Saturday, May 11, 2013

Another County Heard From: NIMH Boss Takes Aim at DSM-5

I have been becoming a bore in this blog in my ongoing criticisms of DSM-5, the new "bible" of psychiatric diagnosis, most recently in the post immediately preceding this one. So now, here's apparent help from another quarter, as nicely reported by Pam Belluck and Bernedict Carey in the NY Times:

(Sorry if the link above does not work; if so you may have to manually type in the "&" at the end)

The rest of this post is a further development of the word "apparent" in the above comment.

Dr. Thomas Insel, the controversial figure we've met before:
--advises his colleagues in psychiatric research to ignore the DSM-5 categories and work harder to discover the biological basis for mental disease. He's quoted: “As long as the research community takes the D.S.M. to be a bible, we’ll never make progress ... People think that everything has to match D.S.M. criteria, but you know what? Biology never read that book.”

Such an observation from arguably the top person in psychiatric research in the US is very important in bursting one bubble of the DSM-5. When DSM undergoes one of its periodic major revisions, in this case the first since 1994, one hopes that the impetus for this is a significant change in the basic science of mental disorders, so that we can better bring clinical practice into line with the new science. Critics of DSM-5 have charged among other things that we don't really have the scientific advances to justify a brand new edition in the first place, and accordingly, the new DSM-5 cannot claim to be based on science to the extent that its advocates claim. As Belluck and Carey nicely summarize, most of the important brain science since 1994 has gone to remind us of how much we don't yet know--and hence, the (apparent) justification of President Obama's recent call for mapping the human brain as the next huge scientific frontier after the human genome (the genome thus far having proved largely a psychiatric bust).

But at the same time that Dr. Insel bursts one DSM bubble, he reinforces the use of DSM that has most worried critics like me: "Dr. Insel said in the interview that his motivation was not to disparage the D.S.M. as a clinical tool..." Well, sorry, disparaging the DSM-5 as a clinical tool is highly appropriate when, based on bad or incomplete science, the American Psychiatyric Association assembled panels of "experts" riddled with industry conflicts of interest, and allowed them to construct psychiatric diagnoses that will end up labeling millions more people as mentally ill and appropriate for drug therapy. 

Now whether Dr. Insel is right in calling for the program of psychiatric research that he favors is another question entirely, and goes well beyond my competence. I will simply note as an interested observer (and philosopher of medicine by training) that psychiatry seems to tack back and forth over the decades between biological psychiatry, that all mental illness results from measureable chemical lesions in the brain, and a more holistic psychiatry that takes things like early life experiences and other environmental factors more into account. Dr. Insel, if I understand, seems to be calling for a deeper turn toward the biological. An appropriate model would in any case include the biological component; the only querstion is whether research into links between biology and environment will be pursued adequately, or whether only biologically-restricted studies will be funded by NIMH. But as I say this is above my pay grade--I hope some real experts will comment.

So Dr. Insel is no doubt right in saying that future psychiatric research should not be guided by DSM-5. He's dead wrong in saying that DSM-5 works as a clinical practice "bible." He may or may not be right in what sort of improved psychiatric research program he's calling for.


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Dear Dr. Brody:

I am a huge fan of this blog and a skeptic of many things in medicine and psychiatry -- and I am also a psychiatry resident. And I assure you that the DSM is both worthy of criticism and also an incredibly useful guide to diagnosis when used skillfully and humanely.

The key assumption that you're making, and that nearly everyone makes, is that a diagnosis equals an indication for medications. Surely this is the epistemology that the drug companies themselves would promote. But it's far from true. And we've got great studies to show that things like psychoeducation -- simply sitting down to explain syndromes to patients and their families -- can in certain diseases be more efficacious than any pharmacology. Or in PTSD: sure there are classes of medications that are useful, but cognitive processing therapy (and other related psychotherapies) are much more effective.

Another poor assumption is that a diagnosis that *might* be applied to a surprisingly large population should and will be. Again, psychiatry is different than other fields in that we only make certain diagnoses when they come to clinical attention, as if that says something about their severity. This might dissatisfy those of us who want a clear sense of what is pathological and what is not. But for those of us who want to intervene and support people in crisis, it makes perfect sense. For example, I have been taught by some of the smartest psychiatrists to make use of the V-codes. They're not discrete medico-psychiatric syndromes; they say things like "Educational problem" or "Partner relational problem." But often they say so much more about the person and their struggles. When I put down that diagnosis I am not saying that *everyone* with a partner relational problem is sick; I am not saying that there's some profitable treatment for it; I am just trying to understand and describe a person's crisis so as to focus on their recovery. Many of us are also keenly aware of the way that people use their illnesses to keep from getting better, and have many lines of thinking about these identities and conflicts that could help such folks where no other branch of medicine can even come close.

My field is definitely full of conflicts of interest and problematic politics. And DSM5 may not be all that modern (the definition for major depression is a half-century old!). And many people practice psychiatry horribly, just like many practice primary care or GI surgery so. But there's a lot there that is useful and humane when the practice itself is.