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?

Making psychology more textual but still statistical

I just read a couple of textbooks on anxiety. I was looking to see if anxiety was ever described as manifesting in a particular way and I found both textbooks to be largely unhelpful. They were severely lacking in qualitative descriptions of patients, very little on the experience of anxiety. Instead it is mainly statistical, describing statistical correlations between anxiety and gender, age, upbringing, other psychological traits etc.

I was particularly concerned by how anxiety was demarcated from other psychological states (depression, worry, fear etc) and different types of anxiety were demarcated (social, agoraphobia, phobia, PTSD, etc) without employing much qualitative descriptions by patients. Without such information are we really sure the boundaries between, say, anxiety and depression have been adequately drawn, similarly so with boundaries between different types of anxiety. Psychologists certainly have criteria, checklists and questionnaires to make such distinctions on but how much trust should we put in them? To be fair, both textbooks were aware of this problem but unfortunately seemingly suggested more studies using those same criteria would solve the problem, rather than trying think about and improve the criteria.

If we want to get clear about something then you might consider asking a philosopher to think about it, to analysis the concepts, to look for assumptions. All well and good. However, I also think this approach is severely limited, since philosophers have a tendency of making distinctions on obscure grounds little connected to everyday experience. Also, it is difficult to put diverse human experience like anxiety into necessary and sufficient without risking turning the concept of anxiety into some abstract notion far removed from human experience. In my experience, sometimes conceptual analysis of psychological states results in something largely unrecognisable. The psychologists ‘anxiety’ I can relate to, this will not always be the case with the philosopher’s ‘anxiety’.

There may be a middle ground. Conceptual analysis is important but can only go so far, at some point concepts should be opperationalised and need applying to the world. Philosphers should ideally give their concepts formalised criteria and then do statistical studies on them. Statistics hopefully should show the concept has some ‘fit’ with the world and the concepts can be modified in light of those statistics to get the fit better, to make it more relevant to patient reports. Unlike the psychologists though, make the opperationalised criteria rich and textual, highlight them with patient case studies, analyse those case studies conceptually to draw boundaries between concepts and draw inter-relations between concepts. More importantly, recognise these are only concepts and recognise that concepts rarely (perhaps never) fully mesh with the world, so employ many different concepts, formulate many different opperationalised criteria for statistical studies rather than continually employing the same old criteria. A psychology which willing drew different boundaries between anxiety and depression in different studies would have greater difficulty comparing results of different experiments but those results themselves would likely be so much more richer empirically, the statistics would reveal so much more.

I’m not sure how closely they can be merged or how exactly how it would be best done (major institutional changes would be ideal!) but the qualitative and the statistical can be brought closer together and this may require both psychologists and philosophers learning from one another.