10

PSYCHIATRIC TIMES
www.psychiatrictimes.com

FUTURE OF PSYCHIATRY

MAY 2008

Child and Adolescent Psychiatry:

The Next 10 Years
by Thomas F. Anders, MD

In 1967, who would have predict- oratively to shape our future. The foled that psychiatry would have re- lowing discussion of the future of
sychiatry is changing so rapid- turned to mainstream
child and adolescent
ly that it seems impossible to medicine, that stigma
psychiatry will focus
Fourth in a Series
predict 1 year ahead, let alone would be significantly
on 5 interrelated areas:
10 years. In 1967, when my psychia- lessened both for our
workforce, access, stigtry training ended, the community patients and for our profession, or ma, research, and ethics and public
psychiatry movement had just begun, that we would have such a large and perception.
DSM-II was in the works, and the bi- diverse armamentarium of effective
ological revolution was still around treatments? Do these advances sug- Workforce
the corner. Psychiatrists of that era gest that the profession of psychiatry There is a serious crisis in the child
were deeply psychodynamic in their has arrived, that our understanding of and adolescent psychiatry workorientation. My view of develop- mental disorders and treatments is force.1 There are far too few of us, and
ments over the next decade stems complete, and that stigma has disap- large parts of the countryespeciallargely from my perspective as a re- peared? Not at all! More work re- ly rural and inner city areashave
cently retired academic child and mains to be done, obstacles still need few if any child and adolescent psyadolescent psychiatrist. While many to be overcome, and more changes chiatrists.2,3 Many studies over the
years, including reports from presiof the programs that I managed were are on the way.
based in community settings, I am not
Child and adolescent psychiatry is dential commissions, surgeons gena community psychiatrist. And al- a unique subspecialty with some very eral,4-7 the Council of Graduate Medthough I saw private patients through- formidable challenges, but our chal- ical Education,8 and the Institute of
out my career, I have never been in lenges are not too dissimilar from Medicine,9 attest to the dire shortage
full-time private practice. So beware: those of many of our physician col- of child and adolescent psychiatrists
future predictions are most likely bi- leagues. As part of the US healthcare relative to the almost 20% of our naased by past experiences.
system, all of us need to work collab- tions children who are deemed in
need of care. This shortage embraces
all childrens mental health profesPoetry of the Times
sions and severely impacts access.
Fewer than half of the children in
need of care are evaluated, and even
fewer are treated effectively.
Projections from the studies mentioned above estimate a need for
by Richard M. Berlin, MD
30,000 child and adolescent psychiatrists.10 Currently, there are about
7000. However, since many of these
child and adolescent specialists also
treat adult patients and/or engage in
After I thought I had heard it all,
administrative, supervisory, or other
a woman tells me her story, the one
nonclinical activities, the direct care
with the drunk father who does everything
workforce is well below that number.
Will we reach the goal of 30,000 in
you might imagine while the mother
the next decade when there has been
looks away. I feel so professional,
virtually no change in our numbers
over the past decade?
master of my emotions, armpits dry,
I predict that by 2018, resulting in
heartbeat steady and slow, my stomach
part from recent efforts by the American Academy of Child & Adolescent
rumbling for lunch. When I warn her
Psychiatry (AACAP), we will see a
we have five more minutes, she wipes
modest 30% increase in the number
her cheek and buttons her world back up,
of medical students and general psychiatry residents choosing child and
and when she finally leaves, I click my pen
adolescent psychiatry as a career. One
to write a progress notethats when
of the AACAPs recruitment efforts
includes earlier exposure of medical
I notice drops of blood drying on the cover
students to child and adolescent psyof her chart, my ring finger bleeding
chiatry. The AACAPs partnership
where I tore off a tiny cuticle, the wound
with the Harvard Macy Program for
Educators in the Health Professions is
below the moon in my nail bed burning
increasing the number of competent
like the fire in the last light of sunset.
teachers of medical students to serve
as role models. The Klingenstein
Dr Berlin is associate professor of psychiatry at the University of Massachusetts
Third Generation Foundations genMedical School. E-mail: rberlin@massmed.org.
erous support of medical student fel-

Professional Distance

lowship programs in 12 medical

schools is providing an incentive for
medical students in their first and
second years to participate in clinical
experiences mentored by child and
adolescent psychiatrists. A similar
effort is being mounted by the American Psychiatric Association (APA)
in support of the Psychiatry Student
Interest Group Network, a national
organization of medical students interested in psychiatry.
Additional AACAP efforts have
spawned new training pathways to
child and adolescent psychiatry. The
Post Pediatrics Portal Project, recently approved by the Accreditation
Council on Graduate Medical Education, will attract board-eligible
and board-certified pediatricians who
wish to switch careers. They will train
for 36 months (instead of 48 months)
in integrated child and general psychiatry programs. For medical students who express an interest in early
exposure to children, more flexible
Residency Review Committee requirements provide greater opportunities for parallel child and general
psychiatry experiences throughout
training.
The academic research training
track in child and adolescent psychiatry, initiated at the Yale Child Study
Center and now spreading to other
sites, is yet another pathway for attracting the brightest to child and adolescent psychiatry. Finally, the tripleboard program remains popular with
medical students who are interested
in integrating their training with pediatrics. Despite these innovations,
however, I expect we will not have
10,000 child and adolescent psychiatrists a decade from now.
Rather, I predict that more intensive behavioral health training will
emerge for primary care physicians
and general psychiatrists both during
their residencies and through postgraduate courses. Such advanced
courses will lead to recognition of
special competencies in childhood
behavior and mental disorders. I also
believe that physician extenders such
as psychiatric clinical nurse specialists will be used more widely and that
more psychologists will be specially
trained and licensed to prescribe. Finally, the Internet and technological
advances such as telepsychiatry will
serve to expand the scope of practice
so that child and adolescent psychiatrists will be used much more as

MAY 2008

educators and consultants.

To summarize, about 300 residents
currently enter child and adolescent
psychiatry training each year. These
numbers are likely to increase to
about 400 over the next decade. The
increase will result from earlier exposure of medical students to the field
and a broader set of training pathways
that will satisfy their interests. There
will also be a much larger group of interdisciplinary practitioners providing primary mental health care for
children and their families, including
prevention and early intervention.
There will be more formal collaborative networks, supported by interactive electronic communication, that
use the scarce child and adolescent
psychiatrist as both a consultant and
an educator.

PSYCHIATRIC TIMES

FUTURE OF PSYCHIATRY
spective parents who will become advocates of healthy emotional and psychological development. Starting in
pregnancy, parents will receive information from the AACAP through
each stage of their childs social and
emotional development. Timely educational materials about typical cognitive, social, and emotional milestones, combined with information
about early warning signs of disturbance, will be distributed to parents
at specific points pertinent to their

childs developmenttimes when

they are most receptive to learning
and growth.11 An ongoing relationship with a group of families, built
over time but starting in the prenatal
period, that emphasizes prevention
and early intervention will reduce
stigma, foster positive therapeutic alliances with the field of child and
adolescent psychiatry, and ultimately
lessen the demand for higher-level
specialty services later. Finally, I predict that the AACAP will develop

11

www.psychiatrictimes.com

Web-based iterative and interactive

services that will guide both parents
and professionals to better evidencebased information.

Stigma
Stigma regarding mental disorders,
especially in children, has been an effective barrier to receiving treatment.
On one hand, parents are reluctant to
bring children for care; on the other,
insurance companies have carved
(Please see Child Psychiatry, page 12)

Access
As the workforce becomes more interdisciplinary and collaborative, involving peers and consumers, mental
health and health services will be truly integrated in local communities.
Community systems will become
more prominent, providing a continuum of care in the least restrictive environment. More home-based services, integrated classrooms, and wraparound programs will keep children
with mental and developmental disorders in the mainstream. Parent
support groups and peer counseling
programs will grow. The silos of professional isolationism and noncommunicating/collaborating agencies,
buttressed by misinterpretations of
the Health Insurance Portability and
Accountability Act, will break down
as families assume an ever more active role in partnering with professionals and participating on community boards.
I anticipate that child and adolescent psychiatrists will become more
skilled in integrative, consultative,
and collaborative roles. They will become better adult learners and educators, and they will become more
engaged in prevention and early intervention, as well as better trained
for leadership and building teams and
for managing systems of care characterized by shared governance.
In short, access will be significantly facilitated by teamwork using
child and adolescent psychiatrists in
new roles. Electronic, Web-based,
and interactive information transfer,
including telepsychiatry consultation
between well-resourced sites and
more remote sites, will expand. Further, I envision that the AACAP,
through public education campaigns
focused on risk and resiliency, developmental milestones, prevention, and
early intervention, will organize pro-

15

References: 1. Dauvilliers Y, Arnulf I, Mignot E. Narcolepsy with cataplexy. Lancet.

2007;369:499511. 2. Thorpy M. Current concepts in the etiology, diagnosis and
treatment of narcolepsy. Sleep Med. 2001;2:517. 3. Thorpy M. Therapeutic advances
in narcolepsy. Sleep Med. 2007;8:427440. 4. American Academy of Sleep Medicine.
The International Classification of Sleep Disorders: Diagnostic and Coding Manual.
2nd ed. Westchester, Ill: American Academy of Sleep Medicine; 2005. 5. Green PM,
Stillman MJ. Narcolepsy: signs, symptoms, differential diagnosis, and management.
Arch Fam Med. 1998;7:472478.

Sponsored by

Because many disorders have symptoms resembling those of

narcolepsyexcessive daytime sleepiness, cataplexy, disturbed
nocturnal sleep, hypnagogic and hypnopompic hallucinations,
sleep paralysisa differential diagnosis including narcolepsy is
often required.24
For additional information, call 1-800-206-8115 or e-mail
info@narcolepsyDx.com. You can help narcolepsy patients
finally get the recognition and treatment they deserve.

12

PSYCHIATRIC TIMES
www.psychiatrictimes.com

Child Psychiatry
Continued from page 11

Readers Guide
HOW TO REACH US
By fax:
By phone:
By mail:

By e-mail:

MAY 2008

FUTURE OF PSYCHIATRY

(203) 662-6776
(203) 662-6400
330 Boston Post Road
P.O. Box 4027
Darien, CT 06820-4027
PTEdit@cmpmedica.com

SUBSCRIPTION SERVICES
As a practicing psychiatrist in clinical care, you are
eligible for a complimentary subscription. To qualify,
you must be a psychiatrist in direct patient care with
your specialty registered as psychiatry with the
American Medical Association. To order your
subscription, call (800) 280-0628; fax (866) 328-7123;
or e-mail kate.starostina@cmpmedica.com
Subscribe to Psychiatric Times
Individual Subscription:
One Year: $59 Two Years: $79
International & Canadian Subscribers:
One Year: $120 Two Years: $189
Libraries and Institutions:
One Year: $120 Two Years: $200
Your subscription includes 14 exciting issues per year.
Paid Subscriptions
Contact Customer Service at
Phone: (952) 844-0512
Fax: (952) 844-0017
E-mail: cmesubs@masub.com
Privacy
For more information on our privacy policy,
please visit www.cmpmedica.com and click on
Privacy Statement at the bottom of the page.
Back Issues
Psychiatric Times offers a large selection of back
issues. Contact Customer Service at
Phone: (952) 844-0512
Fax: (952) 844-0017
E-mail: cmesubs@masub.com
Change of Address
Contact Customer Service at
Phone: (800) 280-0628
Fax: (866) 328-7123
E-mail: kate.starostina@cmpmedica.com
Reprints
Reprints of articles are available. Please contact Greg
Rucker by phone at (212) 221-9595 extension 105,
fax (212) 221-9195, or by e-mail at:
Greg.Rucker@parsintl.com
PARS International Corp.
102 West 38th Street, Sixth Floor
New York, NY 10018
Website: www.magreprints.com/quickquote.asp
Earn Credit Online
You can earn category 1 credit instantly online at
www.PsychiatricTimes.com/cme.html.

EDITORIAL INFORMATION
For comments, suggestions or questions, contact
the editorial staff by fax, regular mail, or phone at
the numbers or address listed above, or by e-mail
at: PTEdit@cmpmedica.com.
Submissions
While most of our articles are assigned, we periodically
consider unsolicited materials likely to be of interest to
our readers. Youll find Psychiatric Times writers guidelines at www.PsychiatricTimes.com/writers.html, or
contact us and we will provide the information by fax or
mail.

ADVERTISING INFORMATION
To receive a complete media kit or additional information
on other CMP publications, call (949) 250-1008 or
(800) 993-2632, or fax (949) 474-5936.
Cindy Flaum, Publisher
cindy.flaum@cmpmedica.com
Brett Baxter, Regional Sales Manager
brett.baxter@cmpmedica.com
Jules Leo, Classified Sales Manager
jules.leo@cmpmedica.com

ON THE WEB
Youll find select articles from Psychiatric Times
online at www.PsychiatricTimes.com.
In addition to indexed, full-text articles from
Psychiatric Times, the Web site includes:
Latest newsUpdated information about
psychiatric issues
Classified ads
Online CME credits
CMPMedica journals include The AIDS Reader, BioMechanics, Consultant,
Consultant for Pediatricians, Diagnostic Imaging, Diagnostic Imaging Europe,
Drug Benefit Trends, Infections in Medicine, The Journal of Musculoskeletal
Medicine, The Journal of Respiratory Diseases, Oncology, Oncology News
International, Psychiatric Times, The Journal of Critical Illness, Psychiatric Issues
in Emergency Care Settings, and Abstracts in Hematology and Oncology.

out mental health benefits inequitably and have prescribed how different mental health professions should
practice. Stigma also exists in school
systems, where children in need may
be overlooked or labeled inappropriately, and it remains among our medical colleagues who counsel bright
medical students interested in psychiatry to choose a more rigorous specialty. But over the past several years,
a reduction in stigma at all levels has
occurred. Our research advances have
provided more and better treatments.
Parent advocacy groups have become
more strident and politically active.
Over the next decade, alliances between parent groups and professional organizations will become stronger. Joint lobbying efforts and public
awareness campaigns at the federal,
state, and local levels will become
ever more popular.
The AACAP executive team has
formed a national summit of partners
that includes executive leadership
teams from the National Alliance on
Mental Illness, Children and Adults
with Attention Deficit/Hyperactivity
Disorder, the Autism Society of
America, the National Mental Health
Association, the Federation of Families for Childrens Mental Health, and
the Child and Adolescent Bipolar
Foundation. The group meets twice
yearly to work on issues of mutual interest, with discussions often focused
on access and stigma, and jointly visits Capitol Hill on an annual basis.
The APA has developed a comparable program of collaborative lobbying. The Paul Wellstone Mental
Health and Addiction Equity Act is
likely to become law and will certainly contribute to the reduction of
stigma. In the next 10 years, these national partnerships will spread to regional levels, with local parent groups
partnering with local child psychiatry
and pediatric professional groups. I
also expect that universal health care
with mental health parity will come to
pass. The stigma of mental illness and
substance abuse will largely vanish.

The research imperative

Research currently drives our field,
and I expect that it will continue to do
so in the years ahead. Propelled by
NIMHs highly successful Decade of
the Brain and the subsequent delineation of the human genome, the field
of neuroscience has made major advances in our understanding of the
structure and function of the brain
and how biology interacts with the
environment to affect behavior and
mental disorders. The speed of the ad-

vances in our knowledge over the past

10 years will only increase over the
next 10. Thomas Insel, MD, the current director of NIMH, has wondered
why so few medical students choose
careers in psychiatry when so many
majored in neuroscience as undergraduates. After all, psychiatry is one
of the few medical specialties that
comprises clinical neuroscience. It is
my prediction that given some of the
workforce and stigma reduction efforts outlined above, this lack of interest in clinical neuroscience will
dissipate.
Research in genetics, genomics,
proteonomics, and neuropharmacology will continue to advance and attract the brightest MDs and PhDs to
our field. Research will lead to even
better, more specific individualized
treatments for mental disorders. Responses to treatment will be more
rapid and more sustained. Medications will have fewer adverse effects.
An increased focus on developmental
neuroscience will specifically result
in better treatments for children and
attract more people into child and
adolescent psychiatry. More researchfocused, academic training programs
for child psychiatrists, similar to
those developed at Yale and the University of Colorado, will appear.
I doubt, however, that our newfound knowledge will ever determine
that all psychiatric disorders are
uniquely genetic. We will become
more knowledgeable about how
genes are regulated at the molecular
level by environmental events and
developmental experiences. In short,
we will learn much more about behavioral genetics and about the multi-dimensional context of behavior. In
10 years, I predict that child and adolescent psychiatrists will practice a
much more sophisticated version of
evidence-based developmental psychiatry with more individually relevant evidence to inform our clinical
decisions.
But there are also dangers ahead.
The budgetary constraints that are affecting our economy in general and
our research enterprise in particular
are significantly curtailing our research productivity. The politicization
of research priorities and federal prohibitions on some kinds of research
potentially add to the loss of the US
research enterprises competitive
edge. Globalization of research has
intensified competition and may result in a reverse brain drain. These political, economic, and regulatory pressures have impacted the morale of
scientists and altered the publics perception of our research enterprise. At
least in the press and in the halls of
Congress, there appears to be a pro-

gressive loss of confidence in our

work.12,13 These perceptions have often, although not exclusively, been
particularly directed at general and
child and adolescent psychiatry.
Despite these concerns, I anticipate that the current economic and
political pressures will lessen and that
our research results will lead to even
better understanding of basic mechanisms of brain function and behavior
and to ever better treatments for mental disorders. I am optimistic that our
economy will strengthen and that our
nations commitment to innovation
through research will again flourish.
I further predict that the publics trust
in medicine in general and psychiatry
in particular will be restored after a
period of reflection and soul searching by our professional groups as we
resolve serious concerns related to
ethics and influence. In 10 years, the
psychiatry research enterprise (basic
and clinical neuroscience) will be
more vigorous than it is today, and a
developmental focus will dominate
the research agenda and involve more
child and adolescent psychiatrists.

Ethics, influence, and

public perception
There are forces afoot that are undermining our credibility with the public
and our relationships with our patients and their families. They have
come at us from several sides. On one
hand, antipsychiatry groups question
our scientific integrity and portray us
as greedy practitioners who lack a research base for our clinical decisions.
They suggest that psychiatric disorders, for the most part, are a figment
of our imagination and that child and
adolescent psychiatrists pathologize
what is within the bounds of typical
development. On the other side, extraordinarily large marketing expenditures and controversial marketing
practices by the pharmaceutical and
medical device industries influence
our clinical judgment and professional behavior.
Gifts and honoraria, large and
small; biased Continuing Medical
Education (CME) activities; kickbacks; and free lunches of various
kinds have been designed to influence
and reward physicians specific decision making.14 Direct advertising to
consumers also affects prescribing
practices.15 Industry-supported clinical trials in academic medical centers,
advertising in medical journals, and
lavish exhibits at annual meetings all
have contributed to the credibility gap
with the public.16 Yet, how would
many professional and advocacy organizations fare without such direct
and indirect industry support? How
much would subscription prices for

MAY 2008

journals need to be increased without

such advertising? And how would
physicians competence and knowledge be affected without industrysupported CME programs and office
visits by sales forces? These are complicated issues that affect all the specialties of medicine and certainly
psychiatry and child and adolescent
psychiatry.
The media have investigated these
marketing practices and recently have
begun to paint a grim picture of child
and adolescent psychiatrists diagnostic inconsistencies, individual ethical lapses, and clinical prescribing
practices guided by pharmaceutical
influence.17-19 The publics perception
of our professionalism has dimmed as
a result of these media reports, as has
its belief in the integrity of our research findings.
I believe that industry influence
can and should not be eliminated. The
pharmaceutical companies have successfully contributed to the success of
our research agenda. Child and adolescent psychiatry as a field is better
off because of that support. However,
it is a good sign that at all levels, academic institutions, professional organizations, and individuals have begun
to openly discuss the issues. Verbal
and written dialogue among members
of the AACAP and between industry
leaders and the AACAP about acceptable ethical practices mirrors the
discussions within other professional and academic groups. Similarly,
the recent dialogue begun between
the Journal of Child and Adolescent
Psychopharmacology and its readership is laudable.20 A similar effort has
been mounted in the AACAPs newsletter. These efforts will guide us in
our efforts to manage conflict. We
will never be able to eliminate conflict, but we need to become more capable of managing it. I predict that 10
years from now, the management of
influence and conflict will be significantly improved, resulting in significantly greater transparency through
more pertinent and meaningful disclosure. The relationships among
industry, practitioners, professional
organizations, and academic centers
will become more transparent and
trusted, and the publics confidence in
our skills, knowledge, and professionalism will be restored.

Conclusions
So how will the professional lives of
child and adolescent psychiatrists
change over the next 10 years? I expect that our practices will be largely
unrecognizable in terms of current
practice patterns. As specialists, we
will be much more knowledgeable
about brain and behavior mechanisms

FUTURE OF PSYCHIATRY
at both cellular and systems levels,
and our treatments will be much more
individually specific and effective.
However, our numbers will continue
to be inadequate, and direct care will
be provided by a variety of professionals who will work collaboratively with us. Our roles will be as educators, consultants, and leaders of
teams. Parent partnerships with professionals around advocacy and collaborative treatment will prevail as
will strategies focused on prevention
and early intervention. Parity and universal health insurance will reduce
stigma and improve access. Finally, I
am confident that the publics trust in
our competence and professionalism
will be restored. As a result, in 2018,
children with mental disorders and
their families will receive much better treatment than they do today.
Dr Anders is distinguished professor of psychiatry and behavioral sciences, M.I.N.D.
Institute, University of California, Davis, and
immediate past president, American Academy
of Child & Adolescent Psychiatry. He reports
that he has no conflicts of interest concerning
the subject matter of this article.
References
1. US Dept of Health and Human Services. Report
of the surgeon generals conference on childrens
mental health: a national action agenda. http://www.
surgeongeneral.gov/topics/cmh/childreport.htm.
Published September 2000.Accessed April 10, 2008.
2. Thomas CR, Holzer CE III. The continuing shortage
of child and adolescent psychiatrists. J Am Acad Child
Adolesc Psychiatry. 2006;45:1023-1031.
3. Garland AF, Hough RL, McCabe KM, et al. Prevalence of psychiatric disorders in youths across five
sectors of care. J Am Acad Child Adolesc Psychiatry.
2001;40:409-418.
4. US Department of Health and Human Services.
Mental Health: A Report of the Surgeon General.
Rockville, MD: US Dept of Health and Human Services;
1999.
5. US Department of Health and Human Services.
Mental Health:The Surgeon Generals Call to Action to
Prevent Suicide. Rockville, MD: US Dept of Health and
Human Services; 1999.
6. US Department of Health and Human Services.
Mental Health:A Report of the Surgeon Generals Conference on Childrens Mental Health:A National Action
Agenda. Rockville, MD: US Dept of Health and Human
Services; 2000.
7. US Department of Health and Human Services.
Mental Health:Youth Violence:A Report of the Surgeon
General. Rockville, MD: US Dept of Health and Human
Services; 2001.
8. Council on Graduate Medical Education. Fourteenth
Report: COGME Physician Workforce Policies: Recent
Developments and Remaining Challenges in Meeting
National Goals. Rockville, MD: US Dept of Health and
Human Services; 1999.
9. Institute of Medicine. Research Training in Psychiatry Training: Strategies for Reform. Washington, DC:
Institute of Medicine; 2003.
10. Kim WJ, Enzer N, Bechtold D, et al. Meeting the
Mental Health Needs of Children and Adolescents:
Addressing the Problems of Access to Care. Report of
the Task Force on Workforce Needs. Washington, DC:
American Academy of Child and Adolescent Psychiatry; 2001.
11. Brazelton, TB. Touchpoints: Your Childs Emotional and Behavioral Development. Cambridge, MA: Da
Capo Press; 1992.
12. Shuchman M. Commercialing clinical trials
risks and benefits of the CRO boom. N Engl J Med.
2007;357:1365-1368.
13. Roberts E.A rush to medicate young minds. Washington Post. October 8, 2006:B07.
14. Brennan TA, Rothman DJ, Blank L, et al. Health
industry practices that create conflicts of interest: a
policy proposal for academic medical centers. JAMA.
2006;295:429-433.
15. Donohue JM, Cevasco M, Rosenthal MB.A decade

of direct-to-consumer advertising of prescription

drugs. N Engl J Med. 2007;357:673-681.
16. Korn D, Ehringhaus S. Principles for strengthening the integrity of clinical research. PLoS Clin Trials.
2006;1:e1.
17. Healy M. Sold on drugs, building the market. Los
Angeles Times. August 6, 2007.
18. Carey B. Whats wrong with a child? Psychiatrists

PSYCHIATRIC TIMES

13

www.psychiatrictimes.com
often disagree.New York Times. November 11,2006:A1.
19. Harris G, Carey B, Roberts J. Psychiatrists, children and drug industrys role. New York Times. May
10, 2007: A1.
20. Anders TF.The pharmaceutical industry, academic medicine, and the FDA. J Child Adolesc Psychopharmacol. 2007;17:727-730.

Book Review
The Loss of Sadness:
How Psychiatry
Transformed Normal
Sorrow Into
Depressive Disorder
by Allan V. Horwitz
and Jerome C. Wakefield; New
York: Oxford University Press, 2007
312 pages $29.95 (hardcover)

Reviewed by Randolph M. Nesse, MD

When historians try to understand
why psychiatric diagnosis abandoned validity for the sake of reliability in the years surrounding the
millennium, they will rely on The
Loss of Sadness: How Psychiatry
Transformed Normal Sorrow Into
Depressive Disorder. In measured
tones and exacting prose, Horwitz
and Wakefield deliver not only a
devastating critique of the DSM diagnostic criteria for depression but
also a thoughtful and authoritative
assessment of how they came to exist and persist.
Their main point is simple. For
thousands of years physicians relied
on the presence or absence of an adequate cause to distinguish ordinary
sadness from abnormal depression.
Starting with DSM-III, however,
consideration of causes was abandoned. Instead, any combination of
a sufficient number, intensity, and
duration of symptoms now suffices
to diagnose major depression. There
is one telling exceptionsymptoms
that occur within 2 months of bereavement. Horwitz and Wakefield
ask: What about those whose symptoms are precipitated by divorce or
loss of a job? Do they all have mental disorders? Of course not.
The authorsanalysis derives from
Wakefields definition of mental disorders as harmful dysfunctions
arising from abnormalities in the
evolved mechanisms that regulate
emotions and behavior. Emotions,
including negative emotions such as
anxiety and sadness, exist only because they gave a selective advantage
in certain situations. Normal and abnormal emotions can be distinguished only by determining if the
person is in one of those situations.
Loss is certainly the crucial situ-

ation that elicits sadness, but is depression just excessive sadness as

the authors report? Many now believe that sadness and normal depression symptoms are aroused by
different situations: respectively, a
specific loss versus continuing pursuit of an unreachable goal. Horwitz
and Wakefield review this research,
but they do not pursue the implications, perhaps because the task of
deciding what is and what is not normal is already problematic enough.
The authors also imply that drug
treatment is appropriate mainly for
persons with disorders. However,
general physicians routinely use
medications to block the suffering
associated with normal protective
responses, such as pain and cough.
A genuinely medical model for psychiatry would try to find and correct whatever is arousing anxiety,
depression, or other defensive responses. If the cause cannot be
found or corrected, then treatment
to block the defense and relieve suffering is entirely appropriate. However, general physicians know the
purpose of pain and cough. Psychiatrists lack comparable knowledge
about when low mood is useful.
This is the missing foundation on
which scientific diagnostic criteria
for depression will eventually be
constructed.
For now, Horwitz and Wakefields suggestion is sensible; the diagnosis of major depression should
be excluded if symptoms result
from major life events. If this book
cannot change the DSM criteria for
depression, nothing will. The authors emphasize how many interests
converge to block major corrections
in DSM. That seems right. But I will
wager that future historians will give
equal weight to current psychiatrys
imitation of the reductionist methods that have worked so well in the
rest of medicine, even though what
we lack is a functional understanding of emotions comparable to the
functional framework physiology
offers for the rest of medicine.
Dr Nesse is professor of psychiatry and
psychology; research professor at the Research Center for Group Dynamics; and director of the Evolution and Human Adaptation program at the University of Michigan,
Ann Arbor.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.