Pursuing treatments that are not evidence based: How DSM IV clarifies, how it blinds psychiatrists to issues in need of investigation

Summary 

Evidence based medicine claims to be the paradigm for modern psychiatry. It represents proven treatments for defined diagnoses. But there are major problems with this position, starting with the fact that while they are superior to placebo, evidence based treatments too often are ineffective.

It cannot be assumed that classifying psychopathology diagnostically is the best way to move forward. Established diagnostic entities, are as much wish as reality. They are the result of committee decisions so tentative that DSM III and IV refuse to use the term “diagnoses” in the diagnostic manual.

There is also a more fundamental issue, not answerable to the vote of even the most “expert” committee. What do diagnoses represent? Does every diagnosis in DSM IV represent an actual real illness, in the sense that polio, cancer, or a strept throat actually exist? Or can they represent the reification of an idea, taking diagnoses beyond useful limits? Evidence based medicine, it is implied, should monopolize clinical approaches. But at this stage the proper question is not should we exclusively use treatments that have proven superior to placebo? It is what is the best way to formulate treatment strategies when now, and in the foreseeable future, science cannot offer answers that we need? Conjecture, out of necessity, must play a significant role. Given mediocre treatment results, we need all the help we can get, the art of psychiatry as well as the science.

Pharmacological agents can be viewed as inducing particular psychological states which, though not specifically related to diagnosis, are nonetheless the basis for their usefulness. SSRIs are efficacious in a broad range of conditions because increasing serotonin has a psychological impact that is nonspecific to the disorders. It can be used in treatment contexts when diagnosis is irrelevant (e.g. helping a picked on, thin skinned adolescent, develop thicker skin).

The core issue is our approach to patients. Evidence based medicine eschews the anecdotal in the name of generalized conclusions, based on the odds that the patient’s ailments are typical for their group. This is not a ridiculous consideration, but it can miss important particulars brought by the patient. Knowing a patient well can be the difference between effective and ineffective treatment. Premorbid defenses, character style, the nature of the patients’ stressors, their story can guide clinicians to a particular medication, and influence dosage. While evidence based medicine has a place, especially when low cost is a consideration, it cannot lay claim to being optimal treatment. It is especially detrimental if this perspective acts like blinders, obscuring more than it clarifies.