Why psychiatry needs therapy

...For those more seriously ill, contemplating suicide or pacing restlessly and saying "It's all my fault," melancholia was the diagnosis of choice. The term has been around for donkey's years.

All the serious disorders of mood were once lumped together technically as "manic-depressive illness"—and again, there was little point in differentiating, because medications such as lithium that worked for mania were also sometimes effective in forestalling renewed episodes of serious depression.

Psychopharmacology—the treatment of disorders of the mind and brain with drugs—was experiencing its first big push, and a host of effective new agents was marketed. The first blockbuster drug in psychiatry appeared in 1955 as Wallace Lab's Miltown, a "tranquilizer" of the dicarbamate class. The first of the "tricyclic antidepressants" (because of their chemical structure) was launched in the U.S. in 1959, called imipramine generically and Tofranil by brand name. It remains today the single most effective antidepressant on the market for the immediate treatment of serious depression.

In the 1960s an entirely different class of drugs appeared, the benzodiazepines, indicated for anxiety rather than depression. (But one keeps in mind that these indications are more marketing devices than scientific categories, because most depression entails anxiety and vice versa.) In the benzodiazepine class, Librium was launched for anxiety in 1960, Valium in 1963. Despite an undeserved reputation for addictiveness, the benzos remain today one of the most useful drug classes in the history of psychiatry. They are effective across the entire range of nervous illnesses. In one World Health Organization study in the early 1990s, a sample of family physicians world-wide prescribed benzos for 28% of their depressed patients, 31% of their anxious patients; the figures are virtually identical. In the 1950s and '60s physicians had available drugs that truly worked for diseases that actually existed.

And then the golden era came to an end. The 1978 article of British psychiatrist Malcolm Lader on the benzos as "the opium of the masses" would be a good landmark. The patents expired for the drugs of the 1950s and '60s, and the solid diagnoses were all erased from the classification in 1980 with the appearance of the third edition of the DSM series, called "DSM-III." It was largely the brainchild of Columbia University psychiatrist Robert Spitzer, an energetic and charismatic individual who had been schooled in psychometrics. But his energy and charisma nearly led psychiatry off a cliff...

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