Mounting Opposition to DSM 5

[David Baxter PhD]

NIMH vs DSM 5
by Allen J. Frances, M.D.
May 10, 2013

No one wins, patients lose

The flat out rejection of DSM 5 by National Institute of Mental Health is a sad moment for mental health and an unsafe one for our patients. The APA and NIMH are both letting us down, failing to be safe custodians for the mental health needs of our country.

DSM 5 certainly deserves rejecting. It offers a reckless hodgepodge of new diagnoses that will misidentify normals and subject them to unnecessary treatment and stigma.

The NIMH director may have hammered the nail in the DSM 5 coffin when he so harshly criticized its lack of validity.

But the NIMH statement went very far overboard with its implied promise that it would soon find a better way of sorting, understanding, and treating mental disorders. The media and internet are now alive with celebrations of this NiMH 'kill shot'. There are chortlings that DSM 5 is dead on arrival and will perhaps take psychiatry down along with it.

This is misleading and dangerous stuff that is bad for the patients both institutions are meant to serve.

NIMH has gone wrong now in the very same way that DSM 5 has gone wrong in the past- making impossible to keep promises. The new NIMH research agenda is necessary and highly desirable- it makes sense to target simpler symptoms rather than complex DSM syndromes, especially since so far we have come up empty. And the new plan will further, and be furthered, by the big, new Obama investment in brain research. But the likely payoff is being wildly oversold. There is no easy solution to what is in fact an almost impossibly complex research problem.

Isaac Newton said it best almost 250 years ago; 'I can calculate the motions of the heavens, but not the madness of men." Figuring out how the universe works is simple stuff compared to figuring out what causes schizophrenia. The ineffable complexity of brain functioning has defeated past DSM hopes and will frustrate even the best NIMH efforts.

Progress in understanding mental disorders will necessarily be slow, retail, and painstaking- with no grand slam home runs, just occasional singles, no walks, and lots of strikeouts. No sweeping explanations- no Newtons, or Darwins, or Einsteins.

Experience teaches that there is very little low hanging fruit when you try to translate the results of exciting basic science into meaningful clinical advances. This is true in all of medicine, not just psychiatry. We have been fighting the war on cancer for forty years and are still losing most of the battles.

If it has been so hard to figure out how simple breast tissue goes awry to become cancerous, imagine how many orders of magnitude more difficult will it be to eventually understand the hundreds or thousands of ways neurons can misconnect to cause what we now call schizophrenia.

We have learned many remarkable things about how our bodies work. But it is much easier to understand normal functioning than to figure out all the ways it can become abnormal.The NIMH effort may (or may not) be the wave of the future, but most certainly, it can have no impact whatever on the present.

Meanwhile, APA and NIMH are both ignoring the very real crisis of mental health misallocation in this country. While devoting far too many resources to over-treating 'the worried well,' we have badly shortchanged the severely ill who desperately need and very much benefit from our help. Only one third of severely depressed patients get any care and we have one million psychiatric patients languishing in prisons because they had insufficient access to care and housing in the community. As President Obama put it, it is now easier for the mentally ill to buy a gun than to get an outpatient appointment- tragic on both counts.

APA and NIMH are both on the sidelines, doing nothing to help restore humane and effective care for those who most need it. DSM 5 introduces frivolous new diagnosis that will distract attention and resources from the real psychiatric problems currently being neglected. NIMH has turned itself almost exclusively into a high power brain research institute that feels almost no responsibility for how patients are treated or mistreated in the here and now.

We are spending fortunes on unnecessary drugs for the worried well while slashing budgets for the care of the really sick. A meta-analytic comparison of treatment effectiveness across medical specialties showed that psychiatry was well above average. But we have to provide the treatment to those who really need and can benefit from it.

With all its well recognized limitations, well done psychiatric diagnosis remains essential to effective psychiatric care. Diagnosis is reliable enough when it is targeted to real psychiatric disorders, is done by well trained clinicians, and is not provided prematurely to provide a code for insurance reimbursement.

The single biggest cause of diagnostic inflation and unnecessary treatment is that eighty-percent of prescriptions for psychiatric drugs are written by primary care doctors who have insufficient training and too little time in their seven minute visits to be accurate- and when both doctor and patient are unduly influenced by saturation drug marketing.

So what is a patient or potential patient or parent to make of the confusing struggle between NIMH and DSM5 debacle?

My advice is to ignore it. Don't lose faith in psychiatry, but don't accept psychiatric diagnosis or treatment on faith- particularly if it is given after a brief visit with someone who barely knows you. Be informed. Ask lots of questions. Expect reasonable answers. If you don't get them, seek second, third, even fourth opinions until you do.

A psychiatric diagnosis is a milestone in a person's life. Done well, an accurate diagnosis is the beginning of increased self understanding and a launch to effective treatment and a better future. Done poorly it can be a lingering disaster. Getting it right deserves the kind of care and patience exercised in choosing a spouse or a house.

Remember that psychiatry is neither all good or all bad. Like most of medicine, it all depends on how well it is done.

More information:

The NIMH Withdraws Support for DSM-5

Does NIMH Want to "Fail Better" than the DSM-5 Already Has?

Spitzer/Frances Letter To APA Trustees

 

[H011yHawkJ311yBean]

Wow, shows what I know. I didn't even know that the National Institute for Mental Health could reject the DSM...

It seems more of a good thing than bad, doesn't it? I mean with everyone kicking up such a fuss about the changes for this most recent version of the DSM, you'd think it would be a good thing they're re-evaluating...

Or would the APA argue that NIMH is beneath them, and does NIMH kind of feel the APA are a bunch of loony mucky-mucks? That's almost the feeling I get from all of this. Am I way off on this?

 

[David Baxter PhD]

Well, anyone can reject the DSM or any other classification system, I guess, but the reality is that if the rest of the world is using it for communicating about patients it won't go away any time soon.

Basically, the NIMH director is talking about his personal unhappiness with the DSM and proposing to fund mental health research based not on diagnoses but on something else - issues? symptoms? That's not entirely clear to me.

But it is in the end about semantics and the reality that at this point in time our understanding of mental disorders and mental health conditions is still imprecise.

If I give a diagnosis of Major Depressive Disorder, or Panic Disorder with Agoraphobia, or Bipolar Disorder, or Schizophrenia with the appropriate DMS-IV-TR codes (currently, soon to be DSM5 I guess) or ICD-10 codes, it conveys a lot of information to the recipient about the symptoms, the severity and chronicity of those symptoms, the nature of the illness, the degree of probably impairment or disability, and the types of medications and psychotherapy that are likely to be appropriate for that individual. That's what it's about. And whatever system one uses, it need not have 100% agreement on criteria or 100% interrater reliability; it just needs enough agreement and reliability to convey the information we wish to convey from one mental health professional to another, or to insurance companies, etc.

There are things I didn't/don't like about DMS-III, DSM-IIIR, DSM-IV, and DSM-IV-TR, and I'm sure there will be some things I don't like about whatever the final version of DSM5 will turn out to be. That doesn't mean I'm not going to use it. I will hope for improvement in certain ways in DSM6 and future versions but all of this is really a reflection of the evolution of our understanding of the nature and characteristics and treatment of mental disorders.

To be frank, I think the NIMH director is grandstanding.

 

[H011yHawkJ311yBean]

Ah, thanks for that perspective!

 

[David Baxter PhD]

Use DSM-5 'Cautiously, If at All,' DSM-IV Chair Advises

Use DSM-5 'Cautiously, If at All,' DSM-IV Chair Advises
by Pam Harrison, Medscape
May 17, 2013

On the eve of the official launch of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Allen Frances, MD, chair of the DSM-IV Task Force and one of the new manual's staunchest critics, is advising physicians to use the DSM-5 "cautiously, if at all."

"Psychiatric diagnosis is facing a renewed crisis of confidence caused by diagnostic inflation," Dr. Frances, Duke University, Durham, North Carolina, writes in a new commentary published online May 17 in the Annals of Internal Medicine.

Unlike the DSM-IV, which held the line against diagnostic inflation, he states, "The DSM-5, the recently published fifth edition of the diagnostic manual, ignored this risk and introduced several high-prevalence diagnoses at the fuzzy boundary with normality."

For example, the DSM-5 opens the door for patients worried about having a medical illness to be diagnosed with Somatic Symptom Disorder. Normal grief may be misdiagnosed as Major Depressive Disorder. And the forgetfulness of old age may now be interpreted as Mild Neurocognitive Disorder.

"The already overused diagnosis of attention-deficit disorder will be even easier to apply to adults thanks to criteria that have been loosened further," Dr. Frances adds.

Other changes in the DSM-5 will allow clinicians to label a child with temper tantrums as having Disruptive Mood Dysregulation Disorder, and overeating can now be called Binge Eating Disorder.

Real Danger
The real danger in diagnostic inflation is over-diagnosis and over-treatment of patients who are essentially well, he says.

"Drug companies take marketing advantage of the loose DSM definitions by promoting the misleading idea that everyday life problems are actually undiagnosed psychiatric illness caused by a chemical imbalance and requiring a solution in pill form," Dr. Frances writes. "New psychiatric diagnoses are now potentially more dangerous than new psychiatric drugs."

Quite apart from the risk for over-treatment, however, is the risk of neglecting patients with clear psychiatric illness whose access to care has been sharply reduced by slashed state mental health budgets.

As Dr. Frances points out, only one third of persons with severe depression receive mental health care, and a large percentage of the swollen prison population in the United States is made up of true psychiatric patients who have no other place to go.

More damning, however, is the flawed process by which committee members of the DSM-5 arrived at their expanded diagnoses, in Dr. Frances' view. As he states, the DSM-5 did not address professional, public, and press charges that its changes lacked sufficient scientific support and defied clinical common sense. Field trials produced reliability results that did not meet historical standards, and deadlines were consistently missed, he adds.

The American Psychiatric Association also refused a petition from an independent scientific review of the DSM-5 that was endorsed by more than 50 mental health associations.

Dr. Frances, who participated in the preparation of the DSM-5, personally found the process "secretive, closed, and disorganized," he writes. "I believe that the American Psychiatric Association (APA)'s financial conflict of interest, generated by DSM publishing profits needed to fill its budget deficit, led to premature publication of an incompletely tested and poorly edited product," Dr. Frances states. "The problems associated with the DSM-5 prove that the APA should no longer hold a monopoly on psychiatric diagnosis.... The codes needed for reimbursement are available for free on the internet."

The APA declined to comment.

Dr. Frances declares having received money for 2 books critical of DSM-5 (Saving Normal [William Morrow] and Essentials of Psychiatric Diagnosis [Guilford Press]). He has disclosed no other relevant financial relationships.

Ann Intern Med. Published online May 17, 2013. Full article

 

[David Baxter PhD]

DSM5 as a Guide, not a Bible

The DSM5 as a Guide, not a Bible
By RICHARD A. FRIEDMAN, M.D., New York Times
May 20, 2013

The Book Stops Here

There won?t be many book parties when the latest version of the American Psychiatric Association?s official manual of mental disorders, known as the D.S.M.-5, rolls off the presses this week. Instead, the long-awaited guide has touched off a heated debate among psychiatrists about its scientific value and clinical usefulness.

In an interview with The New York Times, for example, Dr. Thomas R. Insel, director of the National Institutes of Mental Health, harshly criticized the new manual for defining mental disorders based on symptoms rather than underlying biological causes; in response, Dr. David Kupfer, the chairman of the task force that revised the D.S.M. and a professor of psychiatry at the University of Pittsburgh, said the new manual did the best it could with the scientific evidence available and added that any shortage of such evidence was ?a failure of our neuroscience and biology.?

What are the public and those who work in medicine to make of this high-level kerfuffle?

Well, Dr. Insel?s call for understanding the neurobiology of psychiatric disorders is laudable but curiously lacking in historical perspective. Scientists have been searching for decades for the neural basis of mental disorders ? the holy grail of psychiatry ? but the goal has proved frustratingly elusive.

Indeed, the official ?Decade of the Brain,? so designated by Congress and the first President Bush, ended 13 years ago. And while that decade (and the decade after that) did yield important findings in basic neuroscience, I am hard pressed to think of a single truly novel and effective biological therapy for any psychiatric disorder that has come of it.

Even with molecular biology and the most sophisticated brain imaging, such knowledge is probably years away. Effective new therapeutics based on that knowledge may take still more years to develop. And even a definitive understanding of neurobiology would not necessarily shed light on the interactions between genetics and environment that lead to many mental disorders.

In the meantime, the millions of Americans with mental illness need treatment now. They and their psychiatrists don?t have the luxury of waiting for definitive scientific knowledge.

Fortunately, we don?t need a complete understanding of the neurobiology of mental illness to treat it. Medicine has always been practiced amid uncertainty.

In his interview with The Times, Dr. Insel said that ?as long as the research community takes the D.S.M. to be a bible, we?ll never make progress.? But most of my colleagues laugh at the notion that the manual is a ?bible.?

We know it doesn?t really describe diseases in the way that pneumococcal pneumonia, for instance, is a disease. Instead, it is a practical way of describing psychiatric syndromes, clusters of symptoms that patients experience and that often predict a course of illness and responses to various treatments.

For example, people who are persistently sad, hopeless and suicidal, and who have trouble eating and sleeping, generally respond well to various antidepressants and different types of psychotherapy. Yet even though they present identical symptoms, these patients almost certainly suffer from a biologically heterogeneous group of disorders; we know that because, among other things, some of them respond to an antidepressant that enhances serotonin while others require a drug that increases dopamine.

Dr. Insel wants researchers to move away from studying syndromes based on symptoms to ?research domain criteria,? which are new ways of classifying mental disorders based on neurobiological measures and dimensions of behavior, like a tendency toward anxiety or disorganized thinking.

Whether this will be a more promising path of exploration is still an open question. For example, studying people who share a particular trait like anxiety or emotional instability may well give us insight into the neural circuitry of emotional regulation, yet tell us nothing useful about the circuitry of depression.

None of this is to say that the D.S.M.-5 is ideal. Far from it. Many psychiatrists, myself included, wonder whether we really need a new D.S.M. in the first place. There is little groundbreaking science that would redefine our diagnostic categories, and some of the changes appear to risk pathologizing everyday human misery.

The old D.S.M.-4, for instance, clearly distinguished normal and expected grief after loss from the more severe and persistent symptoms of clinical depression. The new one encourages clinicians to diagnose major depression in grieving patients after just two weeks of mild depressive symptoms ? a boon to the pharmaceutical industry, which will no doubt sell more antidepressants and antipsychotics, but of dubious benefit to healthy people suddenly labeled with a psychiatric diagnosis.

Or consider the new diagnosis of ?disruptive mood dysregulation disorder? for 6- to 18-year-olds who have ?severe recurrent temper outbursts manifested verbally and/or behaviorally.? This would fit a very large number of cranky adolescents, who are famous for emotional extremes and outlandish behavior.

Still, with all its limitations, the D.S.M. at least gives clinicians a common language to describe and treat mental disorders. Until the underlying biology of those disorders can at last be unlocked, that is about the best we can expect.

Dr. Richard A. Friedman is a professor of clinical psychiatry at Weill Cornell Medical College.