Patients' Diversity Is Often Discounted

Insurance companies found that paying for pills was cheaper and simpler than paying therapists to address the interpersonal causes of suffering -- especially because general physicians could write most of the prescriptions. Patient advocates realized that defining mental illnesses as brain diseases reduced the stigma attached to depression and psychoses -- a patient could hardly be blamed for having an organic disease.

Then came Prozac. Introduced in 1988 and backed by aggressive marketing, the drug brought relief to millions and popularized the notion that depression was essentially an imbalance in brain chemistry. In short order, Prozac and other psychiatric drugs began grossing billions of dollars. Millions flowed back into television advertising, marketing to doctors and grants to organizations that supported the treatment approach.

"The pharmaceutical industry didn't create the notion of the biological revolution in American psychiatry, but it hijacked it," said Lawrence Diller, a pediatrician in Walnut Creek, Calif., and the author of "Running on Ritalin."

While defending the rise of biological psychiatry, Spitzer said his field had tried to accommodate cultural nuances. The newest versions of the diagnostic manual do include references to the role of culture, he noted. One section describes conditions that affect only small groups of people, such as " ataque de nervios ," the very condition -- limited to Latinos, especially from the Caribbean -- that afflicted the woman whom Lewis-Fernandez treated in Cambridge.

But while the section on cultural formulations had a constituency, Spitzer said it lacks scientific support: "They insisted that these things are being ignored, so it is there, but I doubt it is used very much. I don't think the people who have developed that have done any studies to show its value. That's the difference between critics of DSM and us."

Regier, at the psychiatric association, said some advocates of cultural competence deserve credit for trying to marry cultural insights with epidemiological studies, but others are unscientific.

"You've got the cultural people who don't know how to do statistics and say you must only study individuals," Regier said. "That's like the psychoanalysts who say, 'I can't replicate it but I know it works' -- it is not a scientific discipline."

'Hardly Objective'

Advocates for culture's role in psychiatry say such criticism is disingenuous -- because it suggests the medical model itself is objective and free of bias. They point out that doctors cannot examine two brain scans and tell which belongs to a healthy person and which belongs to a patient with schizophrenia, or depression, or bipolar (manic-depressive) disorder, let alone the hundreds of other disorders in the diagnostic manual.

"Psychiatry is hardly objective," Columbia psychiatrist Oquendo said. "The instrument in psychiatry is the doctor. You talk to people in making diagnoses -- how can you say that's objective? We don't have a lab test to make a single diagnosis."

Despite its limitations, the cultural advocates say Spitzer's diagnostic model has acquired the status of gospel. Psychiatrists are too focused on fitting patients into Spitzer's categories, said psychiatrist Keh-Ming Lin, "instead of finding out from the patient where they are coming from."

"Whatever doesn't fit gets ignored, and whatever doesn't lead to medications gets ignored," Lin said.

Here and there, the advocates have made inroads. In 1999, a U.S. surgeon general's report concluded that the effects of culture on mental health "have been historically underestimated -- and they do count."

Prodded by advocates, professional organizations have added discussions of the role of culture to their meetings, and accrediting groups mandate that young doctors study how ethnicity and culture affect illness and treatment.

Insurance companies have also shown interest, said Arthur Kleinman, a psychiatrist and anthropologist at Harvard. Some HMOs, for example, have encouraged immigrants to seek out doctors who speak their native tongue. Kleinman and others welcome such moves but also worry they sometimes amount to lip service: HMO demands for efficiency, for example, have limited interactions between doctors and patients. Discussing cultural issues with a patient might add five minutes, Kleinman said, and "that's five minutes beyond an interview that usually lasts five minutes."

Driven by social, economic and technological forces, the reductionist medical approach to psychiatry is increasingly the norm around the world. Clinicians in distant countries are grappling with Spitzer's classifications in the same way that the theories of Freud once traveled from the parlors of Vienna to New York and Washington.

"What is happening with neurobiological therapy is the same thing that happened with psychoanalysis in the 1950s," said Renato Alarcon, a psychiatrist at the Mayo Clinic, referring to those who once believed Freudian therapy held all the answers.

"When science becomes a religion, it becomes scientism," he said. "There are fundamentalists among the scientists."