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Shorter believes that, in the process of updating DSM-II, crucial distinctions about different types of depression were lost, handicapping the future development of effective, more focused treatments. What used to be called "melancholic depression" or "endogenous depression," the sort of extreme state that can keep people from getting out of bed for weeks or months, was lumped together with other, entirely different depressions—which confused everyone. The result was that one, overgeneralized condition became the target for a range of drugs, many of which were best suited for "heterogeneous" depressions including "mixed states" of depression and anxiety, circumstantial depressions, and other stresses.
Today, patients can go to a doctor complaining of a variety of quite different symptoms, and still be treated under the "major depression" rubric. Much of modern-day psychiatry—
While Shorter is extremely critical of modern psychiatry, he's by no means antidrug. He just feels that today's psychiatric patients aren't getting the drugs they should be getting. But he has remarkably little to say about how to change this. He insists that no promising new drugs are in the pipeline, and suggests the best we can do is to revisit the old psychiatric medicine cabinet and rediscover pills that worked (and were tarnished) more than half a century ago.
Shorter almost entirely ignores the new brain science and the possibility of a new generation of targeted medications with a different kind of neurochemical action than has been employed so far. These are the meds that resemble smart bombs in comparison with the crude psychopharmacological sledgehammers of today, and are described by psychiatrist Peter Kramer in his book Against Depression. Certainly this is an avenue drug companies in search of greater profits are exploring as quickly as they can. With so many exciting developments in the new neuroscience, Shorter's failure to consider their possible impact is a major flaw in his view of what lies ahead for psychiatry.
While Shorter hardly touches on talk therapy, his argument about the limits of psychiatry, even if overstated, offers reassurance to those who believe that the ultimate answers to mental health issues require something more than the right prescription. It's hard to read his chronicle of the dead-end of modern psychiatric practice without concluding that there are too many complexities in the human experience for even the smartest drugs to smooth over. Even though it isn't his intention, Shorter provides plenty of reason for managed care and insurance companies to reconsider the role of psychotherapy as part of the more enlightened and more effective psychiatric practice of the future.
Richard Handler, M.A., is a radio producer and columnist with the Canadian Broadcasting Corporation in Toronto, Canada. Contact: firstname.lastname@example.org. Tell us what you think about this article by e-mail at email@example.com, or at www.psychotherapynetworker.org. Log in and you'll find the comment section on every page of the online Magazine section.