Robert Whitaker

Prostatic Contribution to Normal Serum Acid Phosphatase

Total and tartrate-labile serum acid phosphatase levels were compared in patients with and without prostates, and in 12 patients before and after cystoprostatectomy. Absence of the prostate seems to make no significant difference to the levels of serum acid phosphatase. There is no justification for referring to the tartrate-labile serum acid phosphatase as “prostatic acid phosphatase.” A substantial incidence of marginally raised levels of serum acid phosphatase in each group of patients suggests that the upper limit of normal for the total serum acid phosphatase should be taken as 5 K.A.u.

Another look at diagnostic pathways in children with urinary tract infection.

This is a discussion paper on better ways of tackling a common problem : looking for the cause of a childs first recognised urinary infection. We describe practical choices and programmes adopted jointly in our departments over the past two years. We would be the first to accept that they may not suit all places. The following factors made us take another look at our diag? nostic pathways: (a) in the past few years new light has been shed on our understanding of reflux and reflux nephropathy; (6) it has become increasingly apparent thai: an intravenous urogram is no diagnostic panacea in very small children; (c) there are no longer (if indeed there ever were) bottomless funds to pay for expensive investigations for all children with a single urinary tract infection; and (d) the concept that only serious conditions threatening life or the kidney need to be diagnosed on a screening programme. The first three factors are self explanatory. The fourth might not be universally acceptable. We believe, however, that for the sake of avoiding overinvestigation and containing costs, we can afford to miss the diagnosis of certain relatively minor conditions during the first investigation of a child with infection. This is on the understanding that if the child has a further infection, more conventional investigations will be performed that will pick up even the least worrying conditions.

Psychiatry Under the Influence

This chapter starts by identifying how, in 1980, the American Psychiatric Association (APA) adopted a “disease” model when it published the third edition of its Diagnostic and Statistical Manual (DSM III). This gave rise to two “economies of influence”—pharmaceutical money and psychiatry’s own guild interests—that biased the APA and academic psychiatry toward privileging psycho-pharmaceutical treatments. This bias led psychiatry, as an institution, to confuse the public about what had become known about the biology of mental disorders and the safety and efficacy of its drugs, to inflate diagnostic boundaries in ways that created expanded markets for psychiatric drugs and to produce biased clinical care guidelines. All of this has led to social injury, as societies have organized their care around a false narrative, which has been presented to the public as a “scientific.” There is a pressing need for societies to address the outcomes of this, which will require neutralizing the two “economies of influence” that have so biased academic psychiatry in the United States and abroad and have driven year-on-year prescribing increases.

Expanding the Market

Once pharmaceutical companies obtained FDA approval for their new psychiatric medications, they naturally wanted to maximize the sale of their products. This meant expanding the pool of potential patients, and to do this, the companies needed the assistance of academic psychiatry and the American Psychiatric Association (APA). From the drug companies’ perspective, the business model to be pursued was obvious: They could provide the financial resources for this task, while academic psychiatry and the APA provided the medical legitimacy. This legitimacy, industry knew, could originate with the DSM: The APA could expand the pool of potential patients by creating new diagnoses or by loosening the diagnostic criteria for existing diagnoses, and then industry could hire academic psychiatrists to conduct studies of the drugs for these new patient populations. Then industry could hire those same psychiatrists, or others in academia, as “key opinion leaders” to speak at professional conferences about the validity of the “illness” and the helpful drug treatment.

The triumph of American psychiatry: How it created the modern therapeutic state

Over the past 170 years, American psychiatry has progressively asserted its authority over a larger segment of the American population. From the mid-1800s to the end of World War II, psychiatry had authority over the asylum population, which markedly increased in the first half of the twentieth century due to the influence of eugenics, an ideology that argued the ‘mentally ill’ had to be segregated from society. After the war, American psychiatry adopted Freudian conceptions of mental disorders, which enabled it to begin treating people in the community who were ‘neurotic’ in some way, which dramatically expanded its influence in society. Then, in the 1970s, when many in American society were questioning psychiatry’s legitimacy as a branch of medicine, the American Psychiatric Association (APA) responded by adopting a disease model for diagnosing mental disorders, which it set forth in the third edition of its Diagnostic and Statistical Manual. There were no scientific discoveries that led to this new model, but soon the APA was informing the American public that mental disorders were diseases of the brain, and that psychiatric drugs helped fix those diseases, ‘like insulin for diabetes.’ The APA, in concert with pharmaceutical companies, has successfully exported this belief system to much of the developed world. In order to break free of this ‘therapeutic state,’ the public needs to understand the history of how it came to be, and see the social injury it has caused.

The End Product: Clinical Practice Guidelines

The ultimate purpose of studies of medical treatments is to provide evidence that will lead to a “best use” of that intervention. The hope is that research can provide an in-depth understanding of a treatment’s risks and benefits, both over the short and long term. The evidence base for any treatment should also provide insight into how a treatment may affect different patient subgroups. For instance, treatment outcomes may differ according to such variables as the severity of the patient’s illness. Expert panels that review the research literature then develop “clinical practice guidelines” (CPGs) for use by the medical community, and in those documents, they can assess the merits of competing therapies. The CPGs are seen as the gold standard of “evidence-based medicine.”

Psychiatry Adopts a Disease Model

The modern era of psychiatry, in terms of its classification of mental disorders, dates to 1980, when the American Psychiatric Association (APA) published the third edition of its Diagnostic and Statistical Manual (DSM-III). This marked the moment that the APA moved away from psychoanalytic explanations for mental disorders and adopted what it considered to be a more scientific way to think about psychiatric difficulties. The disorders were to be diagnosed based on characteristic “symptoms,” a model that other medical specialties, when faced with illnesses of unknown causes, had long used. The public was encouraged to think of mental disorders as “diseases,” and very soon, with this concept in mind and the arrival of new psychiatric medications on the market, the use of these drugs soared. In the United States, spending on psychiatric drugs increased from around

A Society Harmed

800 million in 1985 to more than

Protecting the Market

40 billion in 2011, evidence of how the diagnosis of mental disorders and the prescribing of psychiatric medications have dramatically expanded since the publication of DSM-III.2

The Etiology of Mental Illness Is Now Known

The framework of institutional corruption provides a method for an investigation of an institution to proceed step by step. First, identify the institution’s public mission, that is, its obligation to serve the public good. Next, identify the “economies of influence” that are present and may corrupt the institution. Then document the institution’s “corrupt” behaviors. At that point, seek to understand the harm done to society by the corruption. This step, which can be quite difficult, provides a moment to pause and reflect, for the harm done may go beyond what is immediately visible, and instead reach deep into our collective lives.