with post-traumatic stress are often depressed, sometimes they’re anxious, sometimes they have “social phobia.” Maybe PTSD is really just a form of nerves or psychoneurosis?
You see where we’re heading with this. The academic psychiatrists who designed DSM-3 in 1980 were not under the influence of the pharmaceutical industry. I know this because I’ve seen the correspondence in the archives of the American Psychiatric Association.
But the DSM-3 disease-designers were really keen to break with psychoanalysis and show that there were lots of different psychic diseases out there. Then the pharmaceutical industry glommed onto all these new diagnoses and started marketing them as specific diseases: “Depression” became a disease of its own. “Anxiety” became a disease of its own. And as for the riot of niche diagnoses such a “social anxiety” and being irritable around your period: don’t ask. Academic experts have been dead keen to carve these into little empires and publish puffy little papers on them to qualify for grants.
DSM-5, launched in 2013, has turned into a disaster. It is this gross purple volume filled with bogus diagnoses. We have got to rethink the whole business of classifying diseases. Maybe there are only four or five diseases in psychiatry, which is what Philippe Pinel believed, the Paris psychiatrist whose work around 1800 launched modern psychiatry. Maybe psychiatry today has run into a dead end.
