1 Boring Old Man

ICD-10-CM Delay Removes Excuse for Rushing DSM 5 Into Premature Publication
DSM-5 in Distress: Psychology Today
by Allen Frances, M.D.
February 22, 2012

Until yesterday, there were only two reasons to stick with the projected date of DSM 5 publication [May 2013]: [1] the need to coordinate DSM 5 with ICD-10-CM coding, which was scheduled to start Oct 2013; and, [2] the need to protect APA publishing profits in order to meet budget projections. The first reason just dropped out. Health and Human Services [HHS] Secretary Kathleen G. Sebelius has announced that the start date for ICD-10-CM has been postponed. It is not yet clear for how long, but most likely a year [here ].

This latest delay in implementing ICD-10-CM is the government’s response to pressure by medical providers worried about the cost of changing systems. ICD 10 was available 20 years ago and has been official around the world for some time. The long US lag has been a cost saving measure — it will take billions of dollars to get all health system computers to switch coding systems. Indeed, there are many who would like to take this delay one giant step further by canceling ICD-10-CM altogether and leap frogging to ICD 11 [which will be ready around 2015 or 2016].

This means there is only one reason left to rush DSM 5 to print — the prospect of publishing profits. This would be a shame because DSM 5 is nowhere near ready to be born. Why do I say this and what needs to be done before it can responsibly turned loose on the field?

1. During the past month, there have been well over 100 highly critical news articles in major media outlets all around the world decrying the many risks of DSM 5 proposals. [For a representative sample see Suzy Chapman’s post]. APA’s internal scientific review of these DSM 5 proposals is being conducted in secret and has absolutely no credibility to the outside world. DSM 5 will continue to be ridiculed and ultimately will be rejected unless its extremely controversial proposals are dropped or are subjected to independent scientific review — and such outside review will take time.
2. DSM 5 made a great mistake when it cancelled the crucially important second stage of its field trials. This was made necessary because constant delays in completing its first stage left no remaining time for its second — that is assuming that the May 2013 publication date had to be met at all costs. DSM 5 also warned us that its imprecisely written criteria sets performed so poorly in the first stage of the field trials that historically unacceptable reliabilities[barely better than chance] will now be accepted for DSM 5. This is simply unacceptable. DSM 5 should complete both stages of its field trials as originally scheduled. This means rewriting and retesting the poorly performing diagnoses. And this will take time.
3. The planned DSM 5 clinician’s field trial appears to be almost completely dead in the water — plagued by disorganization, constant delays, and a ridiculously high attrition rate. If this is to be done properly, it too will take time to complete.

^{The original publication date of DSM 5 was 2011. This had to be delayed for a year and then again for another year because of poor planning and disorganized implementation. Continued unexplained delays again have DSM 5 so far behind its own schedule that May 2013 can now be met only with a third rate product that cannot possibly gain the wide acceptance enjoyed by previous DSM ‘s. The only responsible APA action is to delay DSM 5 publication yet again until it has successfully accomplished all the steps planned in its own original timetable. The only reason for APA to prematurely rush out a poor DSM 5 product is profit — and given its importance this is simply no excuse at all.}

^{Definition of Mental Disorder: The DSM-5 Task Force has proposed a new definition of mental disorder which includes, “A behavioral or psychological syndrome or pattern that occurs in an individual that reflects an underlying psychobiological dysfunction” [APA, 2011]. Using the term psychobiological implies that all mental disorders have an underlying biological component. Although advances in neuroscience have greatly enhanced our understanding of psychopathology, the current science does not fully support a biological connection for all mental disorders. We therefore request that the definition of mental disorder be amended to indicate that mental disorders may not have a biological component.}

^{Darrel Regier, the psychiatric group’s research director, characterized critics as being unconvinced medical treatment is better than counseling. The idea of “medicalizing normality comes from a perspective that there are no psychiatric disorders, and you need to avoid stigmatizing people by giving them one,” he said in a telephone interview…}

But, as Dr. Frances says, they’ve been offered a chance to pull this out of the fire – to save face. To regain credibility, they’ll need to change the deadlines, have an external review, alter their stance on transparency, and submit to genuine field trials until they have evidence of real reliability. It probably even means winning over Dr. Frances himself, since he’s come to be the interface between the Task Force and everyone else – a role I expect neither he nor they like very much. That means eating some crow, and I don’t know if this bunch has that in them. So if they come around, we’re all going to have to clap really hard like in the stage productions of Peter Pan to bring the thing back to life. But in the end, it probably all really hinges on this man:

Jeffrey Lieberman APA’s New President-Elect
Medscape
by Deborah Brauser
February 22, 2012

Jeffrey Lieberman, MD, has been named the next president-elect of the American Psychiatric Association [APA], according to election results released by the APA. Dr. Lieberman, who is chair of psychiatry at Columbia University and is a member of Medscape Psychiatry’s editorial advisory board, was the clear victor of a 3-way race for the title, with 52.3% of the votes…

In statements published on his election Web site, Dr. Lieberman said that if elected as the APA’s president, his priorities would be to protect "the integrity and viability" of psychiatric practices and mental healthcare services, enhance funding and clinical relevance of psychiatric research, and improve collaboration between psychiatrists and primary care physicians.

Another of his priorities was the effective roll-out of the upcoming Diagnostic and Statistical Manual, Fifth Edition (DSM-5). "I will work to…effectively manage the necessary and complex administrative, policy, and communication tasks involved, including the controversies that this process may evoke," he stated…