In typically melodramatic fashion, the journalist feels he has exposed “deep divisions” because he has gotten quotes on both sides of the issue. The unfortunate reality is that there is too little division over the issue of the necessity of medication in a psychiatric profession in the hip pocket of the pharmaceutical industry. The divisions tend to fall between the medical practitioners (psychiatrists) and the non-medical mental health caregivers; the author of the current study is a pforessor of social work. In making the cse for a portion of the schizophrenic population who do not need antipsychotic medication, he speculates that perhaps they have a milder form of the disease. I think it is even more likely that they do not have schizophrenia at all. Psychiatry has labored mightily to establish a credible diagnostic schema but few realize that it is a work in progress and deeply flawed.

Part of the problem is that the research edifice requires slavish adherence to the diagnostic system to conduct studies. This leads to a misplaced sense of concreteness. “If I say the patient is a schizophrenic (carries the diagnosis of schizophrenia), then they have the disease of schizophrenia…” In other words, making the diagnosis implies, and I would say falsely, that all subjects who share a diagnosis have something meaningful in common, so that research findings on that class of individuals are meaningful. But if you are really lumping together unlikes, the research findings will either be trivial, coincidental, or inconclusive. As an example, if a researcher set out to measure, say, the citric acid content in the fruits he called “oranges”, and included the oranges with the thick pockmarked orange skins as well as those with the smooth thin red skins (more commonly known as “apples”), his findings would be meaningless. If we were uncertain about the distinctions between apples and oranges, in other words, we would be comparing apples and oranges.

It may not be immediately obvious to the public, even the erudite readers of the New York Times, that diagnoses are not etched in stone. There are problems with diagnostic clarity elsewhere in medicine, of course, but none as severe as in psychiatry, where we peer into the ‘black box’ that is the workings of the brain and mind. The situation is particularly acute with schizophrenia, which I find to be a wastebasket diagnosis among the members of which class I discern patients with several distinct clinical entities varying along a number of dimensions including medication-responsiveness. In a less tortured diagnostic system, many of them should not be called schizophrenic at all. Compounding the imprecision of the diagnostic system is the fact that clinicians and researchers vary in the acumen with which they make diagnoses. While particularly egregious with the schizophrenic diagnosis, this is a problem throughout the field of psychiatric diagnosis. Patients who are not responding to treatment x are often referred to me with diagnosis y, for which treatment x would be totally appropriate, only I do not find them to have diagnosis y. There is another factor as well, which becomes most clear when one studies the history of psychiatric classification over the last century or century and a half. The world of psychopathology is parsed up into different diagnoses in an everchanging way. Styles of classification change; we are more inclusivist or exclusivist, more ‘lumpers’ or ‘splitters’ in different eras. Vastly different numbers of patients, different proportions of those with mental illness, were diagnosed with schizophrenia, for example, at some times than at others. Given diagnostic categories expand or contract over time, bumping up against both ‘normals’ and other diagnostic categories. There is a sort of Darwinian competition for niches in the mental health ecology; diagnoses are always trying to maximize their ‘fitness’.

Equally true is that there are cross-cultural differences. The rates of classification with given diagnoses vary significantly between European and American practitioners, even when they are seeing the same patients, as in one famous study where diagnosticians were brought across the Atlantic to compare their skills and styles.

One of the reasons diagnostic categories expand and contract is the development of new medications. If the only tool you have is a hammer, it pays to see everything as if it is a nail, I am fond of saying. The most dramatic example of this was the expansion in those who were seen to be bipolar (manic depressive) after the introduction of lithium, the first effective modern mood stabilizer, in the ’50’s. Most of the newly-recognized manic depressives would have been called schizophrenics previously, when in essence the distinction had not mattered as much. But one has to be wary of arguing that the new diagnostic distinction is driven entirely by newfound utility. The refinements in diagnostic classification are by no means inevitably improvements. It is equally likely, and more worrisome, that change is driven by marketing pressures to sell the new drug. We have seen something similar with depressive diagnoses since the development of the SSRI antidepressants, and their descendants, in the last two decades. No only do the antidepressants reach more depressed people, but more people are defined as having a depressive condition in order to be eligible for medications. No one is doing this consciously, but it happens inexorably nonetheless. Furthermore, as psychiatrists scramble for market share in the face of competition from competing nonmedical mental health professionals, it pays to expand the definitions of medication-responsive diagnoses so they have more people to treat.

This leads me to subscribe to a “one-third” rule, almost regardless of diagnosis. One third of patients diagnosed with a given disorder will respond to the appropriate treatment; one third will be poor responders; and one-third would get better regardless of, or without, treatment. Part, but not all, of this is based on the diagnostic issues I have discussed above (for example, do the one third who would respond anyway, as the ‘schizophrenics’ in the study under current consideration, really have the condition in question? In essence, is the treatment wrong for the diagnosis or is the diagnosis wrong for the treatment? We ignore either wing of this quandary at our peril.).

As I grow older, I become much more of a diagnostic nihilist, finding the misplaced concreteness of the system and of my colleagues increasingly painful to bear. At least as far as my professional work as a psychiatrist goes, the older I get, the less I know. The important question: does that make me of more or less help to my patients?