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Posted on Wednesday 7 September 2011

Is the DSM-V Necessary?
NEI Blog
by Dr. Stephen Stahl
September 06, 2011

^{We don’t need a new version of the DSM now. I am blogging today from Paris at the ECNP meeting, having attended the Royal Society of Medicine meeting outside of London last week to discuss the future of new drug development in psychiatry, paid by the taxpayers of the UK and charities, not Pharma. This meeting involved US colleagues Tom Insel, David Kupfer, and several academic experts and industry executives from the US and the UK and was covered by the BBC and a report of it aired on UK television. I will report the results of our discussions of new drug development in another blog in a few days. Having read the hailstorm of postings on our blog, I thought I would choose a topic on which many of us might agree. For now, many of us might actually agree on the value of the DSM 5 rewrite efforts – which is that it might be of little or no value…}

After his recent irrational rant [Are future psychiatric treatments doomed? Be careful what you ask for…you just might get it.], I’m finding it hard to agree with Dr. Stahl about much of anything. And in this post, he doesn’t work very hard to win me over.

^{… many of us are asking whether we need a DSM 5 at all. Those who do not believe there is any such thing as a mental illness like Scientologists and anti-psychiatrists, including people like Dr. Marcia Angell, in her recent NY Times Book Reviews, saying there is no such thing as depression in her reviews of various antipsychiatry books, will of course say no. The pharmascolds who think that Pharma is behind the invention of psychiatric disorders in order to market their drugs will also say no. However, you may be surprised how many of the mainstream scientific community would also agree that a revision of the DSM 5 may be unnecessary and certainly premature. I certainly think so.}

One of the most ubiquitous mental mechanisms available to the human mind is simplification, reducing one’s critics or enemies to one dimensional characters with a single motivational system [usually based on some selected reading], then attacking the caricature pretending it represents actual real person rather than a monotonous phantom. Dr. Stahl is so facile at simplification that it’s difficult not to react and play an-eye-for-an-eye, simplifying Dr. Stahl and his "mainstream scientific community." But I would like to comment on a few of the things he says – assuming that he is a representative of a particular GroupThink [because he is]:

^{The reality is that psychiatric disorders are not diseases at all and are not based on science or pathology, but on sociology, and politics of experts with opinions. Although those experts can no longer have any Pharma ties if they participate in the DSM revision process, they do have their pet theories to insert, and until there is a scientific basis of psychiatric conditions, based on genomics, environmental stresses, development, and brain circuits, the process will not be scientific and I am not confident that further advances can be made upon the sociology and politics of the previous DSM IV group.}

His thoughts here mirror the objections to many of my own, a panel of experts is bound to come up with a diagnostic scheme that expresses their biases and interests. No complaint there. But then he says:

^{until there is a scientific basis of psychiatric conditions, based on genomics, environmental stresses, development, and brain circuits, the process will not be scientific}

So Dr. Stahl is actually saying something bigger than, "We don’t need a new version of the DSM now." He’s saying that the current process of revision of the DSMs is intrinsically flawed. In fact, he’s saying that the DSM itself is intrinsically flawed. Thus far, we’re still sort of on the same page, Dr. Stahl and I. But alas, our chummy moment is short-lived. If you deconstruct and simplifies his sentence, you get:

^{until there is a scientific basis of the psychiatric conditions … the process will not be scientific}

This simplified version of his sentence is a meaningless tautology [a logical statement in which the conclusion is equivalent to the premise]. Reinserting:

^{based on based on genomics, environmental stresses, development, and brain circuits}

doesn’t help us much [even if he did throw in environmental stresses and development to cover the things he’s not particularly interested in]. He’s a "brain guy." Now that psychiatry has eliminated the "mind guys," the DSM is no longer of use to him except as a historical marker for the transition. His notion that we can just coast along with the DSM-IV until the bottom line sciences as defined by Dr. Stahl come up with clearly defined fundamental causes is a remarkably naive assertion – bordering on delusion.

My take on Dr. Stahl is that from his perspective, psychiatry today is exactly where he wanted it to be. Last time, in his blog [Are future psychiatric treatments doomed? Be careful what you ask for…you just might get it.], he raled against the same group he’s after today – those "who do not believe there is any such thing as a mental illness like Scientologists and anti-psychiatrists, including people like Dr. Marcia Angel … saying there is no such thing as depression" because he thinks they’ve chased the pharmaceutical companies away from mental health. This time [Is the DSM-V Necessary?], he’s saying that the DSM is superfluous and subjective, hardly worth thinking about, because it is only an exercise in opinion instead of a definitive causal classification [he sounds a lot like the psychoanalysts of thirty years ago]. While that may sound like he’s got his eye on the future, I no longer believe that line, since he’s talking about an unattainable future. Nor does he seem terribly interested in that particular future in the way he occupies his time. Here’s the future he’s spending his time on:

^{… having attended the Royal Society of Medicine meeting outside of London last week to discuss the future of new drug development in psychiatry}

So I’m afraid that I have to simplify Dr. Stahl and put him in a group of one dimensional characters with a single motivational system [in spite of my introductory protests]. There are lots of these characters. They talk biology and brain, but what they’re interested in is new biological treatments – drugs etc. They focus their attention on the future, but it’s not on the future of psychiatry as a specialty, or the fate of our patients, or even the future of neuroscience. It’s a future of constantly generated new treatments [drugs]. And the trajectory is neither directed by nor for the development of clinical psychiatry, it’s driven by pharmaceutical neuroscience as it has been for the last twenty-five years. It’s beyond telling that Dr. Stahl is joined in his meeting by "colleagues Tom Insel [head of the National Institute of Mental Health], David Kupfer [head of DSM V rewrite], and several academic experts and industry executives from the US and the UK." Unfortunately for psychiatry, the group he represents is our current empowered gentry.

They’re near the end of their road, Dr. Stahl and his group. They’ve worn out the injunction to keep our eyes of the prize that sits just over the horizon. The metaphors of chemical imbalance, treatment resistant depression, evidence-based medicine, speculative neurobiology of this-and-that, augmentation, comorbidity, etc. have lost some of their former magic. So they live in a world of disillusionment with psychopharmacology and psychiatry in general, and an empty pipeline. Dr. Stahl and his cohorts are desperate to keep us where we’ve been – in the universe of science fiction where mental illness is to be treated solely with a steady stream of new pharmaceutical agents that appear [about the time the last group goes off-patent]. Ain’t going to happen. They’re out of drugs, and the marketeering hype that kept people trying to get more from the drugs than they ever had to offer is in the back-fire stage of its history. The days of Oz are over and the Wizard’s balloon headed back to Omaha.

So now we have to pick up the pieces. The real biological psychiatrists need to get back to the business of neuroscience that has to do with inching our understanding of mental illness forward rather than pretending that research means doing endless clinical trials. Clinical Psychiatrists have to rediscover the skills that justify including the treatment of mentally ill in a separate specialty of medicine – other than simply tweaking the drugs du jour and serving as detail men to the pharmaceutical industry. And the DSM definitely needs a revision – but not the one it’s getting. It needs a revision that puts it on an iterative path towards clinical usefulness. That process starts with a thorough reassessment of the Major Depressive Disorder diagnosis and its progeny. The category has essentially been unchanged for the last twenty-five years when it was created to eliminate depressive neurosis. It has remained hopelessly vague through the rise and fall of the SSRI antidepressants, justifying their widespread over-utilization. Both reasons are anachronistic. Maybe the time is finally right to make it into something that is useful to patients, clinicians, and researchers.

And as for Dr. Stahl, his formerly revolutionary now reactionary paradigm is beyond exhausted. He and his colleagues would be best advised to give it a long needed rest. Twenty-five years ago, he "stated that the future could not be more promising." From his perspective, he was absolutely right. Now "with our collective tail between our legs, we are stating that ‘things could not be worse’." Absolutely right again…

Henk

September 8, 2011 | 3:49 AM

Just want to say how much I appreciate your blog. I discovered it a few months ago. I work as a psychiatrist in the Netherlands and recognize the things you write about all too well.
What also worries me in today’s psychiatry, besides the dominant role of psychocofarmacology you write about so well, is the growing bureaucracy: protocols, evidence based psychiatry, DSM based treatment guidelines, CBT as a panacee for almost everything etc. etc. A broad, humanistic view of psychiatric problems is almost absent. We are forced to diagnose en treat in one prescribed mode. And reality is so much more rich and complicated.
Peggi

September 8, 2011 | 1:41 PM

Dr. Marcia Angell doesn’t believe there is such a thing as depression?? Dr. Stahl does appear to have gone off the deep end.

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