the best of times…

Posted on Friday 30 March 2012

Conflicts of interest and DSM-5: the media reaction
By Clare Weaver
March 26, 2012

The fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) will be published next year, but concerns surround its financial competing interest disclosure policy and the ties its panel members have to drug companies. Last week PLoS Medicine published an analysis by Lisa Cosgrove and Sheldon Krimsky , who examined the disclosure policy and the panel members’ conflicts of interest, and call for the APA to make changes to increase transparency before the manual’s publication.

Within three days of publication the paper had been viewed over 4000 times, and several major media outlets reported on the authors’ findings and the wider issues they relate to. In the news section of Nature, Heidi Ledford drew attention to the fact that panel members with competing interests are not evenly distributed throughout the panel work groups, commenting that “the committees with the highest number of industrial links are those evaluating conditions for which drugs are the first-line treatment.” She also described the failure of the policy to require its panel members to specify participation in speakers’ bureaus, arrangements “in which a company hires someone to give a presentation about its product.”

The DSM-5 is unpopular for reasons other than its panel members’ competing interests. Peter Aldhous at New Scientist reported on the controversial changes to certain diagnostic categories, such as the mood disorders group, “which proposes including bereaved people in the definition of major depression,” and adds that, according to critics, “definitions of psychiatric illnesses have broadened over successive editions of the manual as a result of pressure from the pharmaceutical industry.” He also discusses the criticism the DSM proposals have attracted from psychologists, who “tend to favour counselling over the drug treatments that dominate modern psychiatry,” and links to an online petition calling for greater involvement from psychologists in the DSM-5. Katie Moisse at ABC News quotes David Elkins, president of the American Psychological Association’s society for humanistic psychology and chairman of the committee responsible for the petition, who is “dismayed” that seven in 10 DSM-5 task force members have drug company ties.”

Writing for California Watch, Bernice Young highlighted the authors’ findings – that the proportion of the DSM-5 panel with financial conflicts of interest between 2006 and 2011 stands at 69% – and provided a link to the APA’s refutation of the paper’s conclusions. This includes a statement saying that many members have now divested themselves of previously declared competing interests, and that in fact, for 2012, 72% of panel members declare no financial ties to industry…

DSM-5 Proposals for Generalized Anxiety Disorder
By Allan V. Horwitz
March 28th, 2012

…Nevertheless, the proposed changes in the Generalized Anxiety Disorder (GAD) have been relatively neglected. Changes in the GAD category are potentially the most important because they would impact the largest number of people. Anxiety disorders are the single most common class of mental disorders in the population and, historically, GAD has been the central anxiety disorder. The changes that the DSM-5 anxiety working group proposes for GAD have the potential to massively increase the number of people subject to GAD diagnosis and, correspondingly, the number of people at risk for false positive diagnoses of GAD.

The DSM-III, following Freud, had defined Generalized Anxiety Disorder as a “generalized, persistent” condition that lacked the more specific symptoms characterizing the other anxiety disorders. It also made it a residual condition that couldn’t be diagnosed in the presence of other anxiety or depressive conditions, so that its actual prevalence was quite low: patients who met GAD criteria typically also met criteria for other disorders. The DSM-III-R (1986) abandoned the hierarchical rule that disallowed GAD diagnoses in the presence of other disorders. It also transformed the nature of GAD from generalized anxiety to a focus on specific worries, stating:

    Unrealistic or excessive anxiety and worry (apprehensive expectation) about two or more life circumstances, e.g. worry about possible misfortune to one’s child (who is in no danger) and worry about finances (for no good reason), for a period of six months or longer, during which the person has been bothered more days than not by these concerns.
The central place this definition accords to worries not only changed the core nature of the diagnosis but also — given the omnipresence of things that people have to worry about — could potentially pathologize common anxious conditions. However, the many qualifiers such as “two or more life circumstances” and examples of limiting diagnoses to anxiety about children who are “in no danger” or about finances “for no good reason” clearly distinguished realistic worries from anxiety disorders. The DSM-III-R also required that symptoms must endure for six months, reducing the possibility that purely situational anxiety would be misdiagnosed as GAD. For the most part, the DSM-IV maintained the DSM-IIIR criteria for GAD.

The DSM-5 proposals for Generalized Anxiety Disorder run the risk of extensively pathologizing what could become an extraordinarily common disorder. They would lower the duration and severity thresholds for GAD from six to three months and from three of six to one of four symptoms, respectively. Moreover, they lack the contextual qualifiers that the DSM-IIIR had used to distinguish disordered from natural worries: “Excessive anxiety and worry (apprehensive expectation) about two (or more) domains of activities or events (for example, domains like family, health, finances, and school/work difficulties).” Worse, the types of worries these criteria specify are exactly the most common concerns in the population, so that lower thresholds have the potential to vastly increase the number of people subject to this diagnosis. The criteria leave unclear what the meaning of “excessive” is — patient self-definition, social norms, clinician judgment, etc. — so this qualifier does not provide much help in limiting false positives. Given the ubiquity of common worries in the population, these lower thresholds could pave the way for GAD to replace depression as the most common diagnosis of twenty-first century psychiatry.

In certain respects, the DSM-5 recommendations for Generalized Anxiety Disorder reverse the ages old dictum that mental disorders must be without cause, that is, not understandable in terms of the person’s actual life situation. From Hippocrates through the DSM-IV definition of mental illness, worries about family, health, finances, or work would have been excluded from the domain of mental disorders. Indeed, they are the very model of conditions that arise with cause. The DSM-5 proposals for GAD could classify even the most understandable sorts of worries as mental disorders.

Do We All Have Behavioral Addictions?
Huffington Post
by Allen Frances

The relentless march to medicalize normality out of existence is opening a new and especially ridiculous front. The DSM-5 suggests providing a new section for "behavioral addictions." The category would begin life nested alongside the substance addictions and would start with just one disorder (gambling). Fortunately, none of the other "behavioral addictions" suggested for DSM-5 would gain official status as stand-alone diagnoses. But if a clinician felt that someone were "addicted" to sex, or to shopping, or to the Internet, or to working, or to video games, or to model railroading, or to whatever else (the list is long and could easily expand into every area of popular activity), this could be diagnosed as "Behavioral Addiction Not Otherwise Specified" and thus receive the dignity of an official DSM code. This Pandora’s Box of diagnostic possibilities could turn all manner of passionate interests into psychiatric illnesses…
I love reading things like this. While it might seem discouraging to many that there are so many things wrong right now – the DSM-Task Force debacle, J&J Trials monthly, blogs everywhere cataloging deceitful science – this is the best of times. All of this stuff has been going on for years, actually for decades. If you’re a 70 year old me, the fact that it’s being talked about and visible in open court, and on Huffington Post and Reuters and the New York Times, is just plain remarkable. In my case, if I said anything about it for the twenty years before this, I was immediately discounted because I was a psychoanalyst [we were the last bad guys]. Nobody says that anymore. It’s almost like I finally get to be a psychiatrist again – even though I never stopped being one from my perspective.

I’m a southerner, born in 1941 just before Pearl Harbor. I love the South and grew up standing when they played Dixie. I didn’t know how fortunate I was to grow up in an anti-racist family. My father was an immigrant Italian who had felt the sting of prejudice and my mother was a Georgia Peach, but she had a father who had quit the Klan as a young man and made "the change" in a big way. The open "trouble" in the South started when I was in high school, and by college, I was on board the Civil Rights train, as was my mother, as was my now wife who I met in Medical School. I remember the days in the mid-1960s when it finally became okay to be on that train. It started slowly, but then built steadily. From where I sat, it started changing when those four little girls were killed in the Birmingham bombing, and it has crept upward since.

I think of that now because it’s discouraging when we look at the abysmal behavior of the DSM-5 Task Force, or read things like my last post where an article that shouldn’t have been published is touted so highly. I feel discouraged when I look at the APA Meeting Brochure and see people presenting who I think should’ve been removed from the membership roster altogether. But then a friend down the road calls for me to turn on CBS Sunday Morning because they’re talking about antidepressants, or when I run across an article in the Press without even looking for it about the antipsychotics. The reason this is the best of times is that this is what it feels like when things begin to change. It always feels this way. Discouraging. Too slow. They are too powerful. They act as if nothing needs changing.

Segregation, Women’s Rights, Johnson’s Viet Nam, Bush’s Iraq, Gay Rights, now Pharma’s psychiatry – these things come in waves. Just few more insiders [like Allen Frances], the clear unearthing of a few more scandals [plenty to chose from], another Senator Grassley or two [very key], and the pace will pick up – wait and see. The other reason this is the best of times, is that once things become clear to enough people at large, then you’ve got to do something about what’s wrong, and that’s plenty tricky, shoals everywhere. So this is the best of times right now because all we have to do is keep pointing out what’s wrong – which is a piece of cake compared to what comes next.

When I was a boy, I used to marvel at how the old people thought. Something would come up and the adults would be up in arms, but the old people weren’t. They’d talk about the Depression, or FDR, or WWII or something equally historic. They’d seen the world not come to an end enough times and could sit in front of a television and remember the first radio they ever heard. There was a balance unavailable to the younger adults. I may not be old enough for that much perspective, but I’m old enough to know that the strangle-hold the pharmaceutical industry and their misguided friends have had on the mental health world is on the wane. It has been a very long wait. I honestly didn’t think I’d ever even see it at all…
    Joel Hassman, MD
    March 30, 2012 | 6:01 PM

    At the end of the day, we have thankless jobs. We help people help themselves, hopefully more than less, and people basically act like “hey, you’re a doctor, you’re supposed to do and not expect rewards.”

    And you know what, I can deal with that. It’s dealing with irresponsible, selfish, and destructive colleagues I have zero tolerance to handle. Hey, twice this week I had experiences with patients who have PCPs prescribing Adderal to people allegedly with ADD being started on what could be complicated, if not lethal initial dosages. I can’t believe PCPs want to jump on that ship!

    March 30, 2012 | 7:16 PM

    Thank you for this glimpse of the silver lining.

    March 30, 2012 | 7:21 PM

    Jeez I read 1 Boring Old Man at least once a day, without fail. I wonder if that entitles me to a DSM-V code? I sure hope so! Instead of being like people who go around saying “Hey, I’m bipolar II” I can go around and say, “Hey, I am 1 Boring Old Man, NOS!” I can hardly wait!

    March 30, 2012 | 7:35 PM

    I thank you, Mickey, for the comparison to the 60s and reminder of how some important change came about. I’m a decade younger, but also a Southerner and one who has long been grateful to have had a father who was anti-racist (not an Italian,but a minister, so his anti-racism was faith based). So, yes, please remind me that once upon a time, racism was the DSM of today’s world. While racism continues to exist, at least for the mainstream culture it is no longer “acceptable” and those who practice it try to conceal it. The last six years have felt very lonely to me…I’ve had to shut up quickly in many circumstances where people looked at me as though I had lost my mind…and it is for me “the best of times” that I no longer feel alone. And my thanks to you and to Robert Whitaker and to Alison Bass and to Marcia Angell and to David Healy and Stephany for making that isolation go away.

    March 31, 2012 | 1:33 AM

    Thought you might be interested in this news related to your old buddy & pal Nemeroff

    The The Anxiety Disorders Association of America in steeped in Pharmaceutical money… Check out their boards that are chalked full of the usual suspects… then check out how Pharma has found another way to subvert the money reporting issue with their shill doctors.

    ADAA takes loads of cash from Pharma that they then supply to their shills in the form of grants and CME… So instead of the money coming directly from Pharma….it goes through the washing machine @ ADAA and gets passed around to the shills cleaned & non-reportable…

    Just thought it was interesting….

    March 31, 2012 | 2:29 AM

    Thank you Peggi, for thinking of me, and yes we are not alone! I am excited to see Dr Healy, Mickey, Whitaker, Alison, Marcia all speaking out we are all learning a lot and for myself, it is a great thing to see all of my “connect the dots” moments I had while blogging, be taken on my true experts with massive ability to take on data and details, and yes validate what I have thought for so long about so many things in how this all works…

    March 31, 2012 | 7:00 AM

    Nemeroff rides again!
    Stan, I’ve been trying to find info on ADAA with little yield. You found any references? This really smells like old fish…
    Tom, I like 1bom-NOS. How about Soulful-II, Pharmalot-I, etc. We might could make some real money here…
    Peggi, it’s a kind of isolation similar to that sick people feel. Even well wishers don’t totally help, because they’re ‘out there’…

    Allen Jones
    March 31, 2012 | 12:45 PM

    Great post Mickey! Apt analogy!

    March 31, 2012 | 5:11 PM

    Dr. Mickey, I agree we are approaching some kind of tipping point.

    What people have trouble remembering is that change is never initiated by the majority. Little by little, everyone who wants change adds their mite to the tipping point.

    Yes, it seems criticism of psychiatry is becoming more and more open. I look forward to the day when patient safety is the field’s byword.

    April 2, 2012 | 6:33 PM

    It could also be called, a Flexner moment… (pdf, but well worth the read for anyone unfamiliar with US/Canadian medical education and practice history)

    April 2, 2012 | 7:37 PM

    A post on Mad in America points to a resolution in the Illinois House of Reps, for a task force investigating psychotropic drugs: I’m sure you will have seen it. I’m hoping you might provide some commentary on the blog about its prospects in Illinois and potential significance further afield.

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