Fads in Psychiatry

Dr Edward Shorter' argues that part of the reason for the numerous fads that characterize psychiatry is the way our subject changes its paradigms, and wipes the slate clean each time it does so. The examples he gives are the asylum era, followed by the psychoanalytic era, ending in the era of psychopharmacology, neuroscience, and genetics. He points out that the shattered ruins of psychiatry's past the fads and fashions of today are built.'- p 558 He defines a fad as a bad idea with a short half-life, while a bad idea with a long half-life is a failed concept.In other medical specialties, a fad may be blown away by new evidence, but, in psychiatry, we tend to eliminate fads-when we do so by consensus-rather than by data. Dr Shorter writes that Psychiatry must be cautious about discarding, as fads, concepts that are in fact useful and worthy of pursuit. '*p 558 The Oedipus complex of psychoanalysis and the schizophrenogenic mother of social psychiatry may have been preposterous nonsense, but maternal attachment2-1 and the harm done by maternal deprivation4 and sexual and physical abuse5 were not. There are babies in the bathwater.Dr Joel Paris6 argues that fads are picked upfrom social groups, and shared concepts promote social bonding. In medicine, practitioners often follow what they hear from colleagues, from lectures, and from journals. Fads can spread rapidly when they fit needs for easy answers about diagnosis and treatment-and when supported by experts.6-p 561Both Dr Shorter' and Dr Paris6 give many examples of Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses that they considered faddish, and broaden their arguments to include referring to selective serotonin reuptake inhibitors (SSRIs) as antidepressants (ADs), and other fads brought about by Big Pharma in the naming of classes of drugs, and even to the endless proliferation of psychotherapies claiming to work by different methods. Thus the range and variety of fads is endless.One never knows how long what initially seems to be a fad may, in the long term, be a revolutionary advance; when it was first mooted, the World Wide Web was viewed with suspicion. How short does a half-life need to be? If calling SSRIs ADs is indeed a fad, it has been with us for over 30 years now. My main problem with fads is that many neither have short half-lives nor are they failed concepts: they are strongly held opinions without good supporting evidence. Prominent among these is the idea of comorbidity, based on the idea that the different disorders in the International Classification of Diseases or the DSM are independent disease entities. Alvan R Feinstein7 coined the idea of comorbidity to refer to those cases in which a distinct additional clinical entityp45

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