Tuesday, July 7, 2009

More on Psychiatry's DSM-V Mess

Updating my previous post (http://brodyhooked.blogspot.com/2009/06/will-psychiatrys-dsm-v-be-huge-growth.html) I turn once again to Danny Carlat:


--who tells us about more fallout from the DSM-V drafting and research process. The most important exhibit is a letter to the American Psychiatric Association (APA) Board of Trustees by Drs. Robert Spitzer and Allen Frances. Both were heavily involved in the earlier iterations of DSM (particularly III and IV). They make no bones about their concerns that the DSM-V process has gone totally off the track and that the APA must now take drastic action to regain control and rein in the excesses.

In their letter (http://www.scribd.com/doc/17172432/Letter-to-APA-Board-of-Trustees-July-7-2009-From-Allen-Frances-and-Robert-Spitzer), Drs. Spitzer and Frances make these points:
  • "...the rigid fortress mentality that has prevented the DSM-V process from learning and adapting. The DSM-V leadership has lost contact with the field by restricting the necessary free communication of its workgroups and by sealing itself off from advice and criticism."
  • "The suggested subthreshold and premorbid diagnoses.... If these were to become official categories in DSM-V ... could add tens of millions of newly diagnosed "patients"- the majority of whom would likely be false positives subjected to the needless side effects and expense of treatment. The APA might well be accused of a conflict of interest in fashioning DSM-V to create new patients for psychiatrists and new customers for the pharmaceutical companies. Certainly, the DSM-V Task Force does not have these motives but, in its effort to increase diagnostic sensitivity, it has been insensitive to the great risks of false positives, of medicalizing normality, and of trivializing the whole concept of psychiatric diagnosis."
  • "Keeping rigidly to a fixed publication date even at the risk of producing an inferior and problematic product might suggest that publishing profits are given undue weight in DSM-V considerations."
  • "You must understand that the APA has never held a guarantee on the DSM franchise. There have been serious objections in the past that it is inappropriate for one professional "guild" to control a document with such wide usage and great public health importance. The privilege to prepare the DSMs has been extended only because of the credibility of previous DSMs and it depends upon the continuing trust in the openness and disinterestedness of the process. You need to weigh the risk that the constant airing of DSM-V mistakes may result in this issue being reopened."
  • "The closed and secretive DSM-V process is insulting to the other mental health professions whose acceptance and support is crucial to its legitimacy. All mental health disciplines should be openly invited to participate in troubleshooting DSM-V options."

These comments reinforce the concern I raised in my previous post--that the APA has been hanging out with industry so long that it is starting to think like a for-profit corporation and no longer like a professional society. A manual such as DSM-V is supposed to be a public health and public service tool informed by the best available science. It is not supposed to be managed as a cash cow to bring profits to its publisher (the APA). But the process that is currently being followed raises the specter of the latter, not the former.

Dr. Carlat tells us that besides Drs. Frances and Spitzer, another unhappy camper at DSM-V is Dr. Jane Costello of Duke, who has resigned from the DSM-V working group on child-adolescent disorders. Her letter of resignation is also making the rounds (http://www.scribd.com/doc/17162466/Jane-Costello-Resignation-Letter-from-DSMV-Task-Force-to-Danny-Pine-March-27-2009). Some highlights:

  • "I am increasingly uncomfortable with the whole underlying principle of rewriting the entire psychiatric taxonomy at one time. I am not aware of any other branch of medicine that does anything like this. (The ICD revisions make no attempt to rewrite the details of each diagnosis.) There seems to be no good scientific justification for doing this, and certainly none for doing it in 2012."
  • "When we began this process, we agreed that changes would only be made if there were empirical evidence to support them. Sometimes ... this has been the case. But as time has gone by, the gap between what we need to know in order to make revisions and what we do know has grown wider and wider, while the time to fill these gaps is shrinking rapidly. More and more, changes seem to be made for reasons that have little basis in new scientific findings or organized clinical or epidemiological studies."
  • "One reason why it took so long to get a data base in place was that a decision was made that the work had to be done via a grant application to NIMH, with all the time delays entailed by that process. The reason given was that the funding allocated by the APA for research for DSM-V was not enough to support the necessary work. I continue to be shocked that the APA would even consider revising the DSM without being willing to allocate the funding necessary to carry out the underlying scientific studies. A drug company that tried to bring a product to market on the basis of inadequately-funded research would rightly be censured. This is what the APA is doing, and now that it is quite clear what is happening I am afraid that I cannot bring myself to be part of the process any longer."

We hear from numerous experts in psychiatry that nothing has happened to the basic science of mental illness since DSM-IV to justify a top-to-bottom revision of diagnostic taxonomy. If the goal was to produce an evidence-based document, such a plan would be weird to the extreme. If the goal were to assure maximum sales of the resulting book, it sounds like a good marketing ploy. An even better marketing ploy is to be sure that APA collects all the profits from book sales, while charging all the expenses of gathering the needed scientific data to NIMH!

Finally, we need to make mention of another blogger, Dr. Doug Bremner, whose ongoing criticisms of the pharmaceutical industry and of the DSM-V process in particular seems to have landed him in hot water. He explains (http://www.beforeyoutakethatpill.com/index.php/2009/07/07/in-praise-of-intellectualism-or-notes-from-the-corpademy/ as well as in previous posts) that he was recently instructed by the university at which he is employed no longer to mention its name in connection with his blog, "Before You Take That Pill." (I will of course not mention the university's name, but it rhymes with Emory.) Like the rest of us, Dr. Bremner had never suggested that that university endorsed his opinions; he merely included it for purposes of identification. Anyone who has compared my blog with Dr. Bremner's knows that he and I have very different blogging styles--he's a lot more in-your-face and over-the-top, whereas I favor a stodgy, academic line. So I can see a reason why a university might feel ill at ease having its name linked with that sort of blog--assuming that a faculty member's merely saying that he works at Em--sorry, at that place-- is any sort of connection with approval or disapproval of the person's blogging style, which of course it isn't. But the real issue does not seem to be style but content. Given the past behavior of Emory, and the sorts of folks who have previously been defended by the administration there, it does seem as if the ire is raised much more by Bremner's anti-drug-industry and anti-APA stance than by the specific way he goes about expressing himself. And any such challenge to academic freedom is something that we university professors must unite in opposing. [Comment added 7/13/09: Doug posted today that Emory has seen the light and has withdrawn its indefensible demand that he not identify himself as affiliated with them.]

1 comment:

Dan said...

The Diagnostics and Statistical Manual (DSM), the Shrink's bible, has been around for over 50 years. Within this manual, there are now possibly nearly 300 mental disorders.

As a dictionary of suspected mental illnesses, many redefined diagnoses are added to this manual with each edition, and how such disorders are classified and assessed.

On occasion, a mental disorder is deleted from the DSM, such as homosexuality in the early 1970s. Its purpose, this manual, is to assist mental health professionals to diagnose and classify mental disorders. How a group sponsored by for profit pharmaceutical industry corporations that promote psychotropic drugs for various mental issues that may or may not fully exist make the determinations that they do while maintaining objectivity is a phenomenon.

Published and designed by the American Psychiatric Association (APA), the DSM is also used, I understand, for seeking mental diagnostic criteria to assure reimbursement.

The DSM is organized by the following:

I- Mental disorders
II- mental conditions
III- Physical disorders/syndromes, medical conditions (co-morbidity)
IV- Mental disorder suspected etiology
V- Pediatric assessments

The APA has historically directed the creation of each edition of the DSM, and assigns selected task force members to create this manual. This situation has proven to be controversial.

The next DSM involves 27 people. About 80 percent of these individuals are male, and only 4 members are not medical doctors. Most have had relationships with the NIH, and about 25 percent of these task force members have had relationships with the WHO.

Historically, at least a third of task force members have had, or do, have often monetary pharmaceutical industry ties in some way.

This makes sense, as about one third of the APAs total financing is from the pharmaceutical industry.

The APA required this task force for the next DSM edition to sign non-disclosure agreements- which is rather absurd and pointless. Lack of transparency equals lack of credibility because of these agreements of the content of the next DSM. It opposes any recovery model necessary regarding such disorders, I believe.

The DSM should be evaluated by another unrelated task force or a peer review of sorts to assure objectivity. This is particularly of concern presently, as many more are diagnosed with mental dysfunctions presently at a concerning rate- with very young children in particular.

Dan Abshear