The farce of dueling psychiatrists

July 13th, 2009 by admin

Boston Globe
July 13, 2009

THE RECENT verdict of guilty in the “Clark Rockefeller’’ trial was an affirmation by a jury of his peers that he was not insane at the time of the crime. But the duel of prosecution and defense psychiatrists was at best a farce, at worst a travesty of the profession and the law. As a former psychiatrist I am appalled.

For the prosecution: one psychiatrist, famous from Fox TV and psychiatric thrillers, was paid $10,000 for his expertise as part of an “insanity defense,’’ testimony that was challenged by his offering opinions about Rockefeller on TV in advance of the trial; a prosecution psychologist agreed with his diagnosis, basically of a narcissistic character who was “delusional’’ – that is, insane. For the defense: a psychiatrist who had seen the accused once for 2 1/2 hours and had never before testified in court came up with the diagnosis of narcissism and sociopathy – that is, not insane.

Diagnosis of mental conditions is not the same as that of kidney disease. From the birth of psychiatry, diagnoses have been determined not by hard numbers but by cultural/historical norms. After Freud “discovered’’ During Freud’s time, after he “discovered’’ hysteria to be “a wandering womb,’’ the diagnosis became all the rage, as if suddenly hysteria had become epidemic, wombs wandering all over Europe; in recent decades the diagnosis of attention deficit hyperactivity disorder has boomed. Hysteria is a rare diagnosis now; perhaps ADHD will decline in popularity as well.

These days, psychiatric diagnoses are based on the “Diagnostic and Statistical Manual of Mental Disorders,’’ published by the American Psychiatric Association. This hefty volume is a main money-maker for the association, upward of a million dollars in annual sales. It is written by panels of psychiatrists who are each specialists in their own diagnosis and it is flawed, one example being its listing “homosexuality’’ as a psychiatric disease long after society had not.

It is also tarnished by many of the specialists being paid to be involved in studies of drugs to treat the illnesses they list as their expertise. The temptation for them to find a drug that will treat a diagnosis they can specify and in which they are the expert is significant.

The current conflict-of-interest investigations – including by Congress – into psychiatrists getting paid to do research that might prove the efficacy of the drugs they use to treat their patients are well documented. If a drug company can link a particular drug to a particular diagnosis, bingo – a blockbuster drug can earn over a billion dollars a year. The lucrative link between a diagnosis and a drug to treat it, when diagnosis itself is culture-bound and often subjective, pollutes the impartiality of the “Diagnostic and Statistical Manual,’’ and opens the courtroom door to the psycho-battles that demean and confuse.

If psychiatric diagnoses and treatments have an element of fuzziness, how could doctors paid by one side or the other not come up with a diagnosis wanted by their employer, prosecution or defense? Luckily, juries are savvy and sensible, and seldom buy an insanity defense. Dueling psychiatrists confuse, more than persuade them.

The solution is simple, and clear. First, do away with psychiatrists being paid by either defense or prosecution. Rather, have a paid panel of psychiatrists and psychologists independent of government or law, charged with determining legal insanity; both sides would have to agree to abide by the panels’ conclusion – as in binding arbitration.

Second, instead of either “guilty’’ or “not guilty by reason of insanity,’’ establish a verdict of “guilty and insane.’’ Convicted, the insane guilty would be held in psychiatric prison, eligible for treatment and perhaps available for statistical and clinical studies of the link between insanity and crime. Useful information – like the data suggesting that 80 percent of violent crimes are committed under the influence of alcohol or drugs – could be obtained, and could be useful in early intervention.

The circus atmosphere of shrinks in the courtroom, which devalues the profession and the law, would cease. As for the what’s-in-fashion friability of the “Diagnostic and Statistical Manual’’ and the money-making links of diagnoses to drugs, that’s another, more scary and intractable matter.

Stephen Bergman, MD, is a guest columnist. Under the pen name Samuel Shem he is author of “The House of God’’ and “The Spirit of the Place.’’

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