Tuesday, May 11, 2010

All doctors know when to prescribe Xanax in case of anxiety disorders

Well, it's that time of the decade again and the American Psychiatric Association (APA) is going through it ritual of revising the Diagnostic and Statistical Manual (DSM). Let's be clear why this is important. For better of worse, the DSM is like a bible, containing words of wisdom on which clusters of symptoms represent which disorders. The idea is to do away with the zip code lottery of diagnosis. In one US state you might be diagnosed as a bit eccentric. With the same behavior in a different state, you might be considered a danger to the community and committed to care. With the DSM as a guide, you hope to get the same diagnosis no matter who the patient is, where he or she may be found and who the doctor is. Unfortunately, the APA is caught in a terrible conflict of interest. The majority of its members regularly receive gifts and incentives from the drug manufacturers. This benevolence is designed to encourage the use of the relevant drugs. When these same doctors sit down to discuss diagnoses and which drugs to recommend, they cannot forget all the past generosity. It inevitably influences their decisions. More importantly, if particular drugs receive approval in the DSM, this represents several billion dollars in revenue. The manufacturers therefore spend heavily in trying to ensure their drugs continue to be linked to the relevant disorders. The result is the DSM is full of disorders that are only poorly defined and linked to drugs often little more effective than placebos.

If we go back sixty years, psychiatry in the US was still running in parallel with the European tradition of scientific method. This produced carefully defined diagnoses for general conditions, leaving practitioners with some flexibility to take a common sense view of the individual patient. Hence, the technical term might be a "nervous breakdown" which is a catch-all definition for anyone who has a few problems. But as the pharmaceutical industry used its economic power, these broad definitions were increasingly broken down into separate classes of disorder. As each new batch of disorders was defined, the manufacturers produced drugs specifically targeting each new disorder. In reality, people are still having nervous breakdowns and, truth be told, all the major drugs are interchangeable because the separate disorders are really only one or two basic types.

What prompted this redefinition of terms? Firstly, the introduction of the benzodiazepines. The manufacturers wanted a distinction between anxiety disorders and depression for marketing purposes. Once the APA gave in, it was the slippery slope to the present confused mess. As everyone knows, all depression has elements of anxiety and panic, just as anxiety and panic are indistinguishable from elements in depression. Recent surveys have found doctors routinely prescribing benzodiazepines such as xanax regardless of the diagnosis as anxiety or depression, and finding the same excellent results. Secondly, the APA wanted to move away from Freudian analysis and to ground diagnosis in observable symptoms. This led to the introduction of "major depression" and "bipolar disorder" which lump different sets of symptoms together in either a stable or unstable form. As the SSRIs came in as treatments for major depression, the pressure to keep inventing new disorders grew. Now all the anxiety and panic disorders are multiplying. Needless to say, xanax remains the most effective treatment no matter what labels are attached to the symptoms. If you are anxious, xanax is the answer. Sadly, the APA will not sympathize with such a simple view of the world.


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