Friday, May 4, 2012

Death Penalty Climate Changing - Mike Nova's starred items

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RECENT LEGISLATION: Governor's Signature Makes Connecticut Fifth State in Five Years to End Death Penalty

via Death Penalty Information Center by edeleon on 4/25/12

On April 25, Connecticut Governor Dannel Malloy (pictured) signed into law a bill that replaces the death penalty with life without parole. Connecticut is the fifth state in five years, and the 17th overall, to do away with capital punishment. Governor Malloy, who once supported the death penalty, offered the following statement: “My position on the appropriateness of the death penalty in our criminal justice system evolved over a long period of time. As a young man, I was a death penalty supporter. Then I spent years as a prosecutor and pursued dangerous felons in court, including murderers. In the trenches of a criminal courtroom, I learned firsthand that our system of justice is very imperfect. While it’s a good system designed with the highest ideals of our democratic society in mind, like most of human experience, it is subject to the fallibility of those who participate in it. I saw people who were poorly served by their counsel. I saw people wrongly accused or mistakenly identified. I saw discrimination. In bearing witness to those things, I came to believe that doing away with the death penalty was the only way to ensure it would not be unfairly imposed." See more of the governor's statement below.
Connecticut's repeal of capital punishment is in line with a growing national trend toward alternatives to the death penalty and an increased awareness that it is not serving murder victims' families. The bill gained the support of over 179 victims’ families and friends, who believe the state’s capital punishment statute does not provide the promised “closure” after the loss of a loved one. Since 1976, the state has carried out only one execution. The death penalty repeal bill is prospective and will not affect the sentences of the 11 inmates currently on the state’s death row.
("No More Death Penalty in CT," NBC News, April 25, 2012; "Gov. Malloy on Signing Bill to Repeal Capital Punishment," April 25, 2012). See New Voices.
Governor Malloy's Statement following his signing of the repeal bill:
“This afternoon I signed legislation that will, effective today, replace the death penalty with life in prison without the possibility of release as the highest form of legal punishment in Connecticut. Although it is an historic moment – Connecticut joins 16 other states and the rest of the industrialized world by taking this action – it is a moment for sober reflection, not celebration.
“Many of us who have advocated for this position over the years have said there is a moral component to our opposition to the death penalty. For me, that is certainly the case. But that does not mean – nor should it mean – that we question the morality of those who favor capital punishment. I certainly don’t. I know many people whom I deeply respect, including friends and family, that believe the death penalty is just. In fact, the issue knows no boundaries: not political party, not gender, age, race, or any other demographic. It is, at once, one of the most compelling and vexing issues of our time.
“My position on the appropriateness of the death penalty in our criminal justice system evolved over a long period of time. As a young man, I was a death penalty supporter. Then I spent years as a prosecutor and pursued dangerous felons in court, including murderers. In the trenches of a criminal courtroom, I learned firsthand that our system of justice is very imperfect. While it’s a good system designed with the highest ideals of our democratic society in mind, like most of human experience, it is subject to the fallibility of those who participate in it. I saw people who were poorly served by their counsel. I saw people wrongly accused or mistakenly identified. I saw discrimination. In bearing witness to those things, I came to believe that doing away with the death penalty was the only way to ensure it would not be unfairly imposed.
“Another factor that led me to today is the ‘unworkability’ of Connecticut’s death penalty law. In the last 52 years, only 2 people have been put to death in Connecticut – and both of them volunteered for it. Instead, the people of this state pay for appeal after appeal, and then watch time and again as defendants are marched in front of the cameras, giving them a platform of public attention they don’t deserve. It is sordid attention that rips open never-quite-healed wounds. The 11 men currently on death row in Connecticut are far more likely to die of old age than they are to be put to death.
“As in past years, the campaign to abolish the death penalty in Connecticut has been led by dozens of family members of murder victims, and some of them were present as I signed this legislation today. In the words of one such survivor: ‘Now is the time to start the process of healing, a process that could have been started decades earlier with the finality of a life sentence. We cannot afford to put on hold the lives of these secondary victims. We need to allow them to find a way as early as possible to begin to live again.’ Perhaps that is the most compelling message of all.
“As our state moves beyond this divisive debate, I hope we can all redouble our efforts and common work to improve the fairness and integrity of our criminal justice system, and to minimize its fallibility.”
(Hartford Courant, April 25, 2012).

BOOKS: "The Death Penalty Failed Experiment: From Gary Graham to Troy Davis in Context"

via Death Penalty Information Center by edeleon on 4/27/12

A new book published in electronic format, The Death Penalty Failed Experiment: From Gary Graham to Troy Davis in Context by Diann Rust-Tierney, examines the problem of arbitrariness in the death penalty since its reinstatement in 1976. Through an analysis of the cases of Gary Graham and Troy Davis, the author argues that race, wealth and geography play a more significant role in determining who faces capital punishment than the facts of the crime itself. Both defendants had significant claims of innocence; both were black defendants who were ultimately executed in the South; in both cases, the victim in the underlying murder was white. Graham was executed in Texas in 2000 and Davis was executed in Georgia in 2011. Rust-Tierney writes, “How do you administer the most severe punishment imaginable in a manner that is accurate, free from bias and demonstrably fair? Until we are all seen and treated as equal, we cannot afford to keep capital punishment.” Ms. Rust-Tierney is an attorney and Executive Director of the National Coalition to Abolish the Death Penalty. Download a copy of the ebook here.
(D. Rust-Tierney, "The Death Penalty Failed Experiment: From Gary Graham to Troy Davis in Context," McKinney & Associates, April 2012). The Death Penalty Failed Experiment is the second publication in McKinney & Associates’ Voice Matters: An eBook Series on Public Relations with a Conscience. See Arbitrariness and Race. Read more Books on the death penalty. Listen to DPIC's Podcast on Arbitrariness.

NEW VOICES: Jimmy Carter, Former President and Nobel Peace Prize Winner, Calls for End to Death Penalty

via Death Penalty Information Center by edeleon on 4/30/12

In a recent op-ed in the Atlanta Journal-Constitution, former U.S. President Jimmy Carter called for the end of the death penalty. President Carter cited the risk of wrongful executions, the lack of evidence of deterrence, and the costs of prosecution as reasons to abolish capital punishment. He wrote, “[T]here has never been any evidence that the death penalty reduces capital crimes or that crimes increased when executions stopped. Tragic mistakes are prevalent. DNA testing and other factors have caused 138 death sentences to be reversed since I left the governor’s office. The cost for prosecuting executed criminals is astronomical. Since 1973, California has spent roughly $4 billion in capital cases leading to only 13 executions, amounting to about $307 million each.” President Carter also cited the unfair application of the death penalty as an especially compelling reason for repeal: “Perhaps the strongest argument against the death penalty is extreme bias against the poor, minorities or those with diminished mental capacity. Although homicide victims are six times more likely to be black rather than white, 77 percent of death penalty cases involve white victims. Also, it is hard to imagine a rich white person going to the death chamber after being defended by expensive lawyers. This demonstrates a higher value placed on the lives of white Americans.” Read full op-ed below.
Show death penalty the door
By Jimmy Carter
For many reasons, it is time for Georgia and other states to abolish the death penalty. A recent poll showed that 61 percent of Americans would choose a punishment other than the death penalty for murder.
Also, just 1 percent of police chiefs think that expanding the death penalty would reduce violent crime. This change in public opinion is steadily restricting capital punishment, both in state legislatures and in the federal courts.
As Georgia’s chief executive, I competed with other governors to reduce our prison populations. We classified all new inmates to prepare them for a productive time in prison, followed by carefully monitored early-release and work-release programs. We recruited volunteers from service clubs who acted as probation officers and “adopted” one prospective parolee for whom they found a job when parole was granted. At that time, in the 1970s, only one in 1,000 Americans was in prison.
Our nation’s focus is now on punishment, not rehabilitation. Although violent crimes have not increased, the United States has the highest incarceration rate in the world, with more than 7.43 per 1,000 adults imprisoned at the end of 2010. Our country is almost alone in our fascination with the death penalty. Ninety percent of all executions are carried out in China, Iran, Saudi Arabia and the United States.
One argument for the death penalty is that it is a strong deterrent to murder and other violent crimes. In fact, evidence shows just the opposite. The homicide rate is at least five times greater in the United States than in any Western European country, all without the death penalty.
Southern states carry out more than 80 percent of the executions but have a higher murder rate than any other region. Texas has by far the most executions, but its homicide rate is twice that of Wisconsin, the first state to abolish the death penalty. Look at similar adjacent states: There are more capital crimes in South Dakota, Connecticut and Virginia (with death sentences) than neighboring North Dakota, Massachusetts and West Virginia (without death penalties). Furthermore, there has never been any evidence that the death penalty reduces capital crimes or that crimes increased when executions stopped. Tragic mistakes are prevalent. DNA testing and other factors have caused 138 death sentences to be reversed since I left the governor’s office.
The cost for prosecuting executed criminals is astronomical. Since 1973, California has spent roughly $4 billion in capital cases leading to only 13 executions, amounting to about $307 million each.
Some devout Christians are among the most fervent advocates of the death penalty, contradicting Jesus Christ and misinterpreting Holy Scriptures and numerous examples of mercy. We remember God’s forgiveness of Cain, who killed Abel, and the adulterer King David, who had Bathsheba’s husband killed. Jesus forgave an adulterous woman sentenced to be stoned to death and explained away the “eye for an eye” scripture.
There is a stark difference between Protestant and Catholic believers. Many Protestant leaders are in the forefront of demanding ultimate punishment. Official Catholic policy condemns the death penalty. Perhaps the strongest argument against the death penalty is extreme bias against the poor, minorities or those with diminished mental capacity. Although homicide victims are six times more likely to be black rather than white, 77 percent of death penalty cases involve white victims. Also, it is hard to imagine a rich white person going to the death chamber after being defended by expensive lawyers. This demonstrates a higher value placed on the lives of white Americans.
It is clear that there are overwhelming ethical, financial, and religious reasons to abolish the death penalty.
Jimmy Carter was the 39th president and is founder of The Carter Center in Atlanta.
(J. Carter, "Show death penalty the door," Atlanta Journal-Constitution, April 25, 2012). Read more New Voices on the death penalty. Listen to DPIC's podcast on Deterrence.

COMMENTARY: Death Penalty Climate Changing

via Death Penalty Information Center by edeleon on 5/2/12

Commentary from nationally syndicated columnist E.J. Dionne (pictured) and the New York Times reflected on the changing state of the death penalty in the U.S. in light of recent developments. Dionne cited the repeal of the death penalty in Connecticut as an example of a "remarkable pivot in the politics of the death penalty, the premier issue on which an overwhelming consensus favoring what’s taken to be the conservative side has begun to crumble." He observed that "significant groups of libertarian Republicans and opponents of abortion have crossed to the repeal side." In an editorial titled "The Myth of Deterrence," the New York Times noted that "a distinguished committee of scholars working for the National Research Council has now reached the striking and convincing conclusion that all of the research about deterrence and the death penalty done in the past generation . . . should be ignored." The Times concluded that other states should follow Connecticut’s lead in repealing the death penalty. Read full texts below.
Little Connecticut’s big message on the death penalty
By E.J. Dionne Jr., April 29, 2012
Since the 2010 elections, newly empowered conservative and Republican state legislatures have gained national attention with their wars on public employee unions, additional restrictions on abortion and new barriers to voting.
Against this backdrop, the little state of Connecticut has loomed as a large progressive exception. Last year, it became the first state to require employers to grant paid sick leave. It also enacted a law granting in-state tuition to students whose parents brought them to the United States illegally as young children.
And last week, Connecticut Gov. Dan Malloy signed a law repealing the state’s death penalty. There are now 17 states without capital punishment, Illinois having joined the ranks last year. What happened in Connecticut brings home the flaw in seeing everything that has happened in the states since the midterm vote as embodying a steady shift rightward.
Where they hold power, progressives have also been using their states as laboratories, and Malloy is part of an impressive group of mostly smaller-state Democratic governors who have combined a moderate, business-friendly style with progressive policymaking. Their ranks include, among others, Govs. Jack Markell in Delaware, Martin O’Malley in Maryland, John Hickenlooper in Colorado, Deval Patrick in Massachusetts and outgoing Gov. John Lynch in New Hampshire.
After the 2012 election, a key front in the battle for America’s political future will involve how the various left and right experiments in the states are judged. Aggressive conservatives such as Govs. Scott Walker in Wisconsin and John Kasich in Ohio are in the headlines now, and the recall Walker faces will keep him there for a while. But there will be a quieter and more comprehensive reckoning down the road.
Part of this reckoning will be a remarkable pivot in the politics of the death penalty, the premier issue on which an overwhelming consensus favoring what’s taken to be the conservative side has begun to crumble.
In the 1980s and ‘90s, capital punishment was a staple of Republican campaigns against a handful of liberals who bravely stuck with their opposition to the ultimate punishment. George H.W. Bush used the issue effectively against Democrat Mike Dukakis in the 1988 presidential campaign. Republicans also used it in their 1994 electoral sweep, notably in defeating three-term Democratic Gov. Mario Cuomo in New York. And no wonder: In 1994, support for the death penalty hit its peak of 80 percent nationwide.
But a Gallup survey last fall showed how much things have changed: Support for capital punishment was down to 61 percent. Among the many reasons for the drop are a decline in crime rates, which has increased public confidence in the criminal justice system, and a stream of reports casting doubt on the guilt of some who were executed. In addition, significant groups of libertarian Republicans and opponents of abortion have crossed to the repeal side. An important test of the new politics of capital punishment will come this November in a California death penalty referendum.
For all this, it still takes political courage to end capital punishment. A Quinnipiac University poll released last week as Malloy signed the death penalty repeal found 62 percent of Connecticut voters still favoring executions of those convicted of murder, with only 30 percent opposed. Just 29 percent of those queried approved of the legislature’s handling of the issue, while 51 percent disapproved.
But (and it’s a very important but) support for the death penalty, in Connecticut and elsewhere, is not as robust as it looks. When Quinnipiac posed a different question — “Which punishment do you prefer for people convicted of murder, the death penalty, or life in prison with no chance of parole?” — only 46 percent favored the death penalty. An equal number chose life without parole. Death penalty opponents have an opening they haven’t had for some time.
Moreover, voters aren’t as agitated by the issue as they once were. Only 37 percent of Connecticut voters told Quinnipiac that the issue would be “extremely” or “very” important to how they cast their ballots in legislative elections.
Malloy is under no illusions about the strong residual opposition to repeal. When he signed the repeal bill last Wednesday, he did so with little ceremony, carefully observing that “many people whom I deeply respect, including friends and family ... believe the death penalty is just.”
Nonetheless, what Malloy did was historic, and it was a sign that despite the dreary polarization that characterizes our debates, American politics is still capable of springing surprises.

The Myth of Deterrence
Editorial, N.Y. Times - April 28, 2012
One of the most frequently made claims about the death penalty is that it deters potential murderers. That was the claim when the Supreme Court reinstated capital punishment in 1976. It is the claim today after a revival of research about the topic in the last decade.
But a distinguished committee of scholars working for the National Research Council has now reached the striking and convincing conclusion that all of the research about deterrence and the death penalty done in the past generation, including by some first-rank scholars at the most prestigious universities, should be ignored.
The committee found that the research “is not informative about whether capital punishment increases, decreases, or has no effect on homicide rates.” No study looks at what really matters, by comparing the deterrent effects of capital punishment with other penalties, like life without parole. A lot of the research assumes that “potential murderers respond to the objective risk of execution,” but only one in six of the people sentenced to death in the last 35 years have been executed and no study properly took that diminished risk into account.
“Nothing is known about how potential murderers actually perceive their risk of punishment,” said the criminologist Daniel Nagin, chairman of the committee.
The committee was careful to say what it did not examine, including the proven risk that an innocent person could be sentenced to death and the fact that the administration of capital punishment could well be discriminatory.
On Wednesday when Connecticut’s governor, Dannel Malloy, signed the state’s new law abolishing the death penalty, these problems were on his mind. As a former supporter of capital punishment, he said that he “came to believe that doing away with the death penalty was the only way to ensure it would not be unfairly imposed.”
The 33 states that retain the death penalty should follow that lead.
(E.J. Dionne, "Little Connecticut’s big message on the death penalty," Washington Post, April 29, 2012; "The Myth of Deterrence," New York Times, editorial, April 28, 2012). See Deterrence and Public Opinion. Read more Editorials. Listen to DPIC's podcast on Deterrence.

Honduras - Neglect Cited in Prison Fire - NYTimes.com

Honduras: Neglect Cited in Prison Fire

By ELISABETH MALKIN

Published: May 3, 2012

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The Inter-American Commission on Human Rights said Wednesday that the conditions that led to the Feb. 14 fire that killed 361 people at the Comayagua national prison were the result of decades of neglect of Honduras’s prisons and iron-fisted anticrime policies. A commission delegation that visited the prison and two others late last month concluded that the “most worrisome” problem in Honduras’s prisons was that the authorities had effectively ceded control to the prisoners themselves, in part because guards were not properly trained. This “has led to high levels of violence and corruption, in a context of absolute impunity,” the commission said. The delegation also found severe overcrowding, as well as unsafe housing and inadequate food, water and medical care.

A version of this brief appeared in print on May 3, 2012, on page A14 of the New York edition with the headline: Honduras: Neglect Cited in Prison Fire.

Psychiatric News Alert: APA Invites Third Round of Public Comment on DSM-5

Thursday, May 3, 2012

APA Invites Third Round of Public Comment on DSM-5

For a third and final time, the American Psychiatric Association is inviting public comment on the proposed criteria for the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

The public comment period began May 2 and will continue until June 15. Key changes posted for this round of public review include, among others, proposals to place attenuated psychosis syndrome and mixed anxiety depressive disorder in Section III of the manual, covering conditions that require further research before their consideration as formal disorders. Also proposed is adding language to major depressive disorder criteria to help differentiate between normal bereavement associated with a significant loss and symptoms that indicate a mental disorder.

Feedback to the proposed criteria can be submitted online at http://www.dsm5.org/ until the comment period ends June 15. Nearly 10,800 comments from health care professionals, mental health advocates, families, and consumers were submitted in the first two public comment periods in 2010 and 2011.

For more information about DSM-5 see Psychiatric News here.

APA TV Annual Meeting 2012 | psychiatry.org

APA TV Annual Meeting 2012 | psychiatry.org

APA TV Annual Meeting 2012

Watch APA TV, the 2012 Annual Meeting video highlights from the Pennsylvania Convention Center, Philadelphia, PA, May 4 - 9. Each daily APA TV program includes “Thought Leadership” and “Conference News” segments.

The five-minute Thought Leadership segments showcase case studies and best practices from the psychiatry departments of 17 academic institutions.

Conference News is a daily program of Annual Meeting highlights, featuring “behind the scenes” interviews, coverage of special events, and reactions to the day from attending delegates. Upcoming interviews include APA President John Oldham, M.D., APA President-elect Dilip Jeste, M.D., Retired General Peter Chiarelli, award-winning author Kay Redfield Jamison, Ph.D., Director of the National Institute on Drug Abuse (NIDA) Nora Volkow, M.D., actor Dan Butler of NIDA’s Addiction Performance Project. If you can’t make it to Philly for the 165th APA Annual Meeting, be sure to check back here each day to watch APA TV.

How American Psychiatry Can Save Itself: Part 1 - Psychiatric Times

Psychiatric Times.Vol. 29No. 2

How American Psychiatry Can Save Itself: Part 1

By Ronald W. Pies, MD |February 8, 2012

Dr Pies is Editor in Chief Emeritus of Psychiatric Times and Professor in the psychiatry departments of SUNY Upstate Medical University, Syracuse, NY, and Tufts University School of Medicine, Boston. He is the author, most recently, of Becoming a Mensch; Timeless Talmudic Ethics for Everyone; The Judaic Foundations of Cognitive-Behavioral Therapy; and a collection of short stories: Ziprin's Ghost.

[Note: For Part 2 of Dr Pies' article, click here.] Charles Dickens might well say of American psychiatry, “These are the best of times and the worst of times.” Certainly, our profession can point to some important accomplishments. In the past 30 years, the burgeoning fields of neuropsychiatry and behavioral neurology have begun to bridge the Cartesian rift between mind and body. Using new types of brain imaging, neuroscientists can now peer into the molecular and chemical mechanisms that underlie such basic human emotions as anger and grief.
Devastating illnesses, such as schizophrenia and bipolar disorder, are slowly disclosing the subtle ways in which they affect the brain’s structure and function.¹ And, in the past 3 decades, psychiatry has made notable progress in developing effective forms of both psychotherapy and “somatic” treatment. For example, the 1980s and 1990s saw the growing use of cognitive-behavioral therapies (CBTs) for anxiety and depression and the development of clozapine—arguably the most effective medication for schizophrenia. Technical refinements in the use of electroconvulsive therapy (ECT) led to reduced cognitive adverse effects while efficacy in the treatment of severe depression was maintained.²
And yet, this rather glossy synopsis omits many reasons why psychiatry as a profession finds itself in deep trouble. (Googling the phrase “psychiatry is in trouble” brings up over 2100 hits.) A spate of recent books by psychiatrists and other mental health professionals offers a range of “diagnoses” for psychiatry’s present malaise: for example, claims that psychiatry lacks a unified model of so-called mental illness (a term that is itself a sign of philosophical confusion in the field); that psychiatry has no “objective” criteria or biological markers for any of its principal diagnoses; that psychiatry has “medicalized” perfectly normal human reactions to stress and loss; and finally, that psychiatry has botched its diagnosis and classification system—witness the present debacle over the still-developing DSM-5.
Perhaps most damning is the charge that psychiatry has abandoned its most fundamental and sacred obligation: to see the suffering patient as a whole person and not merely as a cerebral container in which a bunch of chemicals are sloshing around. (Etymologically, our term “patient” is related to the Latin pati, “to suffer.”) Recently, several high-profile articles claiming that psychotherapy has nearly vanished from psychiatric practice³ seem to have convinced the public that psychiatry’s demise is all but certain—and sometimes this conviction is voiced in the spirit of “Good-bye and good riddance!”
Each of these critiques contains at least a grain of truth—and some contain a few drams. Yet, in my view, each of these claims regarding what is wrong with psychiatry either oversimplifies the problem or ignores more fundamental issues. Here I consider each critique in some detail. In part 2 (which will appear in a future issue) I address what I believe are more central problems for American psychiatry and some ways of redressing them.
Lack of a unified model of “mental illness”
It is true that psychiatry lacks a unified model of so-called mental illness. For critics such as psychiatrists Niall McLaren⁴ and Dusan Kecmanovic,⁵ this “conceptual cacophony” is a serious, even a fatal, flaw. To be sure, any modern textbook of psychiatry is likely to explain conditions such as schizophrenia and major depressive disorder by invoking biological, psychological, social, and even spiritual factors, with greater weight usually given to the biological realm, for the most serious disorders.
Yet there is nothing inherently “unscientific” in such pluralistic models; on the contrary, the testing and verification of these potentially complementary causal hypotheses are very much a scientific endeavor. Furthermore, many of the most important advances in the history of psychiatric treatment have occurred in the absence of any single, unifying “model” of mental illness—for example, the discovery that lithium(Drug information on lithium) is effective in stabilizing the mood swings of bipolar disorder, or the development of CBT for mood disorders. (The “fathers” of CBT—psychiatrist Aaron Beck and psychologist Albert Ellis—had to push back hard against the prevailing psychoanalytic model of mental illness.)
Lack of “objective” criteria for diagnoses
The claim that modern-day psychiatry lacks “objective” criteria or biological markers for any of its principal diagnoses is only partly correct. Much depends on what we understand by the term “objective.”^a
Scientists steeped in the philosophical tradition known as logical positivism insist that “objective” data are those obtained by direct observation and measurement—for example, by viewing bacteria under a microscope. But this model is hard to apply to many medical specialties, and the positivist notion of “objectivity” has been largely discounted by many modern-day philosophers of science.
The neurologist who takes a careful history of the patient’s head pain and makes a diagnosis of “migraine headache” sees nothing at all under a microscope: the relevant “data” consist almost entirely of the patient’s narrative, in the presence of a normal neurological examination. This is entirely commensurate with the psychiatrist’s method of arriving at a diagnosis after a careful history and mental status examination, after ensuring that the patient has no medical or neurological disease that explains the symptoms. In so far as their observations are systematic and replicable by other qualified practitioners, the neurologist and the psychiatrist are carrying out “objective” investigations.
Furthermore, there are no “lab tests” or imaging studies that allow the neurologist to “confirm” a diagnosis of migraine. Like epilepsy and many chronic pain syndromes, the diagnosis is clinically based.
Finally, while it is true that no psychiatric disorder has an office-ready, biological marker or “blood test” associated with it, it is incorrect to conclude that no progress has been made in this regard. Several biological markers of psychiatric illness have been repeatedly supported by careful studies over several decades; for example, abnormal smooth pursuit eye movements in schizophrenia⁶ and derangements of hypothalamic-pituitary-adrenal function in certain types of severe (“melancholic”) major depression.⁷Unfortunately, for a variety of practical and theoretical reasons, these tests have not found a useful place in everyday psychiatric practice.
“Medicalizing” normal human behavior
One of the most widely bruited claims in recent years is that psychiatry has “medicalized” or “pathologized” various types of “normal” human behavior. This claim is sometimes voiced most forcefully by psychiatrists themselves, as several widely publicized critiques by Allen Frances, MD, make clear.⁸ (Dr Frances, of course, was Chair of the task force that developed DSM-IV.)
The “medicalizing” claim has been made in relation to a variety of psychiatric conditions, including ADHD, incipient psychotic states, and major depression. For example, in their book The Loss of Sadness, professors Jerome Wakefield and Allan Horwitz argued that recent “decontextualized” DSM criteria for major depression have created a false epidemic of depression in this country. (In fact, however, several epidemiological studies in the US and Canada have shown that the incidence of major depression has remained largely the same over the past 50 years when the same basic criteria are carefully applied.⁹)
The problem with the notion that psychiatry is “medicalizing” normality is that it rests on certain assumptions about the terms “disease,” “disorder,” and “normality”: for example, that there are relatively clear demarcations or veridical tests that define these terms. Seen from this perspective, any attempt at broadening the criteria for a particular disorder runs the risk of creating “false positives” or even “false epidemics.” Yet in truth, terms such as “disease,” “illness,” “dysfunction,” and “disorder” have been in flux throughout the history of clinical medicine. The philosopher Ludwig Wittgenstein¹⁰cautioned us against so-called essential definitions—those specifying the necessary and sufficient conditions that define a term—and argued that words derive their meaning from the diverse ways in which they are used.Therefore, the term “disease” will acquire a variety of legitimate meanings, depending on whether the word is used by an epidemiologist, a psychiatrist, or your next-door neighbor.
Furthermore, since there are no universally agreed on biological criteria for psychiatric disorders, the notion of a “false positive” becomes extremely difficult to explain, in a psychiatric context. Indeed, the term “false positive” was appropriated from fields such as microbiology, where, for example, we can point to the organism Treponema pallidum as the causal agent of syphilis. It is easy to define a “false positive” in such cases—no bug, no disease. It becomes much harder when dealing with the diagnosis of, say, major depression. Much depends on what degree of suffering and incapacity we wish to impute to the realm of the “normal”—and this is only in part a matter of “objective” science. It is, in greater measure, an existential decision, involving very general ideas about health, disease, and how we wish to live our lives.
Botched system of diagnosis and classification
On the claim that the APA has badly mishandled the entire DSM-5 process, much has been written, sometimes based on quite valid concerns. Dr Allen Frances as well as others have complained, for example, that the DSM-5 work groups are planning to reify new, untested diagnoses; that most members of the work groups lack “real-world” clinical experience and have been isolated from much-needed input from everyday clinicians; and that lower thresholds for several diagnoses will lead to excessive prescription of psychotropics. (Dr Frances¹¹ has also called for an independent scientific review of the entire DSM-5 project, and on that issue, we are in agreement.)
But while each of these criticisms of DSM-5 is worthy of debate, they all miss the central problems with the most recent DSMs, which run much deeper than Dr Frances’s concerns. Fundamentally, the entire DSM approach to understanding and classifying psychiatric illness—while useful for researchers—is routinely disparaged or ignored by many work-a-day clinicians, who use the DSM codes principally to satisfy insurers and third-party payers. As Dr James Phillips¹² advised psychiatrists, “Give up your expectations that the [DSM] should tell you what is essential in your assessment and treatment of your patient. Think of it rather as a crude guideline that, we hope, will land you in the right diagnostic ballpark—and not much more.”
To be sure, the DSM criteria sets help researchers by creating what is termed “good inter-rater reliability”; that is, the specific categorical diagnoses can be readily agreed on by multiple researchers. The DSMs have also helped establish “thresholds” of pathology (eg, by stipulating interference with social or vocational function). But, in my experience, most clinicians have neither the time nor the inclination to follow the stringent inclusion and exclusion rules demanded by the DSM—nor do many clinicians believe that these criteria sets tell us much about the nature and “deep structure” of the patient’s problem. The “person” has been lost, as Dr Phillips¹² has put it.
Indeed, DSM-IV and impending DSM-5 share a fundamental and perhaps fatal paradox: by lacking either a sound biological basis or a rich description of the patient’s subjectivity, they create “the worst of both worlds” for clinicians. On the one hand, without biological markers for the major disorders, the DSM diagnoses remain only loosely moored to modern medical science. On the other hand, the DSM does not provide the deep understanding of the patient’s “inner world” that existential, psychodynamic, and phenomenological approaches foster. The solution to this paradox will not come easily, but I will try to sketch some radical ways in which our diagnostic system needs to change.
Acknowledgment—I would like to thank both Joseph Pierre, MD, and James Knoll IV, MD,^a for their helpful comments on this essay.
^aJames Knoll IV, MD, has pointed out to me (personal communication, January 2, 2012) that several judicial decisions reflect the misleading view that psychiatry is “totally subjective.” For example, Dr Knoll notes that in Sheehan v Metropolitan Life Ins. Co., 368 F.Supp.2d 228 (2005), which involved the recovery of unpaid disability benefits, a high federal district court held: “Unlike cardiologists or orthopedists, who can formulate medical opinions based upon objective findings derived from objective clinical tests, the psychiatrist typically treats his patient’s subjective symptoms.”

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2. Kellner CH, Knapp R, Husain MM, et al. Bifrontal, bitemporal and right unilateral electrode placement in ECT: randomised trial. Br J Psychiatry. 2010;196:226-234.
3. Harris G. Talk doesn’t pay, so psychiatry turns instead to drug therapy. New York Times. March 5, 2011. http://www.nytimes.com/2011/03/06/health/policy/06doctors.html?pagewanted=all. Accessed January 11, 2012.
4. McLaren N. Interactive dualism as a partial solution to the mind-brain problem for psychiatry. Med Hypotheses. 2006;66:1165-1173.
5. Kecmanovic D. Conceptual discord in psychiatry: origin, implications and failed attempts to resolve it. Psychiatr Danub. 2011;23:210-222.
6. Levy DL, Sereno AB, Gooding DC, O’Driscoll GA. Eye tracking dysfunction in schizophrenia: characterization and pathophysiology. Curr Top Behav Neurosci. 2010;4:311-347.
7. Fink M, Taylor MA. Resurrecting melancholia. Acta Psychiatr Scand Suppl. 2007;433:14-20.
8. Frances A. Good grief. New York Times. August 14, 2010. http://www.nytimes.com/2010/08/15/opinion/15frances.html. Accessed January 11, 2012.
9. Eaton WW, Kalaydjian A, Scharfstein DO, et al. Prevalence and incidence of depressive disorder: the Baltimore ECA follow-up, 1981-2004. Acta Psychiatr Scand. 2007;116:182-188.
10. Wittgenstein L. The Blue and Brown Books. New York: Harper Torchbooks; 1958.
11. Frances A. DSM-5 will not be credible without an independent scientific review. Psychiatric Times. November 2, 2011. http://www.psychiatrictimes.com/blog/dsm-5/content/article/10168/1982079. Accessed January 10, 2012.
12. Phillips J. The missing person in the DSM. Psychiatric Times. December 21, 2010. http://www.psychiatrictimes.com/blog/dsm-5/content/article/10168/1766260. Accessed January 10, 2012.

How American Psychiatry Can Save Itself: Part 2 - Psychiatric Times

Psychiatric Times.Vol. 29No. 3

NEWS

How American Psychiatry Can Save Itself: Part 2

Keys to Regaining the Confidence of the General Public

by Ronald W. Pies, MD |March 1, 2012

Dr Pies is Editor in Chief Emeritus of Psychiatric Times and Professor in the psychiatry departments of SUNY Upstate Medical University, Syracuse, NY, and Tufts University School of Medicine, Boston. He is the au-thor, most recently, of Becoming a Mensch: Timeless Talmudic Ethics for Everyone; The Judaic Foundations of Cognitive Behavioral Therapy; and a collection of short stories, Ziprin’s Ghost. Acknowledgment—I would like to thank Joseph Pierre, MD, and James Knoll IV, MD, for their helpful comments on this essay.

In the February 2012 issue of Psychiatric Times, I discussed and rebutted some common criticisms of psychiatry, such as its alleged lack of “objective” diagnostic criteria and its supposed tendency to “medicalize normality.”¹I also suggested that most current criticism of DSM-5 misses the fundamental problem with the recent DSMs—namely, that in the absence of either a sound biological basis for the main disorders or a rich description of the patient’s experience of the disorders (phenomenology), the DSM framework has inadvertently left clinicians with “the worst of both worlds.”
Here I address what, in my estimation, are the primary reasons for the American public’s disenchantment with psychiatry; how the profession ought to address these issues; and how we need to replace the DSM’s categorical system with one that is clinically useful for both clinicians and patients.
What must be done?
So far, I have discussed problems with American psychiatry that, in my view, are largely peripheral to the central concerns of the average clinician—as well as to the average person who suffers from a serious psychiatric illness. In particular, the “loss of faith” in psychiatry that many in the general public evince stems from another set of concerns, both more pressing and more pragmatic than the academic debates swirling around DSM-5.
I very much doubt that many Americans lose sleep over whether psychiatry has a “unified model” of so-called mental illness; nor do I believe that the public’s animus toward psychiatry² stems primarily from concerns over the DSM-5’s development or content (although well-publicized critiques of the process have certainly not enhanced the profession’s stature).
I believe the American public’s jaundiced perceptions of psychiatry stem from the confluence of 5 main factors, specifically:

1. Psychiatry’s inability, thus far, to develop robustly effective, well-tolerated treatments for several major disorders, such as schizophrenia, autism, and most of the severe personality disorders (despite our having moderately effective treatments for bipolar disorder, panic disorder, and several other conditions).

2. Psychiatry’s increasingly and inappropriately close ties with the pharmaceutical industry in recent decades.

3. The decline, over the past decade, in the use of psychotherapy among US psychiatrists³and the attendant public perception that psychiatrists “no longer listen” to their patients.

4. A lack of understanding among the general public of the benefits of psychiatric treatments, and not simply the risks; for example, the erroneous belief that psychiatric medications are highly “addictive” or merely “cosmetic” in their effect.⁴

5. Vituperative attacks on psychiatry by critics both within and out-side the profession, often exacerbated by Internet-based anti-psychiatry groups and lurid depictions of psychiatry in the media.^2,4

So, what is required to regain the confidence of the general public? On a concrete level, psychiatry needs to advance goals and initiatives that address each of the factors noted; for example, by: (1) lobbying for more robust and better-funded research to develop more effective and better-tolerated treatments; (2) restraining the influence of pharmaceutical companies on psychiatric education and practice while seeking a healthier and more transparent relationship with such companies; (3) ensuring that comprehensive psychotherapy training is a central part of every psychiatric residency program; (4) bolstering “outreach” and public education efforts² as well as improving communication with non-psychiatric physicians; and (5) rebutting unwarranted attacks on psychiatry while remaining receptive to constructive criticism from within and outside the profession.⁵

What about DSM?
To be sure: I believe that an objective, independent review of the DSM-5 process and its proposed changes would be in the profession’s best interest and might marginally enhance the public’s confidence in psychiatry. In my view, the National Science Foundation would be best equipped to provide such a review. However, I believe more radical changes must be made. With or without an independent review of DSM-5, the DSM framework is simply not serving everyday clinicians very well. As Aaron Mishara, MD, and Michael Schwartz, MD, recently observed, “. . . DSM-III’s logical empiricist agenda inserted a wedge between clinician and clinical researcher which still has not been appropriately addressed.”⁶
I appreciate the perils of suggesting a radical re-thinking of a diagnostic system that has been in place, with many variations, for over 30 years. Nevertheless, I believe that a very different kind of diagnostic model is needed. In brief, I am proposing the following:

1. Changing the name of our classification scheme to the Manual of Neurobehavioral Disease, or MND. This name helps eliminate the confusing Cartesian split between mind and body, implied in the present “mental disorder” designation—a problem explicitly acknowledged in the introduction to the original (1994) DSM-IV. The new MND title also allows for the (continued) inclusion of conditions such as Alzheimer, Huntington, and Parkinson disease, which markedly alter behavior, cognition, and mood. That said, I could also live with, simply, Manual of Psychiatric Disorders.

2. Emphasizing the crucial importance of suffering and incapacity as hallmarks of disease (etymologically, disease) and omitting from the MND’s list of disease entities any condition that lacks these features. This does not mean, however, that non-disease conditions or situations should not be within the purview of psychiatric care; for example, there is no reason a psychiatrist shouldn’t help a family struggling with the death of a parent, or the breakup of a marriage—although neither situation constitutes “disease.”

3. Separating clinical descriptions of disease (“prototypes”) from research-oriented criteria while also ensuring that the two levels of descriptions are compatible. The prototypical descriptions would be aimed at giving the clinician a rich, holistic, phenomenological understanding of a disease—emphasizing the “inner world” of the patient—rather than a “one from column A, one from col-umn B” list of criteria. The research-oriented criteria could appear as an appendix to the main MND text or as a separate document. This “two-tiered” system of diagnosis has its roots in the writings of Hughlings Jackson, and the clinical/research separation I advocate was also re-cently suggested by Prof Joel Paris.⁷

4. Regarding psychiatric classification not as an end in itself, but as a means toward the effective relief of certain kinds of human suffering and incapacity. Thus, rather than viewing diagnostic categories as reified “objects”—like rocks or trees—they would be understood instrumentally; ie, as tools in the service of medical-ethical goals. As Dr Joseph Pierre⁸ has observed, “. . . clinicians do not in general fret over what does or does not constitute a disease. . . . If, for example, a patient’s arm is broken in a car accident, a doctor doesn’t lose sleep pondering whether this represents ‘broken bone disorder’ or simply an expected response to an environmental stressor—the bone is set and the arm is casted . . . mental disorder or not, clinicians working in ‘mental health’ see it as their calling to try to improve the lives of whomever walks through their office door seeking help.” Precisely!

5. Regarding biological data as supporting, but not defining, disease categories. In so far as “biomarkers” and biological data are found to correlate with specific disease categories, this information should become part of the supporting text of the MND. But diagnosis would remain essentially “clinical” (from Gk klinikos “of the [sick]bed”).

6. Applying the principle of parsimony, usually expressed in terms of Occam’s Razor—ie, “entities should not be multiplied beyond what is necessary.” This does not mean deliberately reducing or increasing the number of diagnostic categories, but rather retaining only those categories that are absolutely necessary and that entail substantial suffering and incapacity. Thus, some conditions that involve merely “disapproved of” behaviors, without substantial suffering or functional impairment, would no longer count as instantiations of disease.

But on an even more fundamental level, I believe psychiatrists must reclaim and reinvent our role as holistic healers—doctors who are as comfortable with motives as with molecules, and as willing to employ poetry as prescribe pills.⁹ When guided by sound evidence, this is not promiscuous eclecticism, but rather what I have termed, “polythetic pluralism.” I favor an expansion of the psychiatry residency to 5 years, so that residents may receive enhanced training in psychotherapy and the humanities, eg, literature, comparative religion, and philosophy.¹⁰ The added year could also be used to provide greater integration of psychiatric and neurobehavioral training. To be sure: this expansion would pose additional financial challenges and require greater sacrifice on the part of trainees, but I believe it would strengthen the foundations of psychiatric practice and enhance our stature as a medical specialty. (Ideally, I would also favor a concomitant reduction in medical school training from 4 to 3 years, with substantial streamlining and condensation of the pre-clinical curriculum.)
Finally, and most important, psychiatry must maintain a single-minded focus on our primary ethical and clinical mission: not the development of elegant conceptual models or ideal diagnostic criteria, but the relief of our patients’ profound suffering and incapacity.¹¹

References
1. Pies RW. How American psychiatry can save itself. Psychiatr Times. 2012;29(2):1-10.
2. Friedman RA. The role of psychiatrists who write for popular media: experts, commentators, or educators? Am J Psychiatry. 2009;166:757-759.
3. Mojtabai R, Olfson M. National trends in psychotherapy by office-based psychiatrists. Arch Gen Psychiatry. 2008;65:962-970.
4. Sartorius N, Gaebel W, Cleveland HR, et al. WPA guidance on how to combat stigmatization of psychiatry and psychiatrists. World Psychiatry. 2010;9:131-144.
5. Pies R, Thommi S, Ghaemi SN. Getting it from both sides: foundational and anti-foundational critiques of psychiatry. Association for the Advancement of Philosophy and Psychiatry (AAPP) Bulletin. In press.
6. Mishara A, Schwartz MA. Who’s on first? Mental disorders by any other name? Association for the Advancement of Philosophy and Psychiatry (AAPP) Bulletin. 2010;17:60-63. http://alien.dowling.edu/~cperring/aapp/bulletin_v_17_2/37.doc. Accessed February 7, 2012.
7. Paris J. The six most essential questions in psychiatric diagnosis: a pluralogue. In: Phillips J, Frances A, eds. Philos Ethics Humanit Med. In press.
8. Pierre J. The six most essential questions in psychiatric diagnosis: a pluralogue. In: Phillips J, Frances A, eds. Philos Ethics Humanit Med. In press.
9. Pies R. Reclaiming our role as healers: a response to Prof. Kecmanovic. Psychiatr Danub. 2011;23:229-231.
10. Pies R, Geppert CM. Psychiatry encompasses much more than clinical neuroscience. Acad Med. 2009;84:1322.
11. Knoll JL 4th. Psychiatry: awaken and return to the path. Psychiatr Times. 2011;28(5)1-6. http://www.psychiatrictimes.com/display/article/10168/1826785. Accessed February 7, 2012.

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How do controversial revisions in psychiatry's guidebook make you feel?

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When upward of 10,000 members of the American Psychiatric Association meet here this weekend, they'll be met by protesters - there are always protesters - and tough questions about where their profession is headed and how it will define normalcy for the rest of us. The official theme of the annual meeting, which opens Saturday at the Pennsylvania Convention Center, is integrated care, a nod to the increasingly interdisciplinary nature of medicine in the health-reform era. But many sessions will also focus on the association's highly controversial overhaul of the Diagnostic and Statistical Manual of Mental Disorders, the dominant guidebook to mental maladies and a key factor in determining insurance payments.
The current tome, the DSM-IV, was published in 1994 and updated in 2000. The book now in the works, the DSM-5 (yes, they dropped the Roman numerals), is due out by next year's APA meeting.
Supporters say the revisions incorporate more current science into the highly influential book. It also strives for diagnoses that show how seriously ill patients are.
Critics say the changes jump ahead of the science and expand what is considered mental illness. While the association tries to detect illnesses earlier and possibly prevent their most tragic symptoms, it risks calling essentially normal people mentally ill, needlessly exposing thousands to stigma and strong medicines, and handing drugmakers a bonanza.
One hot-button proposal allows grieving people to be considered depressed after two weeks of symptoms. Another addresses children who were being labeled bipolar by creating a different diagnosis: disruptive mood dysregulation disorder. Some worry that diagnoses meant to identify thinking problems in the elderly will turn normal aging into a disorder.
The University of Pennsylvania was one of 11 academic medical centers that field-tested the book's new approach. It looked at five diagnoses, including three new ones: hoarding disorder, binge-eating disorder, and mixed depression and anxiety.
In what is surely biting criticism in the mental-health world, David N. Elkins, a psychology professor emeritus at Pepperdine University, said the APA "should listen. They don't listen very well. They need to listen to the outcry and take it seriously."
The APA must have listened a little. It announced this week that it had moved the new attenuated psychosis syndrome, which attempted to identify young people likely to develop psychosis, and mixed anxiety and depression to a book section for conditions that need more research. They also tried to better differentiate normal grief from depression.
Last fall, Elkins, president of the Society for Humanistic Psychology, helped draft an open letter critiquing proposed changes. It got 13,000 signatures online, he said.
His and other groups are so miffed that they plan to write their own book. "We are calling for a summit in New York City in the summer of 2013 of all the mental-health professions," Elkins said. "We need a manual that is produced in an egalitarian way."
One of the most vocal critics is psychiatrist Allen Frances, who edited the DSM-IV. He said that overdiagnosing and overprescribing of antipsychotic drugs, particularly in children and the elderly, were already big problems. Psychiatry, he said, should be asking, "How can we put a governor on this? What DSM-5 will do, instead, is open up the flood gates."
The new approach, he said, gives "drug companies a free pass to convince everyone in the world that they have one disorder or two or three."
There's also the matter of autism. Its proposed definition is more restrictive. That has caused an outcry from autism advocates, who fear children will lose school services.
Frances thinks his group has made the current definition too broad. If fewer children with mild symptoms are diagnosed, "that's a good thing."
He also thinks the APA has too much money at stake to be objective. He says it makes $5 million to $10 million a year on sales of the manual.
The APA says it has invested $25 million in developing the new DSM over the last 12 years. It deflected a question about how much income the book generates.
David Kupfer, a University of Pittsburgh psychiatrist who heads the DSM-5 task force, said nothing was set in stone. A third six-week comment period opened Wednesday. The APA already has received close to 10,800 comments.
"We do want more public commentary," Kupfer said. "We are carefully examining this with some of our review groups. We certainly do not want to make changes for the sake of making changes."
For the record, he said, the number of diagnoses is dropping from 280 to 220.
John Oldham, the psychiatric association's president, said one of the DSM's roles has been to provide definitions that lead to better research. Mental health and illness are on a continuum with no clear lines of demarcation, but scientists need to find the earliest signs of dysfunction. "It's important for us," he said, "to be trying to understand when the right time is to intervene."
Thomas R. Insel, a psychiatrist who directs the National Institute of Mental Health, sees psychiatry heading toward what he calls "clinical neuroscience." Psychiatrists should study the brain the way cardiologists study the heart, he said.
While people assume that thinking of mental illnesses as brain disorders will lead to more medication, Insel said his agency has funded research into cognitive training, therapy that uses the brain's ability to change. It also is studying diet and family support.
"There is no biochemical imbalance that we have ever been able to demonstrate," he said. "What we think about are changes in circuitry and how the brain is processing information."
It makes sense to him to try to identify at-risk youths before they develop symptoms that can devastate their ability to work or have fulfilling relationships. The most debilitating of the mental illnesses, schizophrenia and bipolar disorder, often are diagnosed in early adulthood, but researchers are studying signs that emerge years earlier.
Critics say that lots of teens have eccentric behaviors but won't become mentally ill. This is true, Insel said, but "science entirely supports" figuring out who's going to become psychotic and preventing it. "That doesn't mean medicate earlier," he said.
The institute has embarked on its own attempt to classify mental illnesses based on what's happening in the brain rather than on symptoms.
Asked whether the association should delay rewriting the DSM until the science advances, he said, "That's a fair question. I'm not going to answer it." Then he said, "I think the DSM-IV is extremely helpful."
Mahendra Bhati, a psychiatrist who headed the Penn field trial, is confident that the new disorders his clinic tested are genuine mental illnesses. They don't necessarily need drug treatment.
But he found the new approach to personality disorders "clinically impractical."
Overall, he said, "I honestly don't think it's going to make a huge difference in how I practice psychiatry." His prescriptions, he said, are based on symptoms, not diagnoses.
On Saturday, as psychiatrists inside the convention center discuss proposed DSM changes, protesters outside plan to "Occupy the American Psychiatric Association." They'll have a "label rip," where they tear up the very diagnosis names that the psychiatrists are intent on defining.
"We'd have to be Don Quixote to think we're going to stop it at this point," David Oaks said of the DSM-5. A veteran of many such protests, Oaks, a Harvard grad who has been called schizophrenic and bipolar, is executive director of MindFreedom International and one of the event organizers. He says psychiatrists have not listened enough to their "customers," who often find peer and social support more helpful than drugs.