Psychiatrists are medical doctors who after graduation from medical school specialize in the treatment of mental disorders. In 1950 there were about 7000 psychiatrists in the United States. Most of these worked either in the state mental hospitals or in private practice, and in both settings treatment was conceptualized primarily on the lines of talking to the patients, gaining an understanding of their problems, and encouraging them in positive directions.
In the hospitals, considerations of containment and control sometimes eclipsed those of treatment, but in their private practices psychiatrists practiced the newly emerging art of psychotherapy with vigor and enthusiasm. Different schools of thought emerged, and there existed a healthy measure of dialog and debate as to the merits and demerits of various techniques. Articles were published in learned journals, and in every respect psychiatry was poised for development as a “talking” profession.
Despite the enthusiasm with which the psychotherapeutic movement was being greeted generally, it was not without its critics. Physicians generally had always been somewhat skeptical of their psychiatric cousins, but now as the other medical specialties aligned themselves increasingly with the physical sciences, and developed an array of formal tests and procedures to complement their healing arts, the psychiatrists began to feel increasingly self-conscious with regards to the somewhat nebulous and ill-defined nature of their subject matter.
At about the same time, many industrial and commercial organizations in the United States began to offer medical insurance as a fringe benefit to attract employees. Physicians quickly discovered that their bills were paid more reliably and more promptly under these schemes, and not surprisingly, the psychiatrists began to look for ways whereby they also could bill insurance companies for their services. Because of the time-consuming nature of psychotherapy, it was at that time, apart from the state hospitals, almost exclusively the province of the wealthy. Human nature being what it is, however, it is reasonable to believe that psychiatrists had as much difficulty collecting their accounts as other physicians, and their desire to improve their lot in this regard is certainly understandable.
To bill insurance companies, however, they had to specify more clearly than previously what illnesses and disease entities they were purportedly treating. An additional pressure to formalize psychiatric diagnoses arose within the armed forces, where unprecedentedly large numbers of individuals were receiving psychiatric services and where military formalities and accounting were demanding a higher level of precision and definition than psychiatrists had encountered in civilian life. For all of these reasons, the psychiatrists had to produce a formal list of diagnoses, and in 1952, the American Psychiatric Association (APA) published its Diagnostic and Statistical Manual (DSM). The work was not very precise and the diagnostic categories were not clearly defined, but it was a start, and more importantly, the formal endorsement of the APA afforded the diagnoses a respectability and perceived validity that they would not otherwise have achieved.
The first DSM listed four broad categories of mental disorder: psychosis; neurosis; character problems; and psycho-physiological problems. Psychosis embraced what a lay person might term “craziness.” Neurosis referred to worries, anxieties, and depression. Character problems meant bad habits, and psycho-physiological problems referred to mental problems which were believed to be caused primarily by physical factors.
What is especially noteworthy about this early list of mental disorders is that there is no expansionist agenda evident. It was simply an attempt on the part of a helping professional group to codify and systematize the object of their study. They were describing the problems brought to them by their current clientele, and there is nothing in the text to suggest any preoccupation with expanding the diagnostic categories to embrace large numbers of new clients.
By contrast, the current edition of the APA’s manual, DSM-IV, published in 1994, has more than three hundred diagnostic categories and sub-categories, and it is difficult to avoid the perception of expansionist marketing. In addition, the diagnostic categories are so vaguely defined that almost anybody at some time in his or her life will meet the criteria for at least one mental disorder.
To understand how such a major shift in emphasis occurred, it is necessary to examine the role of the pharmaceutical companies.
In the 1950’s, several psychotropic drugs were discovered or invented, and it was clear that further developments in this area were imminent. Psychotropic drugs are chemicals that alter people’s behavior and/or mood, and it was also clear that the sales potential in this area was enormous.
The problem for the pharmaceutical companies, however, was that they needed diseases and illnesses for which these drugs could legitimately be prescribed. In the United States the testing and marketing of drugs is regulated by the Food and Drug Administration (FDA), and part of the regulatory process requires the manufacturer to specify the illness targeted by a new drug and to conduct appropriate clinical trials. The testing procedures are not as rigorous as the public generally believes, but obviously they cannot be completely ignored.
So as the second half of the twentieth century was under way, we had the APA, on the one hand, formalizing and codifying the disorders or illnesses that their members are treating in their daily practices. On the other hand the pharmaceutical companies were looking for illnesses which would legitimize the sale and distribution of their newly discovered psychoactive products. The mutual interests were obvious. The psychiatrists and pharmaceutical companies joined hands in a collaborative venture that flourishes to the present day. The major impact of the “merger” on the psychiatrists is that the nature of their work changed from psychotherapy, which consisted essentially of talking and listening, to prescribing pills. At the present time it is extremely rare to find a psychiatrist who has ever practiced or even received training in any form of “talk” therapy. For the most part a psychiatrist’s workday consists of a succession of fifteen-minute “med checks”: routine interviews for the purpose of renewing psychoactive prescriptions.
Most psychiatrists seem comfortable with this role. They can see more clients and therefore generate more income than their colleagues of former years, and for many the pills and the codified diagnoses lend a “scientific” legitimacy to their activity that they feel was absent in the days of psychotherapy. Successive revisions of DSM have enormously expanded the potential client population to the point where psychiatric services (in other words, psychoactive drugs) are now being actively promoted and advertised for every age group and virtually every problem of human life. It is the pharmaceutical companies, of course, who drive these drug promotion campaigns, the success of which is clearly evident. In the meantime, the number of psychiatrists in the US has risen to over 45,500, a six fold increase since 1950.