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While the randomly controlled trial is more scientifically scrupulous, of course, there's a downside: under the new regime, drug firms weren't required to test their new meds for effectiveness against other, existing medications, many now fading from public favor and losing patent protection. They only needed to measure up against a placebo. Bottom line, says Shorter: "If you can beat sugar pills, you can get your drug licensed." Still, even with this low bar, in preliminary drug company trials, Prozac proved little more effective than the placebo.
For Shorter, the third culprit in all this is the psychiatry profession itself, as it presents itself in its Diagnostic and Statistical Manual (DSM). The first edition of the DSM was published in 1952 and then revised in 1968 and 1980. (We now live with the DSM-IV, and the next version will be out in 2012.) The purpose of these manuals is to standardize psychiatric diagnoses. But in Shorter's judgment, rather than being a product of the most rigorous scientific conclusions about psychiatric conditions, the DSMs are actually consensus documents, which often say more about the politics of psychiatry than anything about the latest empirical findings.
For Shorter, the turning point in the understanding and treatment of depression, and the reason that the diagnosis became so common, happened with the development of the DSM-III. In the 1970s, under the aegis of Robert Spitzer, a Columbia professor, a task force was set up to revise DSM-II. Shorter chronicles in great detil the politicking and in-fighting that went into DSM-III, particularly the psychoanalysts' protests about the elimination of their familiar diagnostic labels.
The upshot of these political battles and compromises was that the new DSM became a kind of "Chinese menu" of psychiatric disorders, with no unifying theoretical or scientific coherence. For example, a range of what many considered separate conditions were put into one big basket called "major depression" (Spitzer's term), graded on a scale of severity from one to three. Dysthymia, a milder, chronic disorder, was given its own category. But according to Shorter, the compromise formulation for depression hopelessly distorted the diagnosis, transforming it into a one-size-fits-all category.