This past month has been disastrous for mental health. One embarrassment has followed another -- leading to a crisis of confidence that is potentially dangerous for those who rely on psychiatric care.
Most damaging were the negative reviews of DSM-5, the new diagnostic manual. It was justly panned for introducing many unsafe and scientifically unsound diagnoses that will worsen the already existing over-treatment of the worried well and the shameful neglect of the really sick.
The National Institute of Mental Health then piled on with a misleading press release that seemed to reject all of current clinical practice in order to pump up support for its expanded budget request for brain research. NIMH failed to admit that it will probably take decades to translate any of its basic science findings into tangible benefits for patients who are suffering now. The exclusive NIMH focus on biology has blinded it to the desperate needs of the one million psychiatric patients now languishing in prison for nuisance crimes that could have been prevented if only they had access to adequate community treatment and decent housing.
Sometimes bad mistakes turn out to be a blessing in disguise -- you realize how far off proper course you have been drifting and can make a needed course correction. The bad mistakes made by DSM-5 and NIMH are a loud wake up call to the current mess in mental health and the compelling need for change.
So, what's next? I am no fan of the U.S. Congress -- it seems to be perpetually paralyzed by foolish partisanship, unable to meet obvious challenges or even debate them rationally. It is a sign of my desperation to suggest that only Congressional hearings can begin to cure the deep-seated disorders that plague our mental health non-system. I suggest that Congress undertake an eight item agenda:
First, the diagnostic system in psychiatry is broken and can't be fixed internally by the American Psychiatric Association -- which currently holds the monopoly. DSM-5 has fanned the flames of diagnostic inflation with definitions that turn everyday life problems into mental disorder -- harming the misidentified 'patients' and costing the economy billions of dollars. Psychiatric diagnosis has become too important (in decisions determining workman's comp, disability, VA benefits, school services, custody, criminal responsibility, preventive detention, and the ability to adopt a child, fly a plane, or buy a gun) to be left to one small professional association
Psychiatric diagnosis is too much a part of public policy to be left exclusively in the hands of the psychiatrists. Experts in psychiatry have no expertise in how their diagnostic decisions will affect public health, public welfare, the allocation of resources, and the health of the economy. Congress should set up an agency to ensure much more careful vetting of risks and benefits.
Second, Congress should also investigate why one million psychiatric patients are occupying expensive prison beds instead of being treated more humanely and economically in the community. Because state budgets for psychiatric care have been slashed dramatically, prisons have inadvertantly become the mental health provider of last resort and are now the biggest system of mental health care in the country. This foolish misallocation of resources results in the barbaric mistreatment of the mentally ill -- a practice the rest of the developed world abandoned two centuries ago.
Third, Big Pharma needs to be tamed -- just as twenty years ago, Congress tamed Big Tobacco. Drug company marketing consists of nothing more than misleading disease mongering -- selling diagnoses to peddle pills to people who don't need them. If it has the political will to take the following steps, Congress can easily end Pharma's hijacking of medical care. No more direct-to-consumer advertising of drugs -- a privilege Pharma enjoys only in the US. No more misleading marketing to doctors cloaked in the sheep's clothing of 'education'. No more financial contributions turning consumer advocacy groups into extenders of company lobbying. No more 'research' guided by the marketing efforts to enhance patent life and stretch indications, rather than aiming for real breakthroughs. No more ghost written papers by thought leaders who mouth party line. No more monopoly pricing power because government is prohibited from bargaining. And no more revolving door politicians drifting back and forth from government to cushy Pharma jobs.
Fourth, Congress should provide more teeth and funding for an under-resourced FDA that is almost by necessity too drug industry friendly -- willing to passively accept costly me-too drugs, ill-equipped to monitor adverse effects, and unable to sunset drugs (like Xanax) that are widely prescribed despite having questionable indications and unquestionable harmful effects.
Fifth, Congress should investigate the research mandate of the NIMH. Is it really meant to be exclusively a brain institute making grand and probably unrealistic promises for the distant future, while completely ignoring the really desperate needs of the mentally ill in the present? If not NIMH, who is charged with studying and improving our current sad state of mental health care?
Sixth, Congress should investigate the CDC's fatally flawed method for determining rates of mental disorder. CDC has a systematic bias toward over-estimating the disorder rates in the healthy and ignoring the needs of the really sick. Its data gathering relies on telephone contacts conducted by lay interviewers who cannot possibly distinguish clinically significant mental disorder from everyday symptoms that are part of the human condition. The wild instability and elasticity of the reported prevalences is proof positive they should be discounted; not taken as credible indication our society is getting sicker. Epidemiological attention should focus instead on the extent and correlates of the more severe mental disorders currently being neglected.
Seventh, Congress should attend to the catastrophe that more people now die from overdoses of prescription than street drugs. High flying prescribers need to be brought to ground with strict monitoring, professional discipline, and public shaming. And real-time computerized control could contain loose drug dispensing. If Visa can put an advance stop on a suspicious $100 purchase, we can develop a proactive check that a prescription makes sense before filling it. Cooperative FDA and DEA scrutiny of drug company marketing practices and distribution methods would reduce the current free availability of lethal narcotics. We are fighting a drug war against the cartels that we cannot possibly win and haven't yet begun a war against the inappropriate use of prescription drugs that we could not possibly lose.
Finally, Congress should expand its existing concern about suicide in the military to discuss the over-prescription of medication to active duty troops (10 percent), the rampant polypharmacy, and the lack of transitional supports between active duty service and civilian life that results in the excessive diagnosis of PTSD and unnecessary disability from it.
Why Congress? With all its obvious flaws, there is no other place to turn. The related problems of out-of-control diagnosis and out-of-control prescription drugs and out of control imprisonment of psychiatric patients are all facilitated by institutions that have proven to be immune to self correction -- the American Psychiatric Association, Big Pharma, state governments, the Center For Disease Control, and the Food and Drug Administration.
Unless Congress does its part, soon most of us will have a fake mental disorder (or a few) and we will live in a Brave New World where nearly everyone uses medicine. Meanwhile, people with real mental illness are treated more shabbily in the U.S. than in any other developed country in the world.
If all this doesn't warrant investigation, what does?