Abstract
With his latest work, Dr Paris continues to serve as a voice of reason against otherwise unchecked trends resulting in overdiagnosis of psychiatric disorders. 1 –3 By outlining how psychiatry has lost its way, the book challenges us to find our way back to a specialty that offers something unique to the field of medicine through our understanding of the human condition, while making judicious use of the tools available to us. Toward this end, Dr Paris provides a systematic analysis of largely nonscientific, sociocultural factors emanating from the medical profession itself, consumers of health care, and the pharmaceutical industry, all leading to the final common pathway of medicalization of normality, overdiagnosis, and overuse of medication. This helps practising clinicians to sift through various fads, rhetoric, and other sources of misinformation disguised as science bombarding us on a daily basis and thereby make intelligent, evidence-based treatment choices.
Throughout the book, the reader is reminded of the state of uncertainty regarding the etiology and pathogenesis of psychiatric disorders. Advances in neuroscience are still very much in their infancy, far from the point of everyday clinical usefulness. For now and the foreseeable future, we will continue to make diagnoses based exclusively on phenomenology, grouping symptoms into syndromes. Dr Paris clearly outlines how the failure to acknowledge this uncertainty, due to the need for psychiatrists to be seen as scientists similar to our other medical colleagues, leads to overgeneralization of existing diagnoses, as well as creation of new ones, to fit available treatments. Most often, this means medication. Because physicians and patients alike do not accept any form of distress as part of the human condition, everything must be packaged as a diagnosable, curable disorder. Within this framework, nothing is normal anymore; everything is on a spectrum of illness. Broader definitions of illness lead to greater prevalence by a process of circular logic. After these concepts are introduced in the opening chapters, the book proceeds, in a compelling manner supported by eye-popping statistics, to show how the confluence of factors results in diagnostic “epidemics”: all unhappiness is depression treatable with antidepressants, all difficulty focusing is attention-deficit hyperactivity disorder treatable with stimulants, and all moodiness is bipolar illness treatable with mood stabilizers.
One of the major strengths of the book is that it is not simply a rant against the state of modern psychiatry, as may be anticipated from the title and the pill bottles on the cover illustration. It is not anti–medication to understand the limits of its effectiveness, nor is it anti–DSM-5 4 to place the manual in its proper perspective as a provisional tool, as opposed to a guide to treatment. The tools are not the problem; it’s how clinicians use them. This point is effectively hammered home throughout the book, reinforced by positive messages to think critically as opposed to robotically, to tolerate uncertainty, to exercise clinical judgment, to avoid fads, and to return to a comprehensive biopsychosocial approach 5 to understanding and treating patients.
Because of its brevity, direct and simple statements, and clear lines of reasoning enhanced by well-placed use of metaphors and clever expressions such as “bipolar imperialism” (my personal favourite), this book is highly engaging, flows smoothly from cover to cover, and is easily readable within one or two sittings. It is useful for psychiatrists and other front-line mental health professionals, including family physicians who could use something brief to give them perspective on the information they receive about psychiatric diagnoses and treatments from the pharmaceutical industry. In addition, it is not difficult to envision a modified version for the general public, to help people become educated consumers of psychiatric services. The book is free of production errors, with a couple of minor exceptions. Although a bit pricey at first glance for a short volume, therein lies its value as it packs a large wallop.