Patients' Diversity Is Often Discounted

Minority patients are not the only ones affected: For one thing, about 40 percent of U.S. doctors training in psychiatry today are foreign-born. "There are so many international psychiatric residents that the real cross-cultural encounters are going to be between foreign physicians and white Americans," Lewis-Fernandez said. "Filipino and Indian doctors [will be] meeting your average Ohioan and saying, 'I don't understand you.' "

Nor are misunderstandings limited to issues of ethnicity. Differences between clinicians and patients in language, social class or religious belief can also be pitfalls, the advocates warn. Janice Egeland, a behavioral scientist who has worked nearly three decades with the Amish, said she realized something was very wrong when an Amish man went to a friend's house to watch baseball on TV. In the context of Amish culture, which shuns material luxuries and modern technology, his seemingly ordinary action alerted Egeland to a problem that might have been missed by a less experienced clinician. She soon discovered the man had not merely watched the game.

"He was jumping all around, pretending to run the bases," she said. After a thorough evaluation, she realized he was suffering from manic depression, a disorder characterized by alternating bouts of euphoria and depression.

In Illinois, a truck driver was diagnosed as psychotic after he said he frequently saw the devil sitting near him, warning that his life was going to take a turn for the worse. Then a doctor trained to pay attention to cultural issues realized the man was an evangelical Christian whose allegorical religious expression had been misunderstood as a hallucination by secular physicians, said Gary Myers, a clinician at Southern Illinois University in Springfield.

Mainstream psychiatrists say such examples are interesting but insist that the field stay focused on biology and brain chemistry. That is the only way to integrate psychiatry with the rest of medicine and to produce objectively verifiable treatments, said Regier, of the American Psychiatric Association.

"If you had to choose between a Western model of diagnosis and treatment and, let's say, an ayurvedic treatment model, what would you take?" he asked, referring to a traditional system of healing in India. "Whether with AIDS therapy, which the South Africans resisted, or psychotropic medicines, there is something objectively superior to a medical model of treatment of psychiatric illness."

A Common Vocabulary

Through much of the 20th century, the long shadow of Sigmund Freud hung over psychiatry. Just as doctors today talk about serotonin and brain structures such as the amygdala, doctors at mid-century evaluated patients through the lens of Freudian concepts such as transference and repression. Without common definitions of the symptoms they encountered, psychiatrists often disagreed over what ailed their patients. Show a patient to 10 psychiatrists, the joke went, and you would get 10 diagnoses.

In response, Columbia's Robert Spitzer led efforts to update American psychiatry's manual of mental disorders in 1980 and again in 1987. Experts drew up lists of specific symptoms associated with particular mental disorders -- and gave the field a common lexicon. The "Diagnostic and Statistical Manual of Mental Disorders," commonly known as DSM, became the bible of the medical model of psychiatry.

Yet, as Spitzer readily acknowledged in a recent interview, the DSM classifications did not rest on new scientific data.

"The DSM is not a scientific document," Spitzer said. "It is a bunch of smart people who studied the literature and then came up with the best way to define diseases -- very few of the categories have an empirical base." As doctors wrestled with overlapping symptoms, he said, subsequent editions greatly expanded the number of disorders: "It is not a scientific document, but it facilitates science."

Spitzer said he had never oversold the scientific credentials of the manual. But powerful factors heightened its prominence.

Drugs were shown to help patients with various symptoms, yielding hard data that most talk therapies and social interventions could not readily produce. Neuroscientists showed that many mental disorders had genetic components.