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Basic Nomenclature Issues for DSM-V
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Neuroscience Research Agenda to Guide Development of a Pathophysiologically Based Classification System
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Advances in Developmental Science and DSM-V
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Personality Disorders and Relational Disorders: A Research Agenda for Addressing Crucial Gaps in DSM
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Mental Disorders and Disability: Time to Reevaluate the Relationship?
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Beyond the Funhouse Mirrors: Research Agenda on Culture and Psychiatric Diagnosis
One might think from these reports that the progression of psychiatry into the realm of brain science had been smooth, linear, on schedule. In 1980, under the direction of Robert Spitzer, the Diagnostic and Statistical Manual [DSM-III] had formally redefined psychiatry along traditional medical lines, eliminating the "mind" from consideration as speculative and focusing only on descriptive signs and symptoms. And while the rhetoric continued to claim to be non-ideological and "evidence-based," there was little doubt that we had replaced one area of speculation with another, exemplified by the NIMH initiated project introduced by George H.W. Bush’s Presidential Proclamation 6158 – the 1990s were to be The Decade of the Brain. During that decade, the Diagnostic Manual was revised again in 1994, lead by Dr. Allen Frances, and while there were a number of changes and new categories, it was essentially continuous with the DSM-III in spirit and direction. So it seems natural for Drs. Kupfer and Regier to open the 2000s with a roadmap for the next DSM revision in 2013, and to escalate attention on its coming as the decade drew to a close.
Unless you’ve been in deep coma or trapped on a remote desert isle, there are a few pieces of this story missing from the above narrative. The notion that psychiatry has organized itself around evidence-based, descriptive clinical findings without ideological bias can only be considered a quaint mythology. Psychiatry has become, as Dr. Insel wished, Clinical Neuroscience – meaning that most psychiatrists spend their days prescribing medications. Our literature has become dominated by Journals of Clinical Neuroscience, if that means filled with clinical trials and studies about the effects of the pharmaceutical agents. Our academic institutions and training programs are now lead by Clinical Neuroscientists. And the intimate marriage between psychiatry and the pharmaceutical industry is readily apparent in the conflict of interest declarations in most journal articles. So maybe a better name for the new psychiatry would be Clinical Pharmaceutics.
Something else missing from Drs. Kupfer’s and Regier’s brackets around the last decade is that Drs. Robert Spitzer and Allen Frances, the leaders of the DSM-III and DSM-IV revisions of the Diagnostic Manual, have been increasingly up in arms about what’s been happening with the DSM-5 revision [Inside the Battle to Define Mental Illness]. Their views were expressed to the APA [American Psychiatric Association] in letters written in 2009 and 2010. Dr. Frances has been the public leader in challenging Dr. Kupfer’s DSM-5 in Psychology Today and the Psychiatric Times. While this opposition to the DSM-5 revision has garnered popular support including a petition from the APA [American Psychological Association], it has fallen on deaf ears at the APA [American Psychiatric Association] so far [Setting the Record Straight: A Response to Frances Commentary on DSM-V][APA Responds Lamely to the Petition to Reform DSM 5]. The other thing absent from Drs. Kupfer and Regier’s brackets around the last decade is what happened in it – The Decade of Corruption Revealed as I like to call it. But we all know about that by now, not because anyone inside the walls of organized psychiatry talks about it much but because we read the newspapers and watch the news like everyone else.
People don’t often speak the problem directly. They don’t simply say that the pharmaceutical industry parasitized academic and organized psychiatry soon after we turned to biology and neuroscience in 1980. I doubt Robert Spitzer had anything of the sort in mind. He was simply a disillusioned analyst who had hooked up with the people at Washington University in St. Louis – at the time the bastion of biological psychiatry. My friends have [almost] convinced me that the pharmaceutical industry wasn’t behind the dramatic change in psychiatry that came in those years, they just saw a great opportunity and quickly seized the day. I know that in only a few short years, research, specifically drug research, was the focus of a lot of attention in academic circles. I know that because we got a new chairman and that’s all he ever talked about – that and the exciting future of biological psychiatry, particularly neuroimaging. I lasted not quite a year on the faculty before resigning, but stayed on for another year [tenure] doing odd jobs while I figured out what to do next [practice]. I was pretty naive then. It didn’t dawn on me how central that "drug research" thing was going to become. It just felt like I had been declared a dinosaur in my mid-forties and did what the dinosaurs couldn’t bring off – retooled. Shortly after I left, that new Chairman moved up to become the Medical School Dean and began a national search that picked his old colleague from Duke as successor, Charlie Nemeroff [1991]. Within a short time, my old underfunded department was well heeled with government and drug company grants – some for research and some ‘unrestricted institutional grants.’
The same thing happened all over the country as biological psychiatrists moved to head up many other departments, actually most. Our journals were filled with clinical drug trials, brain research, and a peculiar kind of review article that started with the "burden of mental illness" and progressed to reports of coming biological treatments. By the 1990s, the eclectic menagerie of various kinds of psychiatrists disappeared, at least from the mainstream journals and faculties. Any fool should’ve seen that the massive influx of pharmaceutical money into psychiatry came with strings attached, and had a lot to do with the explosion of drugs on the market and drug company profits. But psychiatrists aren’t just any fools. During the 90s, psychiatrists were either on the bus [brief sessions primarily for medications] or off the bus [essentially becoming part of the psychotherapy community at large]. I was in Group B. What we know now is that the 90s were a decade of an escalating collusion between pharmaceutical marketing departments and academic psychiatrists unlike anything ever seen or imagined – except it wasn’t seen. It was buried in waves and raves of new treatments and a bristling air of discovery. Certainly a piece of that excitement was legitimate, but there was plenty that was spin. Sales of the expensive new CNS drugs began to soar. It was indeed The Decade of the Brain.
So by the time of Dr. Kupfer’s white papers planning the DSM-5, the neuro-excitement was at a fever pitch, and they planned to incorporate the soon-to-be-discovered biomarkers from genomics and neuroimaging into their next Diagnostic Manual. The "descriptive psychiatry" meme was long gone, replaced by the "advances in neuroscience" fervor. And the blockbuster antidepressants had been joined by the blockbuster atypical antipsychotics – blockbusters all around. The back story was detestable, criminal. Our journals were flooded with industry funded clinical trials conducted by commercial CRO’s, maybe abroad, often ghost-written with guest authors. The corruption had become institutionalized, a machine turning out articles faster than they could engage authors. Psychiatrists were being well paid as KOLs to essentially function as detail men using company slides in speaker bureau presentations. CME presentations were also increasingly industry funded infused with industry messages. And while there were certainly legitimate and dedicated neuroscientists in the mix, it would’ve been pretty hard to find very many that were completely free of conflicts of interest. It was an insidious invasion with its fingers everywhere.
By the mid 2000s, about the time Insel declared psychiatry to be Clinical Neuroscience and Dr. Kupfer’s DSM-5 effort began in earnest, the cracks began to appears in the walls. In 2004, Allen Jones filed a whistle-blower suit against Johnson and Johnson for massive medicaid fraud. In fact, damage suits and false advertising suits were popping up all over the place. In 2005, the NIMH C.A.T.I.E. study debunked the idea that the atypical antipsychotics were any better than the older neuroleptics. Then Dr. Nemeroff had to step down as editor of Neuropsychopharmacology for non-disclosure of his interests in a treatment he was reviewing positively. The secrets were becoming obvious to more and more people. Then came Saints Senator Chuck Grassley and investigator Paul Thacker in 2008 who very publicly called a number of highly placed psychiatrists to task for unreported outside industry income. That lead to three of them stepping down from cushy Departmental Chairs and widespread publicity of their misdeeds, as well as a specialty wide focus on conflicts of interest. So, for Dr. Kupfer’s DSM-5 revision team, the magnifying glass was suddenly firmly in place.
As the process and the product of the DSM-5 became known, Drs. Spitzer and Frances, both retired, came back to the stage to protest. The DSM-5 process was secretive and poorly administrated. That was bad enough, but it wasn’t the center of things. If the length of this post hasn’t already sounded the alarm, psychiatry was in trouble. It was becoming public knowledge that many in the upper ranks of psychiatry had sold their souls to PHARMA, sharing responsibility for shepherding an unprecedented medication of America with drugs that were neither as safe nor as effective [nor as necessary] as advertised. I don’t know either Dr. Robert Spitzer or Dr. Allen Frances personally and I’m not a major fan of their respective DSM productions, but I do certainly respect that each of them acknowledges that their DSMs were co-opted by the pharmaceutical companies and cooperating psychiatrists. Both of them seem to want to make things right. This is no time to go steaming ahead as if we don’t know about all the corruption and stealthy collusion that’s becoming increasingly obvious, and both of them seem to know that. The DSM-5 as it’s developing is a nightmare of silly revisions, ill-conceived idiosyncratic new diagnoses, and unaddressed lingering problems. There’s a PHARMA angle to most of the changes, additions, and omissions [and there’s actually no real reason to revise the DSM at all since the anticipated biomarkers failed to materialize]. They respond to criticism with either haughty denial or polite homilies, but just keep on keeping on. Most of all, like their colleague Tom Insel at the NIMH, they talk as if the devastating revelations of the last five or six years didn’t occur. Everything is just fine.
Milo Minderbinder: No one is trying to kill you sweetheart. Now eat your dessert like a good boy.
Yossarian: Oh yeah? Then why are they shooting at me Milo?
Dobbs: They’re shooting at everyone Yossarian.
Yossarian: And what difference does that make?
Dobbs: Look Yossarian, suppose, I mean just suppose everyone thought the same way you do.
Yossarian: Then I’d be a damn fool to think any different.
I am just a mom who has witnessed my once brilliant son being damaged and diminished beyond description since the mid-nineties by this pseudo-science disguised as medicine. Thankful in the extreme that you are writing…
“Why All of Medicine Should Care About DSM-5”
-Wow. If there ever was a journal article title to sum up the paradoxical mix of cynical hubris and inferiority complex that is modern psychiatry, that is IT.
Wow, just finished reading the article. You really ended it with a bang, Mickey, replete with your philosophical humility.
A quote from your post: “The DSM-5 as it’s developing is a nightmare of silly revisions, ill-conceived idiosyncratic new diagnoses, and unaddressed lingering problems. There’s a PHARMA angle to most of the changes, additions, and omissions [and there’s actually no real reason to revise the DSM at all since the anticipated biomarkers failed to materialize]. They respond to criticism with either haughty denial or polite homilies, but just keep on keeping on. Most of all, like their colleague Tom Insel at the NIMH, they talk as if the devastating revelations of the last five or six years didn’t occur. Everything is just fine. ”
–> Isn’t it amazing how EVERYTHING in this country (and the West in general!) seems to be unraveling almost simultaneously? That is to say, everything ISN’T fine; everything ISN’T under control. I swear the corruption in gov’t and the debt/credit Ponzi is related to the medical ponzi, if only tangentially. It’s like Americans began deluding themselves in a big way in the 1980s that economic (and psychiatric!) miracles could simply be manufactured with Math PhDs and big-shot MDs and pharma research. It’s insane thinking –one part research and two parts wishful thinking — and only in retrospect will we be able to realize that we truly lost our minds and begin to pick through the ashes and rebuild.
As I read your comment about the “nightmare” of unaddressed problems and silly revisions that is the DSM V, I couldn’t help but think of, of all things, the situation in the Eurozone. All of a sudden, a feel-good concept and a sign of “progress” (an economically uniform continental Europe) now appears to be the wrong-headed, untenable concept it always was. It’s amazing to see the daily reshuffling of bailout plans and political theater in Europe — all to no avail. I’m convinced that secretly, some European leaders know the whole thing is unsustainable and it’s only a matter of time before the thing collapses. Same thing with the DSM. Again, the synchronicity of all of these “intellectual Ponzi schemes” (including the housing bubble and the student loan/college bubble) biting the dust is just gob-smacking, and historic.
I also very much respect your transparency in the statement “it now seems so obvious and I feel like an idiot to have not seen it, or at least to have not seen the extent of it.” If it makes you feel any better, I feel the same way, but speaking as a patient. I’m beyond angry I didn’t see the big picture of all the corruption in psychiatry and didn’t listen to my inner voice that I truly DIDN’T need to be on Paxil at age 14 for what was perfectly understandable situational depression. And now I’m stuck with these bizarre symptoms of down-the-road SSRI use over a decade later in what should be the prime of my life (my 20s). .
But what else can we do but what we’re doing? What else can we do but continue to shine an evidence-based (ha!) light on the systemic corruption that occurred (and is STILL occurring) in psychiatry? And, as you suggest, rally for a return to sanity to psychiatry, in which psychiatry does some MAJOR soul searching before trudging forward?
We surely are living in historical times in the Chinese proverbial sense.
*PS: Mickey, I truly, TRULY believe you should write a book, or at least collaborate with someone like Robert Whitaker. The definitive history of psychiatry’s astonishing three-decade long run of institutionalized corruption has yet to be written, and I can’t think of anyone better to do it (or at least provide information on it). We really need people to chronicle this sorry mess so psychiatry can have a prayer of repairing the damage it has caused so many patients and physicians.
SG (and Mickey)–
Thanks for expressing the many-faceted ills with today’s society. Trying to exactly pinpoint the moment it began to unravel is impossible, but acknowledging that what occurred in medicine (the transformation of our medical education and ‘belief’ in magic pills for every ill) has occurred in almost every aspect that impacts our daily lives. Housing, jobs, medicine, law (justice), business, education, outsourcing, attacking public employees and unions, co-option of the Tea Party movement, the rise of OWS. My hubby was in the agriculture field, and years ago saw Monsanto and others extend the same sort of tentacles into academia that medicine did–just a different field.
I suppose what I am saying is that Mickey’s writing, followed by readers’ comments, makes me feel ‘not alone’ in concern for our (formerly) revered professions and institutions–for our people and our society.
I am among your “you should write a book” fans. Who better than you?
It took me 7 years to win back a little cash from Big Pharma for disabling me with their blockbuster psychotropics. Too bad these suits are just a cost of doing business.
my blog: Mad in Vermont
The meds for depression alone are wrecking our whole society.
They are causing a tremendous increase in the number of people being diagnosed as bipolar [manic depression].
The Physicians Desk Reference states that SSRI antidepressants and all antidepressants can cause mania, psychosis, abnormal thinking, paranoia, hostility, agitation, etc. These side effects can also appear during withdrawal. Also, these adverse reactions are not listed as Rare but are listed as either Frequent or Infrequent.
Go to a search engine and type in SSRI Stories where there are over 4,800 cases, with the full media article available, involving bizarre murders, suicides, school shootings/incidents [65 of these] and murder-suicides – all of which involve SSRI antidepressants like Prozac, Zoloft, Paxil, etc, . The media article usually tells which SSRI antidepressant the perpetrator was taking or had been using but sometimes the media article just says “antidepressant” or “medication for depression”.
On December 15, 2010, PLoS Medicine released a study which showed that, in regard to prescription medications and violence, the FDA had received the most reports of violence from the SSRI & SNRI antidepressants (except for Chantix, the smoking cessation drug.) The evidence of an association with violence was weaker and mixed for antipsychotic drugs and absent for all but one of the mood stabilizers. Yet, the antipsychotics and mood stabilizers, given for the most serious mental illnesses, bipolar disorder and schizophrenia, would be the most likely culprit involved in violence but, instead, it was the antidepressants which had the most reports of violence. They were given to patients that traditionally were the least likely to commit violence, the depressed and the anxious.
I know I’m just jumping on the bandwagon and I know I’ve said it in comments before but I do truly wish you’d write a book; as helpful as this blog is, we need it as a book. Not a bad idea to see if collaborating with Whitaker could work; his Mad in America, along with Anatomy of an Epidemic, certainly chronicle much of the history already. Not that you need a collaborator, Mickey. Nice to know I’m not the only one who feels like Alice after she went through the looking glass.
Another interesting thing to look at from mid-2000s is Grace Jackson’s book Rethinking Psychiatric Drugs. It was published in 2005.
Re: this line –
“The notion that psychiatry has organized itself around evidence-based, descriptive clinical findings without ideological bias can only be considered a quaint mythology.”
Amen.
Until this “mythology” disappears, can we all at least agree that nobody should be forced to undergo “treatment” from this mad profession?
Please, let’s stop forced treatment!
And at least protect children, elderly, war-traumatized service members/vets.
Can we at least do those things?
(while the “open-minded” continue to tout this crap we call “medicine”?)
Duane
I’ve just stumbled upon your interesting blog and am keen to become a regular reader. (I do wish the print was bigger and easier to read but perhaps that’s due to my computer and my eyesight being not as good as it once was). What you say makes a lot of sense to me. I live in the UK. Forty years ago I was written off as suffering from chronic schizophrenia (a misdiagnosis, evidence suggests). My life was almost ruined by a rigid application of the medical model, which was not appropriate to my problems and circumstances. I say ‘almost’ ruined because I’ve been absolutely fine since I came off meds and left the mental health system back in 1974. My experiences were a long time ago but what happened to me, and the issues my experiences raise, are still very much relevant today. Thank you for a great blog and long may your blog writing continue.
Thank you for so clearly describing the descent of psychiatry. As a medical student in the mid-eighties, I found the field quite fascinating, especially because of my previous graduate studies in neuroscience. My professors would have loved me to go into the field, but I was already committed to ophthalmology. Fifteen years later I had to quit my oculoplastic practice because of neck problems, and my decision to forgo psychiatry seemed disastrous in retrospect. Grief over my career loss led to deep depression, psychiatric collapse, and a bipolar I diagnosis (after an explosive manic episode triggered by Effexor). At that point I began to see the field from the other side. In short order I was taking five psychotropics. I gained 50 lbs and suffered embarrassing side effects. It was awful. When I finally saw the light it took me four years to taper off all the drugs. Now I feel much, much better. The upshot is that I’m glad to have steered clear of psychiatry, because I’d hate to be looking back on a career built on prescribing toxic medications to vulnerable patients who would have done much better with kindness plus cognitive and spiritual guidance. I’d wonder if my career had done more harm than good and whether I wasn’t ultimately a pawn for ugly forces of greed. I feel sorry for psychiatrists of my generation. They got duped and now they need to either face the truth (which would be devastating to the ego) or continue hiding from it (which would be devastating to the soul). Your courage in writing with such clarity and honesty will help rescue psychiatry, and the rest of us, from its mistakes.
Dear Jeanne Smith:
I’m very sorry to burst your bubble…you did not WIN anything…this is considered a token settlement offer…AstraZeneca admits absolutely no wrong doing, any culpability, or do they accept any responsibility for the massive amount of health damage caused by the drug Seroquel…
The proposed settlement you’re referring to and writing about on your blog is merely a token offer. This offer is only for an amount less than the cost of what AstraZeneca projected to spend defending some of these cases in court…So when you say you WON…you are unfortunately misinforming yourself & others…
Settling and Winning are two very different realities in this instance. I suggest you check out the Seroquel Lawsuit Blog that was written about here in a blog post & become more informed about what is actually transpiring with the Seroquel litigation.
My theory: The name “psychiatry” has become embarrassing because of association with the “chemical imbalance” debacle, hence a major rebranding effort to “Clinical Neuroscience.” Going further out on the hokum jargon scale.