Category Archives: Medication

Reviewing Psychiatry Disrupted

Psychiatry Disrupted was released in 2014, making it a relatively new book on the topic of anti-psychiatry. The editor’s introduction argues that anti-psychiatrists often do not focus enough on what an alternative to psychiatry would look like and this book is intended to fill this gap. Since most the well known classic anti-psychiatry texts are rather old and since they usually criticise psychiatry without sufficiently outlining an alternative I was interested in this book. Whilst I am far from being an anti-psychiatrist myself, I wanted to see what a modern alternative to psychiatry would look like. Unfortunately, I think this book fell quite far short of this objective.

Firstly, many articles often criticise psychiatry without actually explaining why psychiatry might be wrong. This does not occur on every issue but sometimes it is stated as a given that psychiatry is in error. For example, some authors simply criticise psychiatric classifications without explaining why they might be flawed. This is problematic because the problems with classifications are complicated. Generally, most psychiatric classifications are trade-offs, a committee having choices over how to formulate them and generally any advantages to a way of classifying will also involve disadvantages. For example, lumping vs splitting, or not otherwise specified being vague but allows more coverage, or having narrow but specific diagnosis vs broader ones which over-lap with each other. Now, it could be argued that psychiatrists are choosing a bad combination of advantages and disadvantages, or that any possible combination of advantages are always outweighed by disadvantages. I don’t think that myself but at least making that argument would be better than an outright dismissal without argument. This occurs too many times in the book.

Secondly, there was relatively little on what an alternative to psychiatry would look like. There is quite a lot of detail about how different groups with diverse interests could get together to oppose psychiatry. In a sense this moves the anti-psychiatry movement forward, in that we know anti-psychiatry objects to psychiatry and this book shows new ways to go about objecting. But I’m still uncertain what should replace psychiatry. I got the impression that an alternative would involve more psychotherapy, less drugs, more user involvement and more user choice. In principle, I could agree with all that, but doing this would not require an end to psychiatry. This would still leave room for psychiatrists to classify and proscribe drugs, just that psychiatrists would more often refer people for psychotherapy and involve the user more. So this is hardly a massive overhaul of psychiatry. If the anti-psychiatry movement has something more radical in mind then I want to see it explicitly outlined, a detailed alternative of what would replace psychiatry.

The book did have some good points. It went into quite a lot of detail about how various different interests groups might conflict and gave some reasoned arguments about how to resolve these conflicts or who should get priority. It also had some innovative ideas about how different groups could work together. Additionally, it did highlight, often with practical examples, various ways in which psychiatric patients can be oppressed, devalued or misinterpreted, primarily due to false assumptions on the part of psychiatrists and care workers. Some of these issues were subtle and worth reading about.

Classifications and medication

Washington Post headline “Most antipsychotic drugs prescribed to teens without mental health diagnosis, study says” (from article). From the article: “60 percent of those ages 1-6, 56.7 percent of those ages 7-12, 62 percent of those ages 13-18, and 67.1 percent of young adults, ages 19-24, taking these drugs had no outpatient or inpatient claim indicating a mental disorder diagnosis”.

The implicit notion here seems to be one of surprise and concern: surely people should have a diagnosis before they are given drugs. Interestingly, many philosophers of psychiatry might disagree. Philosophers of psychiatry often complain that most people do not neatly fit classifications, typically they meet the diagnostic criteria for numerous classifications, they exhibit symptoms below the threshold of criteria some classifications, their behaviour changes over time so they no longer fits previously diagnosis, the cut off points required for diagnosis are arbitrary conventions, etc. In essence, many philosophers reject the current categorical approach (you have either have this diagnosis or you do not) and instead prefer a dimensional model (you lie on a continuum with normality, exhibiting a range of symptoms to varying degrees [this is somewhat of a simplification]).

A consequence of the dimensional approach is that classifications are not so important. On a dimensional approach a doctor needs know what symptoms you exhibit, not which classification you does a half-hearted job of describing your symptoms. Surely then prescribing medication without providing a diagnosis is perfectly acceptable.

I personally prefer a categorical approach and plausibly this issue over drugs shows an advantage of categorical classifications. You need meet a set of fairly stringent criteria to get a diagnosis. On one hand this means some people who have some but not all the symptoms go undiagnosed, on the other it means diagnosis cannot be (should not be) handed out to all who want it. If a diagnosis is generally required to prescribe strong medication then we have an additional safety net above and beyond the judgment of a single doctor prescribing drugs since diagnosis usually requires a specialist. Of course, there are times when someone needs medication immediately and cannot wait for diagnosis, but surely that situation would not cover half of all adolescents?