Saturday, November 11, 2006

Psychiatric diagnoses: 200 years behind

I've been saying this for years, so it's nice to see that academic psychiatrists, at least, are saying it publicly:
What's Wrong With a Child? Psychiatrists Often Disagree - New York Times

..."Psychiatry has made great strides in helping kids manage mental illness, particularly moderate conditions, but the system of diagnosis is still 200 to 300 years behind other branches of medicine", said Dr. E. Jane Costello, a professor of psychiatry and behavioral sciences at Duke University. "On an individual level, for many parents and families, the experience can be a disaster"
The NYT article is recommended reading for every family with a special needs child.

The relatively meaningless of pyschiatric labels is not new. The family of DSM manuals were all about trying to get a relatively solid grasp on the fluid and sometimes formless world of human cognitive and behavioral variability. Reams of books have been written about social construction of psychiatric diagnoses; many have been misguided but they're not without an element of truth. Psychiatric "diagnoseses" have been much more craft than science.

Psychiatrists are not to blame for being unable to label the formless -- though they could be dinged for not speaking up more clearly about the nosologic (naming) problems they face. In their defense patients and families don't usually want to hear than we're flying blind in this domain. A facade of certainty can be mutually reasurring.

Most of all, labels are about getting services, managing friends and relativelys, and placating schools -- we use what works for those purposes. The last anectdote in the article really tells the whole story:
Camille Evans, a mother in Brooklyn whose son’s illness was tagged with a half-dozen different diagnoses in the last several years, said she concluded, after seeing several psychiatrists, that the boy’s silences and learning difficulties were best understood as a mild form of autism.

“That’s the diagnosis that I think fits him best, and I’ve just about heard them all,” Ms. Evans said.

The label is not perfect, she said, but it is more specific than “developmental delay” — one diagnosis they heard — and does not prime him for aggressive treatment with drugs like attention deficit disorder or bipolar disorder would. He has not responded well to the drugs he has tried.

“Most important for me,” Ms. Evans said, “the diagnosis gives him access to other things, like speech therapy, occupational therapy and attention from a neurologist. And for now it seems to be moving him in the right direction.”
Access to other things, not too discouraging, not too scary. The label works for now and for this family, and, honestly, that makes it right for clinical use, if not for research purposes.

Psychiatric therapy will continue to be empiric at best -- try a diagnosis, try a therapy, try another. Most of the time it helps, sometimes it helps a lot. We're still in the stone ages, but functional MRI, gene analysis and other measures to ground the behavioral in the physical are slowly moving us into the bronze age.

Bottom line: humility is indicated. Good to have it.

PS. Psychiatrists should also stop blaming pediatricians and family physicians for assigning labels that others change. It's not like psychiatrics (or neurologists for that matter) can do any better. Remember - humility.

PPS. My guess? That behavioral disorders in children are particularly dynamic because they represent the combination of initial brain injury, ongoing injury, and unusually active ongoing reparative processes. Superimpose the immense brain morphing impact of adolescence on that and it's no wonder the best available treatment, and the most convenient label, will change from season to season.

1 comment:

Daniel Haszard said...

My issue is Zyprexa which is only FDA approved for schizophrenia (.5-1% of pop) and some bipolar (2% pop) and then an even smaller percentage of theses two groups.
So how does Zyprexa get to be the 7th largest drug sale in the world?

Eli Lilly is in deep trouble for using their drug reps to 'encourage' doctors to write zyprexa for non-FDA approved 'off label' uses.

The drug causes increased diabetes risk,and medicare picks up all the expensive fallout.There are now 7 states (and counting) going after Lilly for fraud and restitution.

Daniel Haszard